For New York City resident Esperanza Muñoz, the attack on the World Trade Centers is not over 10 years later — not by a long shot. At odd moments, the stench of death still rises to her nose, and the 55-year-old woman slides into a haze of nausea and tears. She suffers headaches and is awakened several times a week by nightmares of headless bodies and shoes with bits of feet left inside. She dreads the sound of sirens or a passing plane.
Muñoz lives in the New York City borough of Queens, and can't — or won't — go into Manhattan, even to attend her support group for Latinas still scarred by the events of Sept. 11, 2001. She went to a meeting a few blocks from the site of the former World Trade Center once, six or seven years ago, but she became so panicked she had to leave.
Muñoz has a classic case of post-traumatic stress disorder, or PTSD, even though she is not a classic victim of the disorder. She has not survived a violent crime, warfare or even a clear sense that her life was threatened. She watched the fiery collapse of the World Trade Center towers from the roof of her apartment building in Queens, horrified but safe.
Two days later, the office and residential cleaning company that employed Muñoz assigned her to the blocks surrounding ground zero, where she picked up office mementos, charred debris and body parts from the ground almost every day for nearly four years. By 2009, the woman who had left a peaceful life in Colombia so she could send her son to college had twice attempted suicide.
When Al Qaeda terrorists violently seized control of four U.S. jetliners and crashed them, post-traumatic stress disorder was a diagnosis that had been in psychiatry's diagnostic manual for just 11 years. Most American mental-health professionals would rarely come across the disorder. Cases typically involved isolated patients — survivors of rape, child abuse, home fires or horrific automobile crashes. If soldiers, police officers and others whose jobs revolve around mayhem complained of nightmares, flashbacks and disabling anxiety, they were more likely to be accused of malingering than they were to be ushered into therapy.
But the events of Sept. 11 set in motion dramatic changes on all those fronts. Within months, PTSD was a widely observed condition. Afflicted firefighters, police and recovery workers were hailed as haunted heroes, not slackers. And a new generation of victims — military personnel deployed to two wars sparked by the terrorist attack — would soon bring the disorder home to nearly every community in America.
The sudden abundance of sufferers from the condition, and of research on them, has prompted the nation's psychiatrists to broaden their criteria for diagnosing the disorder in ways that would make room for people like Muñoz, whose exposure to the twin towers' fall was distant and whose symptoms took time to materialize. In the process, psychiatric leaders pondered for the first time how factors such as community cohesion, poverty and media coverage can affect the public's mental health when mass disaster strikes.
"9/11 changed the picture of PTSD, and transformed it from being simply a mental disorder that psychiatrists deal with to a public health issue," says Charles Figley, a pioneer in the study of the disorder who directs Tulane University's Traumatology Institute and Psychological Stress Research Program. Researchers have come to realize how well communities recover from mass violence or disaster is a barometer of their overall mental health, he adds.
For clinicians and researchers who had labored through the 1980s to understand PTSD, those affected by the events of Sept. 11 were a grim windfall — a population large and diverse enough to reveal important truths about the disorder.
The disaster gave researchers opportunities to study how trauma scrambles the brain (in medical terms, the onset of the disease). They could measure how often it appears in a typical population exposed to trauma (the disorder's prevalence) and how long it causes disruption and disability (disease progression). For the first time, the size of the population affected by a single trauma allowed researchers to discern which attributes or experiences make some people more vulnerable to the disorder (the term they use is risk factors) and which may be a source of resilience for others (protective factors).
"Before we had the current notion of PTSD, we tended to think that those who developed it were people with character disorders — there was a sort of 'blame the victim' quality to our thinking," says Dr. David Spiegel, director of Stanford University's Center on Stress and Health. Sept. 11, he says, has challenged much of that thinking.
Researchers have followed populations of cleanup workers like Muñoz, emergency responders, family members of those who perished and Manhattan residents (including children) affected by the coordinated attacks. Experts hope that if they can find a way to predict who is at greatest risk of developing PTSD and identify ways to protect against it, they could fortify vulnerable populations to withstand future disasters.
Here's what a decade of research on those whose lives were changed on Sept. 11, 2001, has taught us about the disorder.
How common is PTSD?
In the first few months following Sept. 11, surveys revealed that more than one in 10 Manhattan residents showed symptoms suggestive of the disorder. Their sleep was fitful; they had nightmares; they were edgy, irritable and easily rattled, and were bothered by the unpredictable return of frightening memories; and they took active efforts to avoid places, people and activities that reminded them of their trauma.
Among those living within close range of the twin towers' debris cloud, one in five reported a level of stress high enough to satisfy a PTSD diagnosis.
For most people, such symptoms weakened within weeks or months, as New Yorkers regained their psychological balance. Researchers found that six months after the attacks, 2% to 5% of New York City residents still could be said to suffer from the condition, and rates remained high among those who lived or worked in Lower Manhattan at the time of the attack.
What factors make people more vulnerable to PTSD?
In at least 34 studies, researchers plumbed the distress symptoms of people directly affected by the Sept. 11 attacks, including evacuees from the World Trade Center and workers at the Pentagon.
Those studies found consistent evidence that certain demographic factors could predict higher rates of the disorder — often twice as high, said psychologist Yuval Neria, director of trauma and PTSD at the New York State Psychiatric Institute. Among the attributes that make people more vulnerable are low income, immigrant status, being female and having a history of depression or other mental illness.
Dr. Carol North, a professor of crisis psychiatry at University of Texas' Southwestern Medical Center in Dallas, says that many of those factors clearly overlap. Low income, says North, "makes everything worse," including higher rates of victimization, more chronic health problems and fewer resources — including money, education and access to medical care and social support — to escape trauma or its psychological toll.
Finally, shame, guilt and a sense of responsibility or blame can be powerful accelerators of the disorder, Spiegel says. In the face of helplessness, many victims of trauma would rather believe they could have done more to stop the crime or save the wounded, and they assume blame for events beyond their control. "That inappropriate shame or guilt is a big part of PTSD," he says.
Are there things that protect against PTSD?
An emerging line of research made possible by Sept. 11 is finding that people who weathered the tragic events in the midst of families, close friends and strong communities were much less likely to develop stress symptoms than those who said they felt lonely or lacked social networks as they dealt with the stress of the attacks. Open discussion of the events, social connectedness and mutual help act like fresh air and disinfectant — they build immunity, prevent infection and promote healing.
"One of the healing factors was the community," says Spiegel, who lived and worked in New York at the time. "People really, genuinely helped one another, and that's a key factor in healing from the bottom up."
Can you develop PTSD by watching gruesome images on TV?
In its latest rewrite of the Diagnostic and Statistical Manual of Mental Disorders, the bible of mental health, the American Psychiatric Assn. has decreed that the answer is no. People cannot get PTSD by experiencing disturbing events "through electronic media, television, movies or pictures, unless this exposure is work related."
But some researchers are not so sure. Direct exposure to trauma "is an important but not necessary condition," Neria says. For instance, people with mental illnesses or a personal history of trauma might be so vulnerable to start with that repeated exposure to horrific events through television could push them into a state of distress severe enough to be called PTSD, he says.
News coverage on Sept. 11 spread the day's violent images — and at least some of their psychological effect — well beyond the site of the former World Trade Center. A Web-based study that queried a national sample of adults one to two months after the attack found that 4.3% had stress reactions that qualified as PTSD — and rates were highest among those who had watched more than 12 hours of television coverage of the event per day or reported having seen a high number of Sept. 11-related graphic images on TV. Those who had seen very little coverage were least likely to report symptoms, according to the study, which was published in the Journal of the American Medical Assn.
Other national surveys that gauged the nation's distress after Sept. 11 found that debilitating symptoms of stress dissipated quickly in people who weren't directly affected by the events. That suggests that images alone are not enough to cause the condition, at least in most cases, the drafters of the psychiatric manual concluded.
Is PTSD real if it develops years after a traumatic event?
It certainly can be, as Esperanza Muñoz's case demonstrates. After Sept. 11, studies found that the onset of the disorder was very often delayed among firefighters and emergency responders — workers whose training allows them to suppress their initial reactions to trauma and gore. That cast new light on the cases of many veterans — including those who fought in Vietnam — who developed PTSD symptoms years after their return home.
The fact that post-Sept. 11 PTSD was more common in people who had experienced previous traumas — such as physical or sexual abuse as a child — also suggests that symptoms may not always develop immediately, experts say. The survivor of one trauma may be scarred but not broken by her first experience, but that wound may reopen in response to a fresh trauma.
Figley says that's a key lesson learned in the decade since Sept. 11: that a person's response to trauma is defined by the lifetime of experience she brought to the event.