PTSD in Survivors of 9/11

Where were you when you heard about the terrorist attacks that took place on September 11, 2001?

Though everyone has a different story to tell, we were all traumatized as we watched the events of that day unfold on television. But, it was the people directly affected, including rescue workers, survivors, and eyewitnesses, who continue to experience post-traumatic symptoms even today. As you might expect, research has consistently shown that individuals exposed to the attacks showed rates of PTSD and depression far greater than lifetime rates found in the general population. For example, a research study looking at police officers who responded to 9/11 showed that 12.9 percent reported PTSD symptoms over a decade after the attacks. Of those who had PTSD symptoms, 72.4 percent also reported problems with depression and anxiety.

Researchers have also identified specific risk factors that made survivors especially vulnerable to trauma and depression afterward. In first responders particularly, having arrived early at the scene (following the first airplane impact) increased the risk of PTSD while history of alcohol abuse was linked to developing depression. Other factors included:

• Being a woman
• Having experienced stressful situations before or after the attacks
• Traumatic symptoms experienced during the attacks themselves
• Having a history of mental health issues
• Loss of psychosocial resources
• Less social support

These last two factors highlighted how important emotional support can be for survivors of trauma. Along with providing an emotional sounding board for survivors to share their experiences, this kind of support can also boost resilience. According to the enabling hypothesis, social support helps survivors by building up their sense of self-efficacy, i.e., belief in their ability to overcome obstacles and face challenges. Still, though social support and self-efficacy seem to play an important role in protecting against PTSD and depression, actual research into the long-term consequences of the 9/11 trauma has been relatively scarce up to now.

But a new research study published in the the journal Psychological Trauma provides the most up-to-date conclusions about the long-term psychological impact of 9/11. Conducted by Shane W. Adams of John Jay College of Criminal Justice and a team of researchers, the study used data taken from the World Trade Center Health Registry (WTCHR) to examine the prevalence of PTSD and depression among 9/11 survivors and the factors that influenced their recovery.

Already the largest registry of its kind in U.S. history, the WTCHR collects information on anyone who lived, worked or went to school in the area of the WTC disaster, or were involved in rescue and recovery efforts to determine long-term health trends. While participation in the registry is strictly voluntary, thousands of survivors have chosen to participate to provide better information about long-term health consequences. By surveying participants in a series of waves beginning in 2003-2004 and extending up to the latest wave completed in 2015, researchers have already completed numerous studies looking at different health issues including depression, mortality, hearing loss, and hospitalizations for asthma, among others.

For their own research, Adams and his colleagues collected data on 1,304 participants who were adults at the time of 9/11 and who were physically present in WTC Towers 1 or 2 between the first plane’s impact and subsequent WTC collapse. None of the participants had been diagnosed with PTSD prior to 9/11 and they all completed PTSD checklists during each of the four waves of the WTCHR survey project. They also completed survey questionnaires measuring perceived self-efficacy, the kind of social support network they had in place, depression, and PTSD symptoms. Participants were also questioned about their level of exposure to the traumatic events of that day. This included dust cloud exposure; horrific events witnessed; encountering problems during building evacuation (eg., fire, poor lighting, smoke, extreme crowding, panicky crowds, water in the stairs/lobby, etc.); and physical injuries occurring on 9/11.

Overall, 13 percent of the participants were still experiencing PTSD symptoms 14 years after 9/11 with 68 percent also reporting depression. Not surprisingly, all participants with PTSD had significantly greater exposure to the events of 9/11 than participants who weren't reporting mental health symptom or who had depression alone. Also, those participants reporting both PTSD and depression scored much lower in perceived self-efficacy than other participants. They were also significantly more likely to abuse alcohol, report a lower quality of life, as well as being less physically active compared with other participants.

When looking at those factors that predicted whether a survivor would develop PTSD, Adams and his fellow researchers found that, while trauma might predict PTSD symptoms, survivors typically only developed depression due to other factors including, later stress issues, more importantly, lack of social support. As for how well self-efficacy helped protect survivors from developing PTSD, that appeared to depend on how much exposure they had to the traumatic events of that day.

But what does this mean in terms of helping 9/11 victims recover from PTSD and depression? Along with demonstrating the need to look at other issues such as depression when assessing victims of trauma, this study also reflects previous research in showing that treatment aimed at depression or PTSD alone may not be very effective for people reporting combined symptoms. In dealing with tower survivors who experienced multiple traumatic events on 9/11, it is often as important to focus on improving self-efficacy as it is to help improve their social support networks. This research also shows that there is no one-size-fits-all therapy for survivors and that the kind of therapy given should be based on the full range of symptoms they are showing.

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There is much more research that needs to be done, especially because many survivors have not come forward to ask for help. As a result, most studies to date may actually underestimate the true extent of PTSD and depression symptoms among tower survivors. Despite this limitation, we can see from this latest study that 9/11 continues to haunt many of the people directly affected. Understanding their symptoms and their treatment needs not only provides better treatment options, but also helps us be more prepared for future disasters.