National Survey of Stress Reactions After the 9- 11-02 Terrorist Attacks

Trauma and Disaster in Psychiatrically Vulunerable Populations

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September Attacks Spark Stress Reactions

The vast majority of Americans, even those geographically removed from the events, had increases in stress-related symptoms immediately after the September 11 attacks, report researchers in the November 15, 2001 issue of The New England Journal of Medicine.

Researchers at the nonprofit RAND group used random-digit dialing three to five days after September 11th attacks to interviewed a nationally representative sample of 560 U.S. adults about their reactions to the terrorist attacks and their perceptions of their children's reactions.  

Researchers asked the respondents about symptoms including "feeling very upset," disturbing thoughts or memories, difficulty concentrating, difficulty sleeping, and feeling irritable or having angry outbursts. Stress was deemed "substantial" if participants answered "quite a bit" or "extremely" on a five-point scale of symptom intensity.  The survey findings showed that

    90% of adults had at least one stress-related symptom to some degree

    people throughout the country had similar reactions

    35% of children had one or more stress symptoms, and

    47% of children were worried about their own or their loved ones' safety.

    84 percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 

    34 percent restricted their children's television viewing. 

    35 percent of children had one or more stress symptoms, and 

    47 percent of children were worried about their own safety or the safety of loved ones. 

The study also examined how Americans were coping with these stress reactions. The most frequent coping mechanisms included

   

    turning to religion (90%)

    group activities (60%), and

    making donations (36%).

In summary, the study showed that the vast majority of Americans suffered increased stress-related symptoms after the catastrophic events, and that significant stress reactions may occur even in persons geographically removed from the events.

Reference

A Report From RAND Health

After 9/11: Stress and Coping
Across America

<Read It On The RAND Website>

As survivors of natural disasters, violent crimes, and war attest, people who are victims or witnesses of a traumatic event often experience symptoms of stress, sometimes for years after. But events in recent years have taught us that individuals need not be present at a catastrophic event to experience stress symptoms.

The terrorist attacks that shook the United States on September 11, 2001 were immediately broadcast on TV screens across the nation. Remarkable video footage that showed the events and their aftermath in graphic detail was repeatedly aired after the attacks. Many Americans may have identified with the victims or perceived the unprecedented attacks as directed at themselves as well. Thus, even people who were nowhere near the locations of the attacks might have experienced substantial stress responses.

Most Adults and Many Children Showed Signs of Stress

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

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

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.

What Next?

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.

Trauma and Disaster in Psychiatrically Vulunerable Populations

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).

The American Psychiatric Association offers suggestions for how to cope with the tragedy of September 11, 2001. [VB]

AU Stephenson, Joan.
TI Medical, mental health communities mobilize to cope with terror's psychological aftermath.
SO Journal of the American Medical Association (ISSN: 0098-7484), v. 286, no. 15, pp. 1823-1825 (October 17, 2001).
AB 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]

AU Hales, Robert E; Brady, Kathleen T; Mellman, Thomas A.
TI Current treatment strategies for posttraumatic stress disorder.
SO Primary Psychiatry (ISSN: 1082-6319), v. 6 (Supplement 11), no. 9, pp. 81-88 (September 1999).
NT Moderator: Hales; discussants: Brady and Mellman.
AB A brief teaching monograph intended to acquaint psychiatrists and primary care physicians with PTSD and its treatment. [FAL]

AU Foa, Edna B; Ehlers, Anke; Clark, David M; Tolin, David F; Orsillo, Susan Marie.
TI The Posttraumatic Cognitions Inventory (PTCI): development and validation.
SO Psychological Assessment (ISSN: 1040-3590), v. 11, no. 3, pp. 303-314 (September 1999).
NT The Posttraumatic Cognitions Inventory is printed on pp. 313-314.
AB This article describes the development and validation of a new measure of trauma-related thoughts and beliefs, the Posttraumatic Cognitions Inventory (PTCI), whose items were derived from clinical observations and current theories of post-trauma psychopathology. The PTCI was administered to 601 volunteers, 392 of whom had experienced a traumatic event and 170 of whom had moderate to severe PTSD. Principal-components analysis yielded 3 factors: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame. The 3 factors showed excellent internal consistency and good test-retest reliability; correlated moderately to strongly with measures of PTSD severity, depression, and general anxiety; and discriminated well between traumatized individuals with and without PTSD. The PTCI compared favorably with other measures of trauma-related cognitions, especially in its superior ability to discriminate between traumatized individuals with and without PTSD. [Author Abstract]

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).

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]

Stephenson, Joan.
Medical, mental health communities mobilize to cope with terror's psychological aftermath.
Journal of the American Medical Association (ISSN: 0098-7484), v. 286, no. 15, pp. 1823-1825 (October 17, 2001).

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, Susan Marie.
The Posttraumatic Cognitions Inventory (PTCI): development and validation.
SO Psychological Assessment (ISSN: 1040-3590), v. 11, no. 3, pp. 303-314 (September 1999).

The Posttraumatic Cognitions Inventory is printed on pp. 313-314.
AB This article describes the development and validation of a new measure of trauma-related thoughts and beliefs, the Posttraumatic Cognitions Inventory (PTCI), whose items were derived from clinical observations and current theories of post-trauma psychopathology. The PTCI was administered to 601 volunteers, 392 of whom had experienced a traumatic event and 170 of whom had moderate to severe PTSD. Principal-components analysis yielded 3 factors: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame. The 3 factors showed excellent internal consistency and good test-retest reliability; correlated moderately to strongly with measures of PTSD severity, depression, and general anxiety; and discriminated well between traumatized individuals with and without PTSD. The PTCI compared favorably with other measures of trauma-related cognitions, especially in its superior ability to discriminate between traumatized individuals with and without PTSD. [Author Abstract]

Summerfield, Derek A.
Trauma, post-traumatic stress disorder, and war.
Lancet (ISSN: 0023-7507), v. 352, no. 9131, pp. 911 (September 12, 1998).
NT A reply to: Joe Herbert, "Trauma, post-traumatic stress disorder, and war," Lancet 352: 152 (July 11, 1998) [20297].

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.
TI Psychophysiologic assessment of mental imagery of stressful events in Israeli civilian posttraumatic stress disorder patients.
SO Comprehensive Psychiatry (ISSN: 0010-440X), v. 38, no. 5, pp. 269-273 (September-October 1997).

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.
Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm.
SO American Journal of Psychiatry (ISSN: 0002-953X), v. 154, no. 2, pp. 173-177 (February 1997).

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) [08331]. 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) [20337]; 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) [20477].

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.
Dopamine D[subscript 2] receptor (DRD2) gene and susceptibility to posttraumatic stress disorder: a study and replication.
Biological Psychiatry (ISSN: 0006-3223), v. 40, no. 5, pp. 368-372 (September 1, 1996).

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.
 Types of dissociation and dissociative types: a taxometric analysis of dissociative experiences.
Psychological Methods (ISSN: 1082-989X), v. 1, no. 3, pp. 300-321 (September 1996).

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]