Charles Dimaggio, Phd, MPH, PA-C, Paula Madrid, Psyd

Chapter X

1.0 THE TERRORIST ATTACKS OF SEPTEMBER 11, 2001 IN NEW YORK CITY

Charles DiMaggio, PhD, MPH, PA-C, Paula Madrid, PsyD

1.1 The Attack

The early autumn morning of September 11, 2001 dawned cloudless and blue in New York City. It ended with images of debris-covered, panic-stricken individuals fleeing down the man-made canyons of lower Manhattan. The exact numbers differ slightly by report, but nearly 3,000 people died that morning as 2 hijacked jet liners smashed into the iconic twin towers of the World Trade Center complex, while a third dropped into the Pentagon in Washington, DC, and a fourth crashed in a rural Pennsylvania field.

Terrorists aim to affect behavioral change through fear. Echoes of the fear planted five years ago in New York City continue to reverberate. A tourist’s photographic flash bulb near a bridge (in this city of gracefully soaring bridges) may result in a police response; a forgotten handbag on the subway will prompt worried glances. The challenge to researchers and mental health professionals, then as now, is to determine where normal adaptive behavior ends and unreasonable responses and pathology begin.

The traumas of that day, and of those following now seem hazy but were startlingly clear at the time. One of the world’s greatest transportation systems came to a sudden, jarring halt forcing a mass migration of all ages across bridges under the perceived threat of renewed attacks. Communication became near impossible as millions attempted to reach out to loved ones. A fog of rumor and fear settled on the city and surrounding area.

The reality of the following weeks was no less traumatizing. Thousands of photos of the missing fluttered from fences surrounding hospitals and morgues. Funeral processions, particularly for firefighters and police officers, became a sadly evocative and almost daily event in some communities surrounding New York City. Internal calculations of potential death from a bridge collapse or tunnel implosion factored into commuting decisions. And through it all, the pervasive daily sensory reminders of an altered visual landscape and the scent of the dying embers of the once massive buildings.

Amid the swirl of confusion and shock, mental health experts began to ask questions. Did the attacks have unique and quantifiable mental and behavioral health consequences? What were those consequences and how long might they last? Who was at risk and what put them at risk? In a city this large (and with constant and reported images of terror beaming into one’s home), what, in fact, constituted exposure to the attacks? Were the effects limited to New York City and could one’s community be expected to modify those effects? What services were needed and how could they best be delivered to a wounded city?

Some of the questions have yet to be answered. In this chapter, we hope to ‘tell the story’ of the terrorist attacks of September 11, 2001 in New York City by allowing the accumulated efforts of some of the many clinicians, researchers and mental health professionals who responded in the weeks and months following the attacks, to speak. We also hope to touch on some of the unique research and practical issues they confronted. Through this process we hope to paint a portrait of how New York City’s mental health community responded to the attacks. And, seven years later, what lessons we’ve learned.

1.2 The Immediate Aftermath

Up until the time of the terrorist attacks of September 11, 2001, with the notable exception of the Oklahoma City bombings, research into terrorism was notably scant. This was due in part to the fact that most terrorist incidents occurred in health-resources poor regions of the world. (Figure 1) Fueled by the resources of a rich nation confronted with the greatest loss of life on its own soil since its Civil War of the 19th century, an effort was undertaken to understand and mitigate the consequences of the event. The effort drew on the existing expertise of disaster preparedness professionals, mental health practitioners, epidemiologists, scientists and well-intentioned volunteers. Owing to the independent nature of these efforts and the varied backgrounds of the researchers, the work itself varied from methodologically world class to scientifically suspect, and the results have been somewhat scattershot in nature. But if we concentrate on the more reliable and valid research, the different pieces begin to fit together and the outlines of a picture soon emerged.

Figure 1: Relative proportion of persons affected by trauma of September 11th, 2001, New York City World Trade Center terrorist attacks.(DiMaggio and Galea 2006)

Fears of the potential for a massive mental health crisis in the immediate aftermath of the terrorist attacks of September 11, 2001 were grounded in part on evidence from the recent bombing of the Murrah Federal Building in Oklahoma City which indicated that over a third of those directly exposed had symptoms consistent with post-traumatic stress disorder (PTSD) 6 months after the event. (North 1999) There was concern that the effects of the World Trade Center attack might extend beyond those traditionally defined as exposed (survivors, rescuers, family members) into the densely populated tri-state region of approximately 15 million residents.

The New York State Office of Mental Health estimated that 3 million people in New York City and the surrounding region could experience substantial emotional distress. (Felton, Donahue et al. 2006) It was estimated that 422,000 individuals could meet the criteria for PTSD and that 129,000 would seek treatment. (Herman, Felton et al. 2002) In fact, 7.6% of New York City’s 8 million residents reported using mental health services in the 30-day period 5 months after September 11th.(Boscarino, Galea et al. 2004) A year later, New York City residents continued to be ‘very concerned’ about future terrorist attacks.(Boscarino, Figley et al. 2003)

For the general population, the direct measurable impacts of the disaster came in many forms including loss of home, employment, and schooling. More than 50,000 people lived in Lower Manhattan and over 30,000 residents were temporarily displaced because of the event (Crow, 2001). It should now come as no surprise that a number of efforts were immediately undertaken to determine the effect and extent of potential mental and behavioral health effects.

1.3 Early Patterns

In the first weeks following the September 11, 2001 terrorist attacks, 1 in 10 New York area residents met the criteria for PTSD. (Marshall and Galea 2004) Additional studies indicated 7.5 % of all Manhattan residents had symptoms consistent with PTSD in the first month after the terrorist attacks.(Galea, Ahern et al. 2002), and that 20% of residents living in close proximity to the events, met the criteria for PTSD during the same time period.(Galea, Resnick et al. 2002) Other studies reported that the prevalence of anxiety-related diagnoses in the population of New York City’s Chinatown which is located in the immediate vicinity of the World Trade Center (WTC),(Chen, Chung et al. 2003) may have been as high as 50%. It was estimated that New York City residents who lived closest to the World Trade Center site had a 3 times greater risk of developing PTSD. (Galea, Resnick et al. 2002) than those who did not.

There were notable efforts to further quantify the prevalence of post-traumatic stress in the general population and identify those most at risk so as to guide interventions.(Ahern, Galea et al. 2002; Boscarino, Galea et al. 2002; Galea, Ahern et al. 2002; Vlahov, Galea et al. 2002) The researchers initially sought to establish a cohort that could be followed over time to better elucidate the time course of PTSD, but, in an example of the particular difficulties attendant on post-disaster research, could not establish institutional review board approval for such a cohort in a timely fashion. They eventually settled on a series of prevalence studies conducted via random digit dial.

A number of results arose from this series of studies. The overall prevalence of PTSD in NYC in the immediate aftermath of the attack was about 6%, dropping to 1% six months later. The risk of developing PTSD following the terrorist attacks were twice as great among Hispanics, and unmarried or divorced individuals, and was directly correlated with social status as measured through yearly income. Experiencing previous traumatic events increased the risk of PTSD as high at 6 times. Controlling for these and other covariates, the researchers ascribed a risk of over 3 times for those directly exposed to the attacks compared to those unexposed.

Surprisingly there were conflicting data on the importance of proximity to the events in the subsequent development of PTSD. Residents of areas outside of Manhattan (notably Brooklyn, Staten Island and the Bronx) were at high risk of PTSD. Various factors could account for this and point up some of the issues attendant in defining spatial ‘exposure’ in the setting of terrorism. Many residents of Brooklyn commute to lower Manhattan, many firefighters and police officers live on Staten Island, the Bronx has a large population of Hispanics. These factors all act as potential confounders of the effect of residence.

This series of studies, also called into question the very definition of PTSD, which requires direct ‘exposure’ to a trauma. What, in the context of this event, constituted such exposure? Does, perhaps, watching horrific televised images of individuals hurling themselves to their deaths from a high-rise building meet the criteria? (Ahern, Galea et al. 2002)

1.4 Trajectories and Long-term Effects

It has been noted, that “…many health effects of a disaster do not occur immediately, but may be increased months or years afterwards.”(Noji and Sivertson 1987) Researchers sought to document the behavioral and mental health effects of the terrorist attacks on a nationally representative sample of US residents and found evidence of persistently elevated prevalence of psychological distress many months after and at long distances from the events of September 11, 2001. (Silver, Holman et al. 2002) By casting a broad net, identifying a large enough group early after the event, and following them over an adequate amount of time, the researchers hoped to more firmly establish the causal role of such variables as pre-existing traumas, the social environment, and coping mechanisms on mental and behavioral health outcomes associated with the terrorist attacks of September 11, 2001.Early results indicated substantial variability in responses.

The researchers conducted a web-based survey of a nationally-representative sample of individuals 1, 3, 6, 12, 18, 24 and 36 months after the attacks. Nationally, high levels of stress symptoms were present in 11.7% of Americans 1 month after the attack. (Silver, Holman et al. 2002) The progression of PTSD symptoms nationwide was particularly instructive. Such symptoms were reported by 17% of respondents 3 months after the attacks, 5.2% of respondents 6 months after the attacks, and approximately 4% of respondents thereafter. Those who reported direct exposure to the attacks, and those who reported exposure to stressful life events following the attacks were at highest risk.(Silver, Holman et al. 2006)

Among the results long-term studies of the attack on New York City, were reiterations that most people cope quite effectively with the traumas that frequently arise in their lives (Neria, Solomon et al. 2000; Bonanno, Papa et al. 2004) and in fact convert them to positive experiences (Dohrenwend, Neria et al. 2004). For some though, trauma, such as that experienced in New York City in September 2001, resulted in long-lasting and debilitating conditions such as Post-Traumatic Stress Disorder, depression, anxiety and panic attacks and substance abuse. The risk of developing these serious conditions is tied to the type, severity and duration of exposure to the precipitating event, previous history of psychiatric disorders, age, gender, and socioeconomic status.(Norris, Friedman et al. 2002; Norris, Friedman et al. 2002)

1.3 Special Populations

1.3.1 Effects on Children

“The special needs of children have only recently begun to be considered and understood in disaster planning and terrorism preparedness.”(Markenson and Reynolds 2006) Children are uniquely sensitive to their environments. Adverse childhood experiences have been linked to a nearly three-fold increased risk of depressive illness in adulthood.(Chapman, Whitfield et al. 2004) Childhood exposure to family dysfunction, such as witnessing maternal violence, has a dose-response relationship to adverse mental health outcomes.(Edwards, Holden et al. 2003) and natural disasters have long been recognized to have an effect on children. Fifty-one percent of children exposed to Hurricane Andrew were reported to have a new onset behavioral disorder; 33% had PTDS, a majority of whom remained impaired half a year after the event.(Norris, Friedman et al. 2002)

In the aftermath of the attacks of September 11, 2001 in New York City the impact on the children of New York City became a pressing issue. While research into the mental health effects of terrorism was at an early stage prior to 9/11, research into its effects on children were even more scant, although there was early evidence that its role could be signficant. Following a 1987 school shooting, for example, 60.4% of exposed children experienced PTSD symptoms.(Pynoos, Nader et al. 1987) Following the terrorist bombing of the Murrah Building in Oklahoma City, nearly half of exposed children had PTSD reactions. (Pfefferbaum, Moore et al. 1999) Indirect exposures such as viewing media images(Pfefferbaum, Nixon et al. 1999) , knowing someone who was affected (Pfefferbaum, Gurwitch et al. 2000) , or hearing about traumatic events such as school shootings (Brener, Simon et al. 2002), have been demonstrated to influence children’s post-traumatic reactions.

Parental response and developmental competency have been cited as key mediators of behavioral vulnerabilities.(Hagan 2005) In a study of 7,000 children 7 weeks after the bombing in Oklahoma City, interpersonal and TV exposure accounted for 12% of the variance associated with the diagnosis of PTSD. The authors concluded that a child’s subjective response to trauma is a key predictor of PTSD, and should be included in the diagnostic criteria for PTSD in children.(Pfefferbaum, Doughty et al. 2002) Another study of 69 6th graders geographically distant from Oklahoma City concluded that “children geographically distant from disaster who have not directly experienced an interpersonal loss report PTSD symptoms and functional impairment associated with increased media exposure and indirect loss.” (Pfefferbaum, Seale et al. 2000)

With this as a backdrop, the effect of the terrorist attacks on the 1.2 million students of New York City’s public school system came to the fore. Students in schools close to the WTC site were evacuated under hazardous conditions, and were caught up in the general transportation shut-down of the day. To help define and address the potential mental health effects of the event on the city’s children, a large multi-disciplinary, multi-institutional group of practitioners and scientists, conducted a city-wide assessment of the mental health consequences of the attacks on New York City’s public school population.(Hoven, Duarte et al. 2003; Hoven, Mandell et al. 2003; Hoven, Duarte et al. 2005).

Using an 8,236 member probability sample of New York City school children in grades 4 to 12, created 6 months after the event, the investigators sought to determine how many children in New York City had a ‘probable psychiatric reaction’ to the terrorist attacks. Exposures were determined to be either direct (such as witnessing the attacks) or indirect (such as having a family member who was a first responder to the attacks). Rates of PTSD, depression, anxiety, agoraphobia, conduct disorder and alcohol use were all elevated compared to previous community assessments.(Hoven, Duarte et al. 2005). Many of the findings from Oklahoma City were echoed.

Results indicated that children nowhere near Ground Zero that day had the same rates of disorder as those that witnessed the attacks first hand. The investigators expected that on average three to five percent of children could be expected to suffer from mental health complaints, but the study found levels of symptomatology at about 15 percent. The study found that all eight of the disorders screened were at elevated levels from what could be expected in the normal population and noted that younger children appeared to be more vulnerable overall. (Hoven, 2002). There was a 46% increase in the diagnosis of PTSD in children in New York City in the months following September 11th, 2001, compared to the previous months. (Hoven, Duarte et al. 2003) The comparable increase for adults was 12%.(Hoge, Pavlin et al. 2002) Among the most common mental health disorders in New York City children following the terrorist attacks of September 11th, 2001, were agoraphobia (14.8%) and separation anxiety (12.3%).(Hoven, Duarte et al. 2005) Exposure also came in the form of interpersonal relationships. New York City school children who had an emergency medical technician as a member of their family had a PTSD prevalence of 18.9% 6 months following the World Trade Center attacks.(Duarte, Hoven et al. 2006)

1.3.2 Low SES and Minority Populations

Prior to the attacks, thousands of New Yorkers were already struggling with unmet psychological issues. For the many New York City communities already burdened with community violence, domestic abuse, poverty and homelessness, the attacks of September 11, 2001 resulted in life-changing stress and trauma. New York City residents of lower socioeconomic status were two and half times more likely to develop PTSD than were those in the norm (Galea, Resnick et al. 2002), and reports of increased alcohol and tobacco use were particularly widespread among drug users (Factor, Wu et al. 2002).

As noted earlier, the impact of the terrorist attacks reached far beyond those in close physical proximity of the World Trade Center. As such, researchers set out to increase their understanding of the traumatic impact of 9/11 on inner city high school students living twenty miles north of Ground Zero, focusing on the presence and prevalence of PTSD eight months after the terrorist attacks of September 11, 2001.(Calderoni, Alderman et al. 2006) While prior studies demonstrated that the majority of adolescents exposed to the trauma of that day did not display symptoms that would lead to a diagnosis of PTSD, these results suggested that some adolescents were in fact suffering from PTSD because of this event.