Stress and Anxiety After 9/11: A Prospective Study

The terrorist attacks against the United States on September 11, 2001, shocked our nation and had a reverberating effect on people worldwide. Media coverage was immediate, intense, and vivid: televised images showed the World Trade Center towers collapsing.1,2,3 Millions of people witnessed the catastrophe through the media.4

Persons need not be physically present at the site of a disaster to suffer stress reactions. In fact, the criteria for the diagnosis of Post-Traumatic Stress Disorder (PTSD), as defined by the American Psychiatric Association, include indirect exposure to traumatic events.5 Even individuals who are far from the impact site can experience lasting traumatic stress, associated with large-scale disasters. Media exposure to the event, its aftermath and personal secondary exposure (i.e. having a friend or relative directly involved in the disaster), are significant predictors of PTSD symptomatology. For example, school children living 100 miles from Oklahoma City at the time of the 1995 bombing of the Alfred P. Murrah Federal Building, showed symptoms of PTSD and associated dysfunction up to two years after the event.6

Large-scale terrorist events can induce traumatic stress in the surrounding population.6,7,8 Based on studies of the Oklahoma City bombing, which prior to 9/11 had been the largest terrorist attack in the United States, Yehuda (Yehuda, 2002) estimates that up to 35% of individuals exposed to the September 11th terrorist attacks may be at risk for developing PTSD. Indeed, a telephone survey of 560 adults across the United States conducted three to five days after the September 11th attacks, showed that 44% of individuals reported one or more substantial symptoms of post-traumatic stress disorder.4

Typical symptoms of trauma-related psychological disturbance include depression, anxiety, impaired concentration, sleep disturbances and somatic symptoms (headache, chest pain, dyspnea, palpitations, dizziness, skin irritation, insomnia, hypo- and hyperphagia).5,9 Traumatic stress is also associated with increased participation in behaviors harmful to health such as alcohol use, poor diet, reduced exercise, and increased smoking or relapse to smoking among those who have recently quit.10,11

Our ability to predict who will be most affected by traumatic events is limited, because traumatic events are unpredictable and provide few opportunities for controlled research designs.12 Studies of the effects of trauma typically employ only post-hoc designs that rely upon historical information, or retrospective recall to determine the pre-exposure status of individuals.4,9,12 Rarely do we have access to reliable pre-event data which can be paired with post-event assessments of the same subjects.8

Following September 11th, we had the opportunity to re-assess men and women enrolled in a smoking-cessation treatment study. They had completed psychological and behavioral assessments six weeks prior to September 11th.

METHODS

The 80 men and women who were enrolled in either of two on-going studies of smoking cessation had completed assessments six weeks prior to September 11th. These subjects were mailed an additional assessment packet six weeks after September 11th. Two supplemental open-ended questions asked subjects whether they had been "personally affected by the terrorist attacks in New York City, Washington and Pennsylvania on September 11th" and if so, to describe how they had been affected.

RESULTS

Ninety-four percent (n=75) of subjects returned completed (post) surveys. Fifty-six percent (N= 42) were women. Total medical visits increased from 1.86 (SD= 1.4) per month in the pre-Sept 11th period to 2.53(SD=2.0) visits per month post-Sept 11th (t[74] =2.46, p=0.017). Total somatic and cognitive symptoms increased significantly between the pre and post assessments (t[74]=2.84, p

Forty percent of our subjects (n=33) responded to the open-ended survey questions. Of these, 61% (n=20) replied "yes" to the question of whether they had been personally affected by the attacks. Of those, 65% elaborated on their connections; i.e., they knew someone killed in the attacks, knew or were related to survivors, or knew someone working as a volunteer at the WTC disaster site.

DISCUSSION

A cardinal feature of traumatic events is their ability to provoke fear, helplessness or horror in response to the threat of injury or death. Individuals exposed to traumatic events either directly (e.g., being physically present at the event) or indirectly (e.g., witnessing events on television) are at increased risk for PTSD, depression, anxiety disorders and increases in both somatic symptoms and physical illness.13 These effects lead to palliative attempts at coping, including healthful choices such as seeking medical treatment and less healthful options including substance use.

Among participants in our study, medical utilization, including physician visits and emergency room utilization, increased dramatically during the weeks following September 11th. Physician visits increased 30% from pre-September 11th levels and emergency room visits more than doubled. Overall, medical utilization increased 36%. Somatic and psychological symptoms also showed notable increases between pre and post assessments for the overall sample. The largest changes were in reports of sleep disturbance. In the post-September 11th period, participants reported considerable increases in symptoms of hyper-arousal including difficulty falling asleep, difficulty staying asleep and experiencing vivid or disturbing dreams. Surprisingly, stress, anxiety and depression levels did not show a similar overall increase among these participants.

Millions of people either directly or through televised images witnessed the horrifying events of September 11. For these people, the attack may have had a major psychological impact.

REFERENCES

1. Katutani M. Critic's notebook: Rituals for grieving extend past tradition into public displays. New York Times, September 18, 2001.

2. Barringer F & Fabrikant G. As an attack unfolds, a struggle to provide vivid images to homes. New York Times, September 12, 2001.

3. Shales T. On television, the unimaginable story unfolds. The Washington Post, September 12, 2001.

4. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001 terrorist attacks. NEJM 2001;345:1507-12.

5. American Psychiattic Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision, 1994. Washington, D.C.: American Psychiatric Association.

6. Pfefferbaum B, Seale TW, McDonald NB, et al. Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry 2000;63:358-70.

7. Dixon P, Rehling G, Sciwach R. Peripheral victims of the herald of Free Enterprise disaster. Brit Jf Med Psychol 1993; 66:193-202.

8. Nolen-Hoeksema S, Morrow J. A prospective study of depression and post-traumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. J Personality Social Psychol 1991;61:115-21.

9. Shairat S, Mallonee S, Kruger E, et al. A prospective study of long-term health outcomes among Oklahoma City bombing survivors. Jf Oklahoma State Med Assoc 1999; 92:178-86.

10. Posner I, Leitner LA, Lester D. Diet, cigarette smoking, stressful life events and subjective feelings of stress. Psychol Rep 1994;74(3 Pt 1):841-2.

11. Shiffman S, Hickcox M, Paty JA, et al. Progression from a smoking lapse to relapse: prediction from abstinence violation effects, nicotine dependence, and lapse characteristics. J Consult Clin Psychol 1996;64:993-1002.

12. Tucker P, Dickson W, Pfefferbaum B, et al. Traumatic reactions as predictors of posttraumatic stress six months after the Oklahoma City bombing. Psychiatric Services 1997;48:1191-4.

13. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-60.

Beth C. Bock, PhD, Bruce Becher, MD, MPH, Robert Partridge, MD, MPH, Raymond S. Niaura, PhD, and David B. Abrams, PhD

Beth C. Bock, PhD, is Assistant Professor of Psychiatry and Human Behavior, Centers for Behavioral & Preventive Medicine, Brown Medical School & The Miriam Hospital.

Bruce Becker, MD, MPH, is Associate Professor, Community Health, Brown Medical School, and Attending Physician, Department of Emergency Medicine, Rhode Island Hospital

Robert Partridge MD, MPH, is Assistant Professor of Medicine, Brown Medical School, Department of Emergency Medicine, Rhode Island Hospital.

Raymond S. Niaura, PhD, is Professor of Psychiatry and Human Behavior, Centers for Behavioral & Preventive Medicine, Brown Medical School & The Miriam Hospital.

David B. Abrams, PhD, is Professor of Psychiatry and Human Behavior, Centers for Behavioral & Preventive Medicine, Brown, Medical School & The Miriam Hospital.

CORRESPONDENCE:

Beth C. Bock, PhD

Centers for Behavioral & Preventive Medicine

Coro West, Suite 5000

One Hoppin Street

Providence, RI 02903

Phone: (401) 93-3812

Fax: (401) 793-8078

Email: Beth_Bock@Brown.edu

Copyright Rhode Island Medical Society Nov 2003
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