Who could blame him? Disasters cause psychic wounds as well as physical ones, and the consequences can be serious. By rough estimates, at least 40,000 people–survivors, witnesses, emergency workers–suffered serious psychological trauma during the attack on the Trade Center. Countless others will experience weeks of grief, shock, fear and even despair as they replay the televised images in their minds. Eventually, most of us will put the experience behind us. Most, but not all. Past experience suggests that a third or more of the people touched directly by this event will develop post-traumatic stress disorder (PTSD). For those people, every day will be Sept. 11.
It’s no accident that we respond to life-threatening events the way we do. The stress response is a biological adaptation, as essential as hunger and as finely regulated as pain. When we perceive immediate danger, our bodies institute what Stanford neuroscientist Robert Sapolsky describes as a “triage economy.” Adrenaline and cortisol speed the heart and dilate the bronchial tubes while slowing nonessential functions such as digestion and tissue repair. “You want to secrete these hormones by the boatload if you’re at the foot of the World Trade Center and need to run like hell,” Sapolsky says. Unfortunately, an overwhelming trauma can distort the stress response, causing symptoms that may persist for months or even years.
PTSD is at least as old as war, but it didn’t become an official medical diagnosis until 1980. Its causes are still murky and its course is unpredictable, but the key symptoms are unmistakable. A month or more after the original trauma, people with PTSD remain hyperalert and easily startled. They suffer recurring nightmares and an inability to recall the experience with-out physically reliving it. Any passing reminder–a sound, a smell, a song–can trigger intense distress. Dr. Arthur Rousseau, a psychiatrist in Oklahoma City, recalls the case of an armored-car guard who was standing in an elevator when gunmen sprayed it with bullets, hitting him three times and killing the two people flanking him. The bullet wounds healed, but the guard developed an uncontrollable fear of elevators. He knew they weren’t dangerous, yet he couldn’t ride one without panicking.
These reactions are normal in the aftermath of a disaster, but when they persist, they can cause a cascade of other problems. To escape a terrifying memory, people with PTSD typically avoid activities that trigger it, and that response can turn them into prisoners. One of Rousseau’s patients–a rescue worker who pulled a dead baby from the wreckage of the 1995 Oklahoma City bombing–withdrew from his family during the months afterward. He was contemplating divorce when Rousseau met him. During therapy it emerged that the sight of his young daughter triggered memories of the corpse. By recognizing the pattern he had fallen into, the man was able to work consciously on breaking it.
PTSD is hard to predict, for people vary widely in resiliency. Most of those now pulling body parts from the Trade Center will quickly rebound–while some who watched the collapse from Greenwich Village rooftops will suffer for years. The risk of PTSD depends partly on past experience (previous trauma makes it more likely) and a person’s psychological condition (a history of anxiety or depression raises the risk). Sex is a factor (women suffer at twice the rate of men), and so is the nature of the experience. PTSD rates hover around 5 percent among people who survive natural disasters but rise to 50 percent among rape victims and Holocaust survivors.
It’s too early to assess the psychic toll of the attacks on New York and Washington, D.C., but experience suggests it will be substantial. Dr. Carol North, a professor of psychiatry at Washington University in St. Louis, has studied more than 2,000 survivors of a dozen different disasters. Of the tragedies she has analyzed, the highest rate of PTSD was in Oklahoma City, where 34 percent of the survivors went on to develop it. “That’s not a surprise,” she says. “The larger the disaster, the more cases you expect to see.” People far beyond the East Coast may experience several weeks of insomnia, nightmares, irritability and anxiety. But as Health and Human Services Secretary Tommy Thompson observes, “The biggest impact will be on the first responders, and on the children and families that lost loved ones.”
At Manhattan’s Saint Vincent Catholic Medical Centers, counselors and psychiatrists have seen thousands of them. “Nothing can prepare you for what we’ve experienced,” says Dr. Spencer Eth, the hospital’s medical director for behavioral-health services. “It’s far more exhausting than anything else I’ve ever done.” As the closest major hospital to the blast site, Saint Vincent’s received several hundred injured victims–followed by successive waves of people desperate for information and emotional support. “There are fewer of them now,” Eth says, “but their emotions are far more intense.”
Can the fallout be contained? No one doubts that talking and sharing can help people cope with the grief of the moment. In the immediate aftermath of the Trade Center attack, Dr. Gail Saltz of the New York Psychoanalytic Institute walked into her local fire department with a cup of coffee and announced that she was available to talk. The station had just lost nine men, and the survivors were reluctant to engage with her at first. But once they got started, they had a lot to say. They described how helpless they felt, whether digging in vain for their buried brothers or trying to reassure their worried spouses. No one has proved that talking can ward off chronic distress, but common sense suggests it’s therapeutic. “I worry most about the ones who haven’t started processing the event,” says John Draper, the director of Lifenet, New York’s mental-health crisis hot line.
Images of Sept. 11 will haunt us all to one degree or another, but they can also give us new perspective. In the days since the disaster, San Francisco psychiatrist Fred Parris has seen a number of patients suddenly become more grounded. “When something like this comes along, their own problems seem less important,” Parris says. “They start to look outward instead of inward.” Could these awful attacks do the same for the whole society? New York has become a small town in recent days, and America has taken a hard look in the mirror. “The tragedy has [brought] relationships and generosity to the foreground,” says Harvard psychiatrist Michael Craig Miller. Both will be essential as we strive to put this experience behind us.
