9/11 Attacks Changed Understanding of Trauma, Elevated Disaster Psychiatry

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On the morning of September 11, 2001, psychiatrist John Markowitz, M.D., was home at his Westside Manhattan apartment near Columbus Circle, preparing to commute to work across town to New York Hospital/Cornell University Medical Center, when a friend called and told him to turn on the television.

“One plane had already hit the World Trade Center, and looking downtown, I could see a plume of black smoke rising in the distance,” he recalled. “It was clear that this was a catastrophe, so I hurried out to find that traffic had ground to a halt. I walked east to the hospital, where I found myself among scores of doctors, nurses, and other personnel waiting for patients to arrive in the emergency room. The hospital has a specialized burn unit, so we expected lots of victims.”

But after a couple of hours, Markowitz said, it dawned on everyone there that no one would be coming. “People had either escaped or died,” he said.

Anthony Ng, M.D., could see the first tower burning as he left his home in Brooklyn and headed for a train into the city. But the trains had been stopped, phone lines were down, and it was difficult to connect with anyone. “I had to wing it on my own,” he said.

He managed to get into Manhattan that night to stay with his sister. As medical director of the volunteer Disaster Psychiatry Outreach and medical director of the New York City Voluntary Organizations Active in Disaster (VOAD), Ng would be busy in the days and weeks after the attacks (see box on page 6). One of his most potent memories from those early days: Dust and debris from the pulverized buildings in lower Manhattan had coated parts of Brooklyn, across the East River.

For psychiatrists in the city that day—as for all Americans of a certain age and many around the world—the memories of the September 11, 2001, terrorist attacks are indelible. In the years that followed an enormous body of research on the effects of 9/11 on mental illness and substance abuse accumulated; it became clear that the attacks were also a watershed for the psychiatric understanding of acute and chronic trauma and posttraumatic stress disorder (PTSD) and for the practice of disaster psychiatry (Psychiatric News).

“More research has been conducted on the mental health effects of 9/11 than any other single act of mass violence in U.S. history,” said Joshua Morganstein, M.D., assistant director of the Center for the Study of Traumatic Stress at the Uniformed Services University in Bethesda, Md. “This has helped us to understand the broad range of psychological and behavioral responses to disasters, including distress reactions, health risk behaviors, and psychiatric disorders.”

Exposure Is Central to PTSD

Carol North, M.D., M.P.E., has over three decades of experience conducting federally funded studies of disaster mental health. Yet it was the terrorist attacks on September 11, 2001, that crucially altered the way she thinks about PTSD criteria and what it means to be exposed to a traumatic event. She is medical director of the Altshuler Center for Education and Research at Metrocare Services in Dallas and director of the Division of Trauma and Disaster at the University of Texas Southwestern Medical Center.

The question of exposure is central to a PTSD diagnosis, North explained. There are four types of exposure, according to DSM-5: being directly exposed to the traumatic event, witnessing the event, having a loved one experience it, or being exposed to repeated details of the traumatic stressor (though not through the news).

“When we were looking at our 9/11 data, we discovered that just because a trauma occurred did not necessarily mean an individual was exposed,” North said. “The thing that was so unique about 9/11 is that the disaster was huge, and somewhere you have to determine the line of where the trauma exposure ends.”

During a presentation on disaster mental health at APA’s online 2021 Annual Meeting (Psychiatric News), North emphasized that most responses to disaster trauma are not pathological. It is common to experience distress after a disaster, and those experiencing distress may require treatment, but inappropriately diagnosing someone with PTSD who does not meet the criteria trivializes the diagnosis, she said.

North and her team looked specifically at the traumatic events to which individuals were exposed, depending on their location when the planes hit the World Trade Center and the towers fell. They conducted a series of focus groups, and the participants told them the specifics of their trauma exposures. “Some people were in a stairwell trying to get out after the towers had been hit,” she said. “Some people were outside, and bodies were falling from the tower around them. Some saw people who were bloody or burned, and some had to run from the dangerous debris cloud.”

North and her colleagues found that, for the most part, people who had qualifying PTSD exposures according to DSM criteria were within a block of the towers. Yet at the time, other studies were applying PTSD criteria on a nationwide scale. “There were studies applying PTSD screenings to people all over the nation—in Houston or Los Angeles—but those people weren’t exposed according to the definition of trauma required for a diagnosis of PTSD,” North said.

Typically, after other disasters that North and her colleagues have studied, an average of about 20% of individuals develop PTSD. But following severe disasters of greater magnitude, like the September 11 attacks or the Oklahoma City bombing in 1995, the rate of PTSD among people who were exposed rose to over a third, North said.

The experience of studying the September 11 attacks as closely as she has—20 years later, she is still publishing papers based on the data she and her colleagues collected—forced her to seriously rethink what it means to be exposed to a traumatic stressor and how the PTSD diagnosis should be applied based on the DSM criteria.

“Because 9/11 was such a complicated disaster, it opened new vistas in my thinking that just hadn’t occurred to me before and sent me on a pioneering journey to better understand the definitions of disaster trauma and personal exposure,” she said.

Haunting Images, Memories Remain

For New Yorkers who were in the city that day, the attacks left a mark. Markowitz, who has specialized in research on PTSD and interpersonal psychotherapy, continues to treat individuals who lived through the day. “New Yorkers took it personally,” Markowitz said. “They were aiming at us, destroying our landmark, marring our skyline.”

Ng agreed. “For those of who lived here, the images stick with us.” He noted, for instance, that the recent images of the condominium collapse in Miami, with its pancaked floors, elicited stark memories. “9/11 changed how we see things now,” he said.

And certain memories linger and haunt. “I was active in a homeless outreach program near the World Trade Center,” Ng said. “I used to go into the World Trade Center all the time. I don’t know where some of those homeless people who used to hang around the trade center are now. I don’t know if they ever made it out.” ■