As a full-time academic researcher, I immediately planned for and obtained human subjects institutional review board approval from New York University to conduct several surveys throughout New York City. The first of these protocols  was a systematic survey of randomly selected adults throughout New York City. These individuals were approached by psychiatrically trained interviewers who requested their participation in answering a questionnaire about their physical and mental health prior to and 3-6 months subsequent to the event. Various stresses were recorded, such as their proximity to and involvement in the events of September 11, whether they lost close relatives or friends, and specifically questions about anxiety, depression and the symptoms of PTSD. Each of the 17 items on the Davidson Trauma Scale [4,5] was scored from 0 to 4 for both frequency (0 = none to 4 = every day) and severity within the past week (0 = not at all distressing to 4 = extremely distressing). A total score was obtained by adding the frequency and severity scores for each item (range = 0-136). Three subscales were defined by using this scale: intrusion, avoidance/ numbing, and hyperarousal. The intrusion score was calculated as the cumulative score of frequency and severity scores for five questions relating to this category, the avoidance/numbing score as the cumulative score for six corresponding questions, and the hyperarousal score as the cumulative score for four corresponding questions. A score of 8.0 on any one item was considered the highest level of pathology; while a score of 0.0 meant that the item was not present. On the basis of previous studies, Davidson considered a score of 24 or higher as suggestive of PTSD. A total of 1,009 adults (516 men and 493 women) were interviewed in person throughout
Manhattan. The results from this survey showed that a total of 56.3% had at least one severe (score greater than 8.0) or two or more mild to moderate symptoms and that the presence of these was correlated with the amount of time that had passed since September 11, 2001. Thus, over half of the individuals had some emotional sequelae 3-6 months after September 11, but the percentage was decreasing over time. Women reported significantly more symptoms than men. Loss of employment, residence, or family/ friends correlated with greater and more severe symptoms. The most distressing experiences appeared to be painful memories and reminders; dissociation was rare. What appeared most concerning, however, was that only a small portion (26.7%) of those with severe responses (a score of 24 or greater) was seeking treatment.
The following are examples of experiences recounted to interviewers:
• One subject's relative broke all his fingers when evacuated from the World Trade Center. While the subject herself was not at the scene, her job was affected because the supermarket in which she served as a clerk received repetitive violent threats and business declined considerably because the owners were Arab.
• After seeing the second plane hit, one subject described seeing smoke coming from the World Trade Center towers and how he ran from the building just as it collapsed. He lost a close friend as well as a family member. After September 11, he also lost his apartment and his job as a building janitor.
• After the attack, a police officer allowed another interviewed subject and her husband to enter their apartment for 10 minutes to obtain essential items. They were not able to return for 8 weeks. She lost a friend (a fireman) and a professional client.
• A 49-year-old man agreeing to be interviewed had worked in the World Trade Center for 20 years. During the attack, he was on the Brooklyn Bridge on his way to work, and he later discovered that many of his close friends and colleagues were missing.
• A 47-year-old male worked in a bank next to the World Trade Center and lived near by. He survived only because on his way to work he saw the Towers from a distance collapsing in smoke and therefore ran back. He had not been allowed back to his apartment and at the time of the interview was still living with a friend's family.
• A 32-year-old female lawyer also worked in an office complex close by. She emerged from the subway just before the first building fell and then saw it fall. It ''felt like an earthquake''. She ran up the main street in front of a dust cloud and walked home to her apartment. Her first thoughts while fleeing on September 11 were of previous traumas. While living in Israel, she barely escaped injury in one bombing and had lost several friends in another. At the time of this interview she was having flashbacks of these previous events.
• A 45-year-old Asian-Indian male stated that he was self-employed as a plumber, but his work was currently scarce because of new prejudice against Muslims on the part of his previous clients.
• One subject was a 24-year-old male restaurant manager. At the time of the interview, he stated that he set his alarm for 9.11 a.m. each day because, he stated, ''It's very important to me that I don't forget how angry and upset I was that day.'' He described September 11 as ''a wake with a closed casket''. He felt the loss of the buildings that were part of the view from his apartment across the river in New Jersey as if he had ''lost a family member''.
• A 53-year-old interviewed male who was a technology manager was walking into Tower 1 when he found out what was occurring. He saw the building on fire and later stood watching until the second plane hit. He lost seven friends and 75 colleagues in the disaster.
• One subject was a 32-year-old female director of a daycare center six blocks away from the World Trade Center. Subject spoke about the daycare center, which was located next to a police precinct. The children were evacuated by police to nearby Chinatown where the parents were able to pick them up. One of the children's parents died; he was a police officer. Subject states that the staff had meetings for 3-4 weeks afterwards about how to approach the issue with the children and it was agreed that they would not talk about it unless the children specifically asked questions. There were some workshops where the children drew pictures and made paper airplanes to tell what happened. About 10 of them had seen the burning buildings. The daycare center was not fully operational for 6 weeks (no phones or fax). There were no psychiatrists on site to be able to tell these workers how to handle the children's questions.
• One subject, a 26-year-old female administrative assistant, worked in Tower 1 on the 27th floor. She managed to escape down the staircase before the building collapsed. However, she lost 10 colleagues and friends. Subject remained quiet during the interview and said that there were parts of the evacuation that she does not remember and parts that she does not want to remember. She did not want to talk about the experience.
• A 27-year-old male interviewee had previously been in the Marine Corps and had seen similar disaster and acts of violence throughout the world. He claimed to be largely unaffected by the events of September 11.
Despite statements of how well they were coping, all of the above had various degrees of anxiety, depression and other symptoms that prevented them from working and socializing up to the time of the interviews. Many others described failed relationships, had difficulty concentrating and acknowledged occasional thoughts of death and suicide.
The second survey focused on patients at the New York City Bellevue Hospital who had serious psychiatric disorders and were hospitalized at the time of the terrorist attacks. Medical records for 156 psychiatric inpatients were examined to evaluate their psychiatric condition during the time prior to and subsequent to September 11, 2001. For 5 of these patients, no diagnosis could be ascertained. Of the subjects, 100 were males (66.7%) and 51 females (33.3%). 44 were Caucasian (28.2%), 62 African-American (39.7%), 25 Hispanic (16%), 17 Asian (10.9%) and 8 of other ethnic origins (5.1%). All diagnostic categories were represented: bipolar disorder (n = 15, 9.6%), schizophrenia (n = 54, 34.6%), schizoaffective disorder (n = 52, 33.3%), depression (n = 8, 5.1%), primary substance abuse (n = 5, 3.2%), miscellaneous (n = 17, 9.9%). 39 patients (29.8%) had increases in their medication the week following September 11, while only 3 had decreases in medication. 37 patients (24.5%) improved. 55 patients (36.4%) worsened after September 11 in the following diagnostic categories: bipolar disorder (n = 3, 20.0%), schizophrenia (n = 28, 51.8%), schizoaffective disorder (n = 17, 32.7%), depression (n = 1, 12.5%), substance abuse (n = 1, 20.0%), miscellaneous (n = 5, 35.7%). It has generally been thought that in the face of a disastrous environmental event, whether natural or man-made, patients with a psychotic illness may actually improve, while patients with pre-existing depression might actually worsen. In the present study of the effects of the New York City World Trade Center terrorist attacks on seriously ill hospitalized patients, we did not find evidence that patients' condition improved in response to the events. Surprisingly, few patients with depression on admission worsened. While some patients across diagnoses were in need of medication for anxiety or sleep in the week following the event, the majority was not. In addition, there were no differences across diagnostic categories, symptoms or medication changes for those patients on wards facing the World Trade Center (n = 40) compared with those who were not (n = 110). It is thus assumed that the secure environment and reassurance of mental health professionals covering the inpatient units at this time provided a therapeutic effect that prevented patients from deteriorating, but we found no evidence that psychotic conditions resolved based on the reality of the disastrous events.
Some descriptions from the records are as follows:
• In a group therapy session, therapists explored the patients' feelings and ideas regarding the terrorist attack in New York City. Patients were encouraged to talk and express their emotions. One patient who was quiet during most of the session, expressed confusion and her speech remained disorganized.
• One patient verbalized that he thought his teacher from Pluto was responsible for the World Trade Center disaster, not Osama Bin Laden.
• One patient was withdrawn and spent most of the morning watching TV news and drawing pictures about the event. In a support group meeting, this patient focused on paranoid and grandiose delusions of FBI/CIA intelligence he ''knew'', drawing loose references to himself and his responsibility for the events that happened.
• Another patient incorporated the terrorist attack into a delusional system in which he believed that the US government had done this as a part of a conspiracy to gain world domination.
Our third set of surveys involved questionnaires to medical students and physicians of all types who aided the victims for the first 6-month period subsequent to September 11, 2001, particularly at the FAC . One study was performed to investigate the emotional impact of this involvement on medical students from a major medical school in New York City, the Mount Sinai School of Medicine. 157 students responded to a mail survey with a set of questions about their personal and professional involvement in the disaster as well as their psychiatric symptoms in the week after the event and at a time 3-4 months later. This study found, similarly to the survey of randomly selected New Yorkers, that there was a greater emotional impact on female students than male and that those students involved in less-supervised and more-stressful activities were more prone to emotional sequelae. However, the intense experience of aiding victims going through profound emotional trauma did not contribute to psychiatric symptomatology per se in the volunteers and, if anything, was associated with enhanced professional self-esteem.
The fourth survey focused on physicians who volunteered to help victims. Very few of them were in fact interested in responding to a survey. In general, they wanted to put the experiences behind them and not to reactivate their emotions by recalling the events. We suspect that they too had lasting effects, but could not find the time or the willingness to express it. However, of the ten physicians that did respond to advertisements throughout New York City about 1.5 years after September 11, 2001, five were male and five female (mean age 46). Nine of the ten wished they could have had some type of psychiatric support system during and after their work with the victims. One felt doctors should be able to ''handle these things themselves''. The following are examples of some of the experiences encountered:
• One physician went to a building close to ground zero to volunteer his services for one day, but stated that other than ''washing out a few firemen's eyes, there was nothing to do. Those people who were physically unharmed had fled, while the others were deceased. It was that extreme''.
• One particular physician, a female psychiatrist, was extremely vocal and felt that she needed to speak about the event. She had volunteered for 1 month after September 11 at the FAC, made referrals, wrote prescriptions, offered general counseling, and staffed a hotline for medical/ psychiatric referrals. She also experienced survivor guilt, and that she needed to be doing more. At the time of the interview, she still felt somewhat removed from other people and irritable, and had upsetting reminders that lingered.
• At the time of the disaster, one physician felt like she could not talk about the events. She did not know anyone in the city who could relate to how she was feeling and what she was going through. She felt isolated, especially when the phones were not working for a few days after September 11. When she finally felt like she could discuss her experiences, all of her friends wanted the events ''behind them'' and were at a different stage than she was. She only felt comfortable talking about September 11 at conferences, but that was a professional setting so she felt that her expression of emotion had to be limited. She relayed that she spent such intense time helping others that she could not deal with the tragedy herself and experienced feelings of guilt that she could not do more.
• Another physician said he drank twice as much alcohol after September 11 than before. He worked at a triage unit close to the World Trade Center site volunteering about 10 hours per day. His apartment was very close to the World Trade Center, and he and some neighbors formed a group where they would get together over drinks and discuss the events. He stated that his worst memory was seeing people jump out of the towers.
• One psychiatrist volunteered at a professional school located near ground zero. She offered general counseling to both students and firemen. The tragedy helped her obtain a research grant on emotional memory and thus she actually gained professional status because of the events. Yet she reported survivor guilt for the month subsequent to September 11 and developed asthma. She lost weight, had problems sleeping and lost her appetite.
• One physician was a staff psychiatrist on an inpatient unit who worked longer hours after the attacks. His alcohol intake increased after the attacks and at the time of the interview he still admitted to being preoccupied with painful images intruding on his thoughts. He still avoided participating in activities that would remind him of the events.
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