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Post-traumatic Stress Disorder and the 9/11 Terrorist Attacks

Courtesy National Geographic

Abstract

 September 11, 2001 was a day of tremendous loss and trauma.  Both people who were directly exposed and those who were indirectly exposed through media and second-hand accounts were shocked by what they heard and saw.  The effects of this tragedy rippled across the globe and have perpetuated an onslaught of post-traumatic stress disorder diagnoses based upon the stress that witnesses endured.  In this paper, post-traumatic stress disorder, or PTSD, will be discussed as it relates to the events of 9/11.

POST-TRAUMATIC STRESS DISORDER AND THE 9/11 TERRORIST ATTACKS

Key Words

Post-traumatic stress disorder

Direct exposure

Indirect exposure

September 11th, 9/11

Ground Zero

Introduction

            The events that occurred on September 11, 2001 will be forever apart of history as one of the most traumatic and horrific days.  For those who directly survived the attacks, most are permanently altered, perhaps not physically, but emotionally.  And for those of us watched in horror as thousands of innocent lives were taken, we will forever have the images burned into our memories.  Many of us can not forget where we were that awful day.  For many people, this event was the first realization that this world is not the place they once thought it to be.  Rocked straight out of their comfortable self-portrait of harmony, suddenly everything was tainted with the possibility of violence and evil.  This event was one of the largest and most visible acts of violence ever carried out.  Because of the accessibility of technology and media, the world watched as violent, raw evil converged upon New York City, Pennsylvania, and Washington D.C.  As a result of the worldwide spread of images through television and internet, thousands of people suffered trauma.  For first responders, survivors, firefighters, police, and scores of innocent bystanders, their ability to easily move beyond their first-hand witness of the events became difficult in the extreme.  Amidst the physical injuries and the respiratory issues that plague many who were there at Ground Zero, there are wounds that are unseen.  Scars that have wounded the mind, dampened the spirit, and cast a shadow on the heart are common for those who were there.  When life as it once was, even in a new light, is unable to continue, the American Psychiatric Association (2000) calls this post-traumatic stress disorder.

Definitions

Post-traumatic Stress Disorder

The Diagnostic and Statistical Manual IV(2000) defines post-traumatic stress disorder, or PTSD, as:

the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death injury or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. (APA, 2000 p. 463)

Some events that are considered traumatic include:  military combat, violent personal assault (sexual assault, physical attack, robbery, etc.), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, and others. (APA, 2000) Criteria for a PTSD diagnosis include:

  • The person has been exposed to a traumatic event in which both of the following were present:  the person experienced, witness, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others or the person’s response involved intense fear, helplessness, or horror.
  • The traumatic event is persistently re-experienced, or re-lived, in one (or more) of the following ways:  Recurrent, distressing recollections of the event, through images, thoughts or perceptions.
  • Recurrent distressing dreams of the traumatic event
  • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)
  • Intense psychological distress at exposure cues that symbolize or resemble some aspect of the traumatic event.
  • Physiological reactivity when exposed to cues that symbolize or resemble an aspect of the traumatic event.
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

Efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arouse recollections of the trauma, or the inability to recall an important aspect of the trauma.

  • Marked diminished interest or participation in significant activities
  • A feeling of detachment or estrangement from others
  • Restricted range of affect or emotional responses
  • Sense of a foreshortened future or feelings of doom
  • Persistent symptoms of increased arousal as indicated by two or more

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigiliance

Exaggerated startle response, jumpiness

  • Duration of the disturbance is more than one month (APA, 2000)

To be diagnosed with PTSD, the disturbance must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (APA, 2000)

Direct Exposure

Direct exposure is defined as someone who “experienced, witnessed, or was confronted with an event or events involved actual or threatened death or serious injury” (APA, 2000, p. 467).

Indirect Exposure

Indirect traumatic exposure is defined as “knowledge of an event through a first person account of actual or threatened death or serious injury (irrespective of the relationship to the survivor)” (Zimering et al, 2006).   Relief workers responding after the towers fell, received direct exposure to traumas at the disaster site and indirect exposure to trauma via survivor accounts of the terrorist attacks. (2006)

September 11th (9/11)

September 11, 2001 also referred to as 9/11 is the day that a terrorist attack upon the United States of America resulted in the death of nearly 3,000 people.  New York City was attacked by two commercial jetliners that crashed into the Twin Towers, causing the fall of both buildings.  Two more airplanes were used as massive bombs, one hitting the Pentagon in Washington D.C. and one diverted by brave passengers, crashing into a field in Pennsylvania.

Ground Zero

Ground Zero is the common reference to the location of where the Twin Towers of the World Trade Center stood and ultimately fell, resulting in a massive loss of life and an enormous pile of rubble and steel.

Statistics

PTSD is a serious and debilitating disorder.  It is estimated that the prevalence of PTSD in the United States is approximately 8%. (Kazi, Freund, Ironson, 2008) Though this disorder was once thought to occur only in veterans, we now know that it also civilians of all ages and walks of life.  It has no limits to culture or socioeconomic groups and can arise from many different traumas.  September 11th, was not exempt from these traumatic events.  Many of those who were directly and indirectly exposed to the tragic happenings of that day were traumatized, some resulting in classifiable PTSD.  In a speech given at Ground Zero, the speaker said, “Here we stand today as the Trade Center casts a shadow over all of us. (Kanarian, 2007, p. 121) An observer wondered what the speaker was talking about, noting that the World Trade Center was gone.

The speaker continued, “The World Trade Center will always cast a shadow over our minds for the rest of our lives; there is no getting over this one.” The observer then remarked, “His words were the truest I have heard relating to the World Trade Center attack and post-traumatic stress.” (p. 121)

Direct Exposure

            When talking about direct exposure as it relates to the 9/11 events, exposure characteristics such as:  injury, exposure to the dust cloud resulting from tower collapses, proximity to the World Trade Center or WTC site, personally witnessing specific horrific events, experiencing panic attacks during the attacks would qualify.  (Neria, DiGrande, & Adams, 2011Among retired firefighters, 22% were found to have symptoms of PTSD four to six years after the attacks (2011).  For those respondents who were at the WTC at the time of the attack, PTSD was almost twice as common compared with those who witnessed the attacks in person from outside the WTC (Bonanno et. al., 2006).  Individuals who were directly exposed to the terrorist attacks exhibited signs of PTSD at a rate of 20% (Zimering et al, 2006).

Indirect Exposure

PTSD was documented in individuals who were indirectly exposed to trauma that did not directly involve a family member or other close person. 4% of individuals living outside of the attack sites who were indirectly exposed to the tragedies via television were found to have symptoms of PTSD (Zimering et al, 2006).  These findings implore us to understand that health care providers should be sensitive to and aware of the enormous variability in response following a major national trauma. (Silver et al, 2004)  It is not only those who are directly exposed to traumatic events who suffer, though, obviously they are most gravely affected.  As Kazi, Freund, and Ironson (2008) state:

 Terrorist attacks may differ from the other traumas that are known to elicit PTSD, as in the case of 9/11, where survivors not only had to manage their own escape but had to witness a national disaster, fellow workers’ deaths, victims jumping out of high windows, physical ramifications of inhaling smoke and dust from the fire, and the demise of the entire buildings. This terrorist attack resulted in the American society’s questioning its fundamental belief of the world as a predictable, safe, and meaningful place to live. (p. 101)

In a national telephone survey of 560 adults three to five days following 9/11, 90 percent had one or more symptom of posttraumatic stress, with 44 percent to a substantial degree (Meisenhelder & Marcum, 2004).  Further, in another study, none of participants in a positive PTSD group reported a 9/11-related death or injury to a family member or close friend (Silver et al, 2004).  This finding supports the notion that PTSD from PTSD from indirect exposure can occur even in the absence of a personal connection a victim (2004).  The researchers state,

We have found significant psychological reactions across the U.S. after the September 11th attacks; our findings strongly suggest that the effects of these terror attacks were not limited to communities directly affected.  Instead, our data show that substantial effects of the events of September 11th rippled throughout the country. Importantly, the degree of psychological response to the September 11th attacks was not explained simply by degree of exposure or proximity to the trauma. Many individuals who lived hundreds of miles from the attacks or had low levels of exposure (i.e., individuals who watched the attacks live on TV and those who reported no direct exposure at all) reported high levels of symptomatology. (pp. 138-139)

Immediately following the attacks, three national studies found posttraumatic stress symptoms throughout the U.S. population (Neria, DiGrande & Adams, 2011). In a national telephone survey conducted within the first week following 9/11 44% of participants reported substantial stress reactions (2011). In a similar internet survey study, with a nationally representative sample of 2,273 adults, 4.3% reported a prevalence of PTSD that was significantly associated with the number of hours of television coverage of 9/11 (Neria, DiGrande & Adams, 2011).

It is clear that the events of September 11th had a tremendous, traumatic impact upon those who were directly exposed and those who were indirectly exposed. Until 9/11, little regarding indirect exposure to trauma has been studied, but is now, clear that there is a prevalent need of further study and examination.  Though it is certain that, naturally, those who were directly impacted by the events of that day were most traumatized, people who were indirectly exposed were also at great risk for tremendous stress and trauma.

Symptoms

            The symptoms of PTSD can be severely impairing to even normal daily activities for the sufferer.  Some symptoms are recalling or recollection, avoidant and numbing, severe, lasting emotional and affect change, hyper arousal or startle response, functional limitation, nightmares and intrusive thoughts, and survivor’s guilt.  (APA, 2000)  Many of these stress reactions are frequently caused by “triggers” that remind the sufferer of the events that were found to be traumatic (Kanarian, 2007).  Kanarian (2007) defines triggers as, “emotional trip wires that evoke memories of traumatic incidents.  They can be sights, sounds, smells, and feelings and are timeless, capable of making memories years later feel as if they occurred yesterday (Kanarian, 2007, p. 122).  When we are able to recognize what situations, sights, smells, or sounds trigger a stressful reaction within us, we are, thus, able to deal with them.  By learning the signs and symptoms of PTSD and strategies for dealing with the triggers, it is possible to become aware of a reaction within ourselves.  The severe affect change within people suffering from PTSD can manifest in edginess, irritability, nervousness, and easily startled (2007).  PTSD can also cause short-term memory loss that may result in repeating questions and trouble concentrating or focusing (2007).

Re-experiencing

Seeing the images that accompany that horrendous day in September can burn the memory into one’s mind, replaying over and over.  For those who were there at the site, stuffing the memories and pictures away is difficult.  As Kanarian (2007), “Even after you have forgotten an incident, one sight, smell, sound, or thought can bring you back to the moment and stimulate a vivid memory of a traumatic incident.” (p. 127)

In an online article about 9/11 survivors,

For about a year afterward [survivor, David Donovan] had nightmares and little appetite. The company hired psychiatrists, but he said he felt more comfortable talking with his colleagues who had been through the same experience. For a year and a half, he couldn’t fly and found being in a subway difficult. He said he still looks for the emergency exit when he’s in a large crowd.  (Ochs, 2011)

Another survivor reported feeling in a state of shock for weeks or months after 9/11 (Kazi, Freund, Ironson, 2008). She related feeling “dull,” had difficulty concentrating, and experienced visual hallucinations of objects falling. She was clinically depressed, crying daily, and felt “paralyzed,” after 8 months.

This survivor’s experience of re-experiencing was discussed,

Judy reported having post-traumatic stress disorder following this event. She admitted to having panic attacks when sitting in traffic on a bridge, overhearing stories about the tragedy, and at the thought of traveling by air. There was a time when the fire alarm was set off while she was in therapy, and she recalled having an overwhelming flashback of being on the 78th floor at the time of impact. She said that she thought that she might be thrown across the room. So she left therapy, walked 13 blocks until she found the subway, and then felt safe. She had difficulty watching the news or reading the newspaper for some time thereafter.  ‘There was all of this awful news coming out at me, so I had to focus only on healing myself and not to get caught up in it,’ she stated.(Squillace, 2003, p. 25)

Numbing

            In trying to cope with the traumatic events that one has witnessed, many times it is natural for a person suffering from PTSD to push the memories, emotions, fears, and feelings away.  Shutting down seems easier than continuing to relive the horror, thus they become numb and avoidant.  Because there are triggers that can continue to evoke a response in the traumatized, many times he or she will simply avoid any place, person, or situation that might bring about a stress-related response.  In the Newsday (Ochs, 2011) article mentioned prior, one survivor states that he simply could not function.  He began avoiding, even simple, daily activities, such as shaving.  He recalls staying in his bathrobe all day.  “I went into a total funk,” he had said (2011).  A first responder related his experience,

At first, it was discouraging to constantly pick up only parts, and after a while it stopped upsetting me. I realized that I was becoming numb to what would have been horrible to others. That is when I knew that I had to stop working and it was time to go home. (Squillace, 2003)

Survivor’s guilt

One survivor of the attacks of September 11th, said that he learned to handle triggers that might prompt a panic attack, such as a car making certain noises, but “the hardest,” he said, “was the survivor’s guilt.” (Ochs, 2011)  Survivor’s guilt can lead a person to ponder why they were spared when others were not.  Guilt colors the elation that might be naturally felt for surviving a traumatic event.  Questions about what more could have been done, why they made it, if they should have done something different, even if it meant their demise, are common.  As one survivor related,

‘There’s always this nagging guilt,’ he said. ‘Should I have stayed to help? What could I have done? The rational part of me knows I did the right thing. I’m not trained to rescue . . . but there’s always going to be a piece in the back of my mind: Could I have done something?’ (2011)

Finding Faith in 9/11

            The days that followed September 11th, 2001 were unique.  Many people, who ordinarily would not, flocked to churches across the nation.  Pews and benches were fuller than usual.  People were looking for reasons, safety, and solidarity.  This seemed to be a temporary comfort for many, but there are some whose faith was strengthened, who changed priorities and re-examined who they were, what life was about, and what purpose it had.  Genelle Guzman-McMillan (2011) is one who took her second chance at life and chose to make changes.  The last survivor pulled from the smoldering pile of Ground Zero, Guzman-McMillan (2011) was pinned under concrete and steel for over 24 hours.  During this time, she relates in her book that she drew near to the Lord, as her only source of survival.  She states,

I haven’t had any marked emotional ‘issues’ over the years as a result of being buried alive.  I mean it when I say that God was my psychiatrist, and still is today.  I have been blessed by never having a single nightmare about my experience.”  (p. 165)

Mental health professionals often remark about the tremendous benefits of “religious coping” with post-traumatic stress.  In particular noted are the feelings of comfort, collaboration, and connectedness evoked by faith and communities of faith (Meisenhelder & Marcum, 2004).

God may be a source of comfort and meaning in the midst of a senseless act. Seeking guidance and support through God decreases the sense of loneliness and isolation. Turning to religious faith brings an omnipotent and ever-present Partner into one’s life, lending a greater sense of control, which is a critical element to decreasing posttraumatic stress.  Lastly, connecting with a faith community entails a support system, a promotion of personal identity, and enhanced intimacy with others.  The combined benefits of positive religious coping result in lower perceived vulnerability, isolation, confusion, and, therefore, lower posttraumatic stress response (p. 157).

Witnessing a traumatic event often causes people to pause and reflect about the purpose of life and mortality.  Some people find tremendous comfort in their faith.  They have an assurance of control, even if they are not the ones who have that control, they know who does.  There are still others who are angry.  Rather than drawing toward their faith, they distance from it and some abandon it altogether.  They simply cannot process and find meaning in senseless tragedy.  But for those who remain faithful, they proclaim that they do not understand either.  That is faith, believing in what is unseen.  The bible gives great hope for those who have walked through a traumatic event.  Jesus said in John 14:27 (NIV),

“Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid.”

There is great hope that in Christ we have assurance of peace.

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  1. November 14, 2011 at 6:26 pm

    An interesting read. It’s great to see people discussing the traumatising effects of events like 9/11, not only on those involved directly but those who witnessed it from afar.

    I believe that only when we can start to understand the psychological effects of 9/11 can we start to really understand the event itself.

    Here’s a video of psychologists talking about this very subject:

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