We assembled a team of researchers who designed and conducted a telephone survey of a nationally representative sample of U.S. households three to five days after the attacks. The purpose of the survey was to determine the immediate reactions of adults to the events and their perceptions of their children's reactions. Our primary goal was to learn whether people around the country experienced symptoms of stress at rates anywhere near those of people who lived within close proximity. In addition, we hoped to learn something about how people coped with their reactions.
Most Adults and Many Children Showed Signs of Stress
Ninety percent of the adults surveyed reported experiencing, to at least some degree, one or more symptoms, and 44 percent of the adults reported a substantial level of at least one symptom of stress (see box, "Some Questions We Asked"). While those closest to the sites of attack had the most substantial stress, respondents throughout the country, from large cities to small communities, reported stress symptoms: 36 percent of respondents over 1,000 miles from the World Trade Center reported substantial stress reactions, compared with 60 percent of those within 100 miles of the site.
Studies have shown that children who were exposed solely through television to such horrifying events as the Challenger disaster, the Oklahoma City bombing, and the Gulf War experienced trauma-related stress reactions. We found that children were also profoundly affected by the events of September 11. Thirty-five percent of parents reported that their children showed one or more signs of stress, and 47 percent reported that their children were worried about their own safety or the safety of a loved one.
The Contribution of Television
Adults watched an average of eight hours of TV coverage of the attacks on September 11, with nearly a fifth of the survey respondents reporting that they watched 13 hours or more. Those who watched the most television reported the most stress.
According to parental reports, children watched an average of three hours of TV coverage about the attacks, with older children watching significantly more than younger ones. Among children whose parents did not try to limit their television viewing, watching more television was associated with having more symptoms of stress.
We cannot say whether more TV viewing precipitated higher stress levels. For some people, television may have been a source of information about the situation and what to do, and therefore may have provided a positive means of coping with stress. Others, especially children, may have reacted to the repeated viewing of terrifying images with heightened anxiety.
Other Ways of Coping
We found that people responded to the tragic events of September 11 in a variety of ways (see the figure). Most people turned to others for social support, and many turned to their religion or another source of spiritual guidance. More than 30 percent donated money or blood, about 20 percent said they began to stockpile things like food or gas, and 60 percent reported participating in group activities like memorials or vigils, which can provide a sense of community.
About 40 percent of people reported avoiding activities (like watching television) that reminded them of the events. Health professionals have tended to regard avoidance as an impediment to the emotional processing needed for recovery from trauma. However, under these unusual circumstances and in the face of continuous TV coverage, avoidance may not necessarily have been an unhealthy response.
Professional organizations like the American Academy of Pediatrics recommend that during crises, parents consider limiting their children's television viewing of the crisis and speak with them about it. Nearly all parents we surveyed spoke with their children about the attacks. More than 80 percent of parents reported talking with their children for an hour or more, and 14 percent spoke with their children for a total of more than nine hours about the attacks. About a third of parents tried to limit the amount of TV news their children watched: Parents of younger children and of children who had more stress symptoms were more likely to limit their children's TV viewing.
Studies of reactions to prior crises have shown that for most people with indirect exposure, stress reactions wane with time. However, the unprecedented nature of the events of September 11, coupled with the continued TV coverage and the ongoing threats that have followed, lead us to speculate that the psychological impact may not diminish as rapidly for some people. Reminders of the events may trigger a recurrence of stress symptoms for some. We are now performing a follow-up survey to assess how people's initial responses have changed with time and to what extent individuals' immediate responses predict later symptoms.
Because interventions are most effective when begun soon after the precipitating event, we hope to identify early signs that children--or adults--need help and ways to respond to their needs. We also hope to identify activities that proved to be positive coping responses. Providing clinicians, clergy and other spiritual leaders, employers, teachers, school counselors, and others with this kind of information should enable them to respond quickly, as soon as symptoms appear, and guide people to more positive ways of coping in the event of further disasters of this magnitude.
AU Pandya, Anand; Weiden, Peter J. TI Trauma and disaster in psychiatrically vulunerable populations. SO Journal of Psychiatric Practice (ISSN: 1527-4160), v. 7, no. 6, pp. 426-431 (November 2001).
We will share clinical observations concerning the impact of the World Trade Center disaster on psychiatric patients treated in New York City and present a selective review of the literature on this topic. This article will not cover the enormous topic of the effects of disaster or trauma on individuals without histories of psychiatric problems, nor will we cover exacerbation of PTSD in patients who already had that diagnosis prior to September 11. Rather, this article will focus on the assessment and management of specific identifiable traumatic experiences in psychiatrically vulnerable populations, including individuals with major depressive disorder, bipolar disorder, obsessive-compulsive disorder, and schizophrenia. For the most part, we will focus on single, identifiable traumatic events rather than chronic or repetitive trauma. [Text, p. 426]
Psychiatric Association, Coping with a national tragedy. SO
Psychiatric Services (ISSN: 1075-2730), v. 52, no. 11, pp. 1427 (November
The American Psychiatric Association offers suggestions for how to cope
with the tragedy of September 11, 2001. [VB]
AU Pandya, Anand; Weiden, Peter J.
AB We will share clinical observations concerning the impact of the World Trade Center disaster on psychiatric patients treated in New York City and present a selective review of the literature on this topic. This article will not cover the enormous topic of the effects of disaster or trauma on individuals without histories of psychiatric problems, nor will we cover exacerbation of PTSD in patients who already had that diagnosis prior to September 11. Rather, this article will focus on the assessment and management of specific identifiable traumatic experiences in psychiatrically vulnerable populations, including individuals with major depressive disorder, bipolar disorder, obsessive-compulsive disorder, and schizophrenia. For the most part, we will focus on single, identifiable traumatic events rather thann chronic or repetitive trauma. [Text, p. 426]
During the weeks and months following the terrorist attacks of September 11, 2001, helping those who have psychological trauma will be an ongoing challenge for primary care physicians and mental health care professionals. [Adapted from Text, p. 1823]
Foa, Edna B; Ehlers, Anke; Clark, David M; Tolin, David F; Orsillo,
The Posttraumatic Cognitions Inventory is printed on pp. 313-314.
Summerfield, Derek A.
Author clarifies his view on the diagnosis of PTSD. "PTSD checklists vastly overestimate the number of those for whom psychiatric casehood is appropriate." [NHF]
AU Shalev, Arieh Y; Peri, Tuvia; Gelpin, Euvgenia; Orr, Scott P;
Pitman, Roger K.
This study explored the physiological responses of PTSD patients to reminders of a stressful event that had preceded the onset of their illness and was not related to its cause: the SCUD missile alarms of the Gulf War. A mental-imagery technique used in previous studies of PTSD was used. Three 30-second audiotapes were presented to each subject, including (1) the Gulf War's missile alarm, (2) a radio announcement of a terrorist attack, and (3) a standardized relaxing scene. Subjects were instructed to imagine each event as vividly as possible while heart rate (HR), skin conductance (SC), and left lateral frontalis electromyogram (EMG) responses were measured. The responses of 12 outpatients with PTSD were compared with those of panic disorder patients (n = 11), survivors of traumatic events who had not developed PTSD (n = 9), and mentally healthy subjects with no lifetime history of major trauma (n = 19). Multivariate analysis of variance (MANOVA) for the 3 physiological measures showed a significant group difference during imagery of the Gulf War alarm, with PTSD subjects showing higher SC and EMG responses than the others. The differences remained significant when age, level of distress during the war, and concurrent anxiety were controlled for. There were no group differences in responses to the other stimuli. We conclude that PTSD patients may either acquire and maintain prolonged conditioned responses to various stressors during their life span or become sensitized to reminders of past traumata following the onset of their illness. Heightened conditionability may be expressed before the trauma in subjects who are liable to develop PTSD. [Author Abstract]
Southwick, Steven M; Morgan, Charles Andrew; Nicolaou, Andreas L;
Charney, Dennis S.
For an editorial introduction to this article, see: Robert E. Hales and Douglas F. Zatzick, "What is PTSD?" American Journal of Psychiatry 154(2): 143-145 (February 1997) . For comments on this article, see "Consistency of traumatic memory" (letters by Lizabeth Roemer, Brett T. Litz, and Susan M. Orsillo, and by Oliver French), American Journal of Psychiatry 154(11): 1628-1629 (November 1997) ; and "Consistency of memories among veterans of Operation Desert Storm" (letters by Lisa D. Butler and Cheryl Koopman, and by David Spiegel), American Journal of Psychiatry 155(9): 1300-1301 (September 1998) .
The nature of traumatic memories is currently the subject of intense scientific investigation. While some researchers have described traumatic memory as fixed and indelible, others have found it to be malleable and subject to substantial alteration. The current study is a prospective investigation of memory for serious combat-related traumatic events in veterans of Operation Desert Storm. METHOD: 59 National Guard reservists from 2 separate units completed a 19-item trauma questionnaire about their combat experiences 1 month and 2 years after their return from the Gulf War. Responses were compared for consistency between the 2 time points and correlated with level of symptoms of PTSD. RESULTS: There were many instances of inconsistent recall for events that were objective and highly traumatic in nature. 88 percent of subjects changed their responses on at least one of the 19 items, while 61 percent changed 2 or more items. There was a significant positive correlation between score on the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder at 2 years and the number of responses on the trauma questionnaire changed from no at 1 month to yes at 2 years.
CONCLUSIONS: These findings do not support the position that traumatic memories are fixed or indelible. Further, the data suggest that as PTSD symptoms increase, so does amplification of memory for traumatic events. This study raises questions about the accuracy of recall for traumatic events, as well as about the well-established but retrospectively determined relationship between level of exposure to trauma and degree of PTSD symptoms. [Author Abstract]
Comings, David E; Muhleman, Donn; Gysin, Reinhard.
Subjects on an addiction treatment unit who had been exposed to severe combat conditions in Vietnam were screened for PTSD. Of 24 with PTSD, 58.3 percent carried the D[subscript 2]A1 allele. Of the remaining 8 who did not meet PTSD criteria, 12.5 percent carried the D[subscript 2]A1 allele (p = 0.04). In a replication study of 13 with PTSD, 61.5 percent carried the D[subscript 2]A1 allele. Of the remaining 11 who did not meet criteria for PTSD, 0 percent carried the D[subscript 2]A1 allele (p = 0.002). For the combined group 59.5 percent of those with PTSD carried the D[subscript 2]A1 allele versus 5.3 percent of those who did not have PTSD (p = 0.0001). These results suggest that a DRD2 variant in linkage disequilibrium with the D[subscript 2]A1 allele confers an increased risk to PTSD, and the absence of the variant confers a relative resistance to PTSD. [Author Abstract] KEY WORDS: PTSD; stress; dopamine; D[subscript 2] receptor; DRD2.
Waller, Niels G; Putnam, Frank W; Carlson, Eve Bernstein.
This article examined evidence for dimensional and typological models of dissociation. The authors reviewed previous research with the Dissociative Experiences Scale (DES) and note that this scale, like other dissociation questionnaires, was developed to measure that so-called dissociative continuum. Next, recently developed taxometric methods for distinguishing typological from dimensional constructs are described and applied to DES item-response data from 228 adults with diagnosed multiple personality disorder and 228 normal controls. The taxometric findings empirically justify the distinction between 2 types of dissociative experiences. Nonpathological dissociative experiences are manifestations of a dissociative trait, whereas pathological dissociative experiences are manifestations of a latent class variable. The taxometric findings also indicate that there are 2 types of dissociators. Individuals in the pathological dissociative class (taxon) can be identified with a brief, 8-item questionnaire called the DES-T. Scores on the DES-T and DES are compared in 11 clinical and nonclinical samples [including a group of 116 subjects diagnosed with PTSD]. It is concluded that the DES-T is a sensitive measure of pathological dissociation, and the implications of these taxometric results for the identification, treatment, and understanding of multiple personality disorder and allied pathological dissociative states are discussed. [Author Abstract]
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