After Sept. 11, Psychic Wounds Slow to Heal
By Shankar Vedantam
Washington Post Staff Writer
Sunday, March 17, 2002; Page A03
In Arlington, firefighter Bob Gray has the same terrifying dream every
few nights. It's Sept. 11, and he finds himself back at the Pentagon,
stunned at the inferno of destruction before him and dwarfed by the scale
of the damage.
In New York, a 16-year-old Stuyvesant High School senior who saw one of
the nearby World Trade Center towers collapse is convinced that a bomb is
about to go off every time his subway train pauses. He's failing in four
classes, which now seem utterly unimportant.
While the fear and anxiety that swept the country after the Sept. 11
attacks have subsided for most Americans, hundreds of thousands continue
to suffer psychic wounds from that horrific day, according to national
mental health experts.
"The majority of people have recovered from the disaster, but there are
those who haven't recovered, and there are those who have gotten worse,"
said Spencer Eth, the top psychiatrist at the St. Vincent Catholic Medical
Centers in New York, which has fielded more than 17,000 calls for
It is far from clear how many people have psychological problems
because of Sept. 11 or how serious those lingering problems are. But there
are hints: Two to three months after the attacks, surveys found that
nearly half of the residents of Lower Manhattan and as many as one in four
Americans nationwide had difficulty sleeping, suffered flashbacks and were
easily startled -- symptoms usually found among patients with
post-traumatic stress disorder (PTSD).
Eth, whose hospital is the closest to ground zero, estimates that
100,000 people in New York alone need treatment for PTSD and another
100,000 for depression.
"There is a tendency for other people to think we've had a few months,
now it's over," said Dodie Gill, director of Arlington's Employee
Assistance Program, in a recent interview. "It isn't over -- not for
people who were involved."
PTSD is usually thought to afflict people who personally experience
life-threatening danger. But because of the unprecedented scale of the
Sept. 11 attacks, experts find themselves in uncharted waters. What
psychological scars, for example, were suffered by Americans who watched
horrific images over and over on TV, and felt personally attacked?
Doctors are finding that a variety of factors -- including an
individual's proximity to the disaster, vulnerability to emotional
assault, social and family supports, and advanced training in dealing with
catastrophes -- influence whether he or she experiences mild or severe
reactions to a disaster like Sept. 11.
Some who escaped the towers may also have escaped with relatively
little emotional damage, while others may have been devastated. Some who
witnessed the collapses close-up may have recovered fairly quickly while
others, such as the Stuyvesant senior, may get diagnosed with severe
problems such as PTSD, depression or substance abuse, and may need
Others may have persistent and sometimes disabling anxiety, stress and
worry simply as a result of sitting petrified before a television set for
days after the disaster. These symptoms can slowly get resolved over time
or with help.
In the first months after the disaster, the Stuyvesant senior, who did
not want to be identified, asked his parents if he could sleep on the
floor of their bedroom. But when he lay down to sleep, he was restless.
And when he fell asleep, he would awake in terror, screaming.
His parents were alarmed and told him not to be "stupid," his therapist
said. But the fears did not go away. His anxieties increased. He started
missing school because he was afraid the building would be attacked. His
guidance counselor finally suggested that he seek help.
When he came in to see Yun Pang, a therapist at the Jewish Board of
Family and Children's Services, he denied that the Sept. 11 attacks had
caused any of his changes. Instead, he blamed a brief switch in schools
for his troubles.
"The kids are using every kind of avoidance strategy not to think about
it," said Robert Abramovitz, chief psychiatrist at the Jewish Board. "But
not thinking about one thing as big as that creeps into everything else.
You start shutting down and lose touch with your feelings."
Getting people in touch with their feelings was the focus of a massive
outreach effort after Sept 11. Gray and his fellow Arlington firefighters
were assigned a "stress management team" that debriefed them regularly.
Gray now sounds like a counselor himself and refers to the extent of his
In a February interview, he said that "anxiety, adrenaline, decreased
sleep, bad dreams" were to be expected, and the norm for all but the very
Gray and other firefighters still find themselves easily roused to
irritation and anger, or impatience with their families. Counselors are
reminding them that mass disasters are known to sharply drive up marital
problems and the divorce rate among rescuers, and to cause some to abuse
alcohol and drugs.
The rate of PTSD among survivors and rescuers at the Oklahoma City
bombing -- the only modern American event remotely comparable to Sept. 11
-- was 34 percent, according to Carol North, a professor of psychiatry at
Washington University School of Medicine in St. Louis, and the divorce
rate among the firefighters' families rose 300 percent.
Pentagon staffers reported grief, anger, disbelief and disturbed sleep
in the weeks after the Sept. 11 disaster, said Lt. Col. Elspeth Ritchie, a
psychiatrist for the Defense Department. While the immediate trauma has
tapered off, the fear easily comes flooding back.
"The people in the Pentagon were moved to one of the adjacent
buildings," said Ritchie. "There were some safes being moved. Some people
came in [asking for psychiatric help] when they heard the safe move -- it
sounded like a bomb and brought back a lot of the symptoms."
Catastrophes such as Sept. 11 reveal a paradox: Even as large numbers
of people who experience disasters initially report psychological
distress, most recover and heal, although that process can last from a few
weeks to several months. Simultaneously, a subgroup gets worse. Scientists
cannot predict which cases will heal and which will deteriorate into
Cases such as the Stuyvesant senior's and Gray's -- along with the
staggering numbers reported in the surveys -- also illustrate the
difficulty in distinguishing psychiatric disorder from normal anguish and
"This could be a normal response to an abnormal trauma," said Roxane
Cohen Silver, a psychologist at the University of California at Irvine. "I
don't believe we are seeing high rates of psychopathology."
A month after the disaster, for example, there were probably thousands
of normal people who had intrusive recollections of the attacks, felt numb
and had trouble falling asleep, which are among the symptoms of PTSD.
"To couch this in terms of PTSD yes/no is an oversimplification,"
agreed psychiatrist Matthew J. Friedman, executive director of the
Department of Veterans Affairs' National Center for PTSD. "Normal human
response to a catastrophic event -- particularly mass terrorism -- is to
be distressed. It becomes pathological when the symptoms persist and
interfere with lives and family function."
Another expert who helped write the official definition of the disease
said the disorder is a constellation of long-term symptoms that spell
trouble. But some of those symptoms can overlap with "normal" ways that
"We did not really talk about the recovery process in diagnosis, and
that's what's missing," said Terry Keane, professor and vice chairman of
research at the Boston University School of Medicine. "What does the
normal process of recovery look like? We don't know."
Most mental health programs launched after Sept. 11 avoided the debate
of whether people's symptoms are a sign of psychiatric illness. They have
simply reached out to everyone.
Counselors such as Arlington's Gill discovered that even those who
rallied after the disaster -- heroically coming forward with blood
donations, philanthropy and a shared sense of community -- have found it
difficult to return to their lives.
Much of the effort in New York and Washington has focused on
re-engaging people and reconnecting them with what's important in their
lives. Numbness after a tragedy is the most potent predictor of long-term
problems, said Fran Norris, a professor of psychology at Georgia State
University in Atlanta, who has studied disaster reactions worldwide.
Eth said medications are effective against PTSD; Keane said that a
technique called cognitive behavioral therapy is the "treatment of choice"
for those diagnosed with the disorder.