| The September 11, 2001 terrorist attacks and the subsequent
mobilization of health care resources to assist victims and their families
were unprecedented in this country. Within days of the events, the limited
data that were available on survivors and other people living in close
proximity, in concert with information regarding previous mass disasters,
were used to map out the extent and nature of the psychological impact
and need for mental health services. Extrapolating from these data, Herman,
Felton & Susser (2002) estimated that over 520,000 people in New York
City (NYC) and surrounding counties would experience post-traumatic stress
disorder due to some aspect of the attacks, and that more than 129,000
people would seek treatment for PTSD in the coming year.
The anthrax bacteria transmitted through the U.S. postal
system shortly after the events of September raised new fears of bioterrorism,
contributing further to heightened anxiety. Even people who were not in
close physical proximity to the events demonstrated moderate to high levels
of stress (Norris, 2001; Schuster et al, 2001; Silver et al., 2002). Reports
indicate that people across the country experienced decreased safety, diminished
sense of control and well-being, as well as perceived discrimination because
of their religion or ethnicity in the U.S. and Canada (Austin et al., 2002;
Norris, 2001). The emotional and financial costs of the terrorist events
are immeasurable (Jack & Glied, 2002).
Many research and scholarly articles have now been published
that assess the impact of past episodes of trauma and disaster on individuals,
families, and communities. Most focus on acute stress disorder (ASD) and
post-traumatic stress disorder (PTSD). For the majority of people, acute
post-traumatic symptoms such as anger, disbelief, sadness, anxiety, fear,
and sleep disturbance tend to recede or resolve over time. Others, both
adults and children, experience PTSD characterized by symptoms of persistent
reexperiencing of the event (e.g., recurrent nightmares, intrusive thoughts),
avoidance of thoughts or activities that remind them of the event and emotional
numbing (e.g., deliberate efforts to forget the event, feelings of emotional
detachment), and increased arousal (e.g., hypervigilance, sleep disorders,
irritability, difficulty concentrating) that persist for over a month (American
Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,
1994).
In addition to this significant and disabling disorder,
other problems and related behaviors may develop as a result of traumatic
events. Adjustment disorders, major depression, and anxiety disorders may
be expressed in indirect ways: complicated bereavement, increased tobacco
and substance use, family violence, poor school performance, increased
risk-taking, and other behavior problems (Norwood, Ursano & Fullerton,
2002). In fact, even patients with PTSD may not present clinically with
psychiatric symptoms as chief complaints: somatic manifestations of stress
can be expressed as symptoms of musculoskeletal, gastrointestinal, neurological,
gynecological, cardiovascular, or respiratory problems. Symptoms include
headaches, back and neck ache, fatigue, indigestion, abdominal pain, nausea
and vomiting, as well as paralysis, double vision, and fainting. Unexpected
symptoms may also occur as a result of self-medication or missed medications
for chronic illnesses (Hassett & Sigal, 2002). Children’s symptoms
may be more subtle, or may be acted out as changes in social behavior (Davidhizar
& Shearer, 2002; Seideman et al., 1998).
Treatment for these problems is far more likely to be sought
in primary care settings than in the offices of mental health professionals.
Many somatic symptoms will be misinterpreted as being related to physical
illnesses and the stigma regarding mental illness may preclude others from
seeking mental health treatment. Primary care settings are an appropriate
first point of contact with the health care system for the majority of
individuals regardless of their symptoms. However, accurate diagnoses are
difficult to make and many primary care providers are not prepared or inclined
to deal with mental health issues (Samson et al., 1999; Stephenson, 2001).
Although the symptoms of PTSD are readily identifiable by a primary care
practitioner, the diagnosis may be missed if exposure to a specific event
is not assessed or symptoms are attributed to depression and other anxiety
disorders (Yehuda, 2002). Perhaps equally important, physicians and other
primary care providers must be sensitive to the vague symptoms that are
not clearly pathological but which do point to mental health problems (Hassett
& Sigal, 2002; Katon, Sullivan & Walker, 2001). Documenting qualitative
and quantitative characteristics of mental health problems resulting from
the terrorist attacks will assist in developing useful resources for health
care providers and contribute to new models of health care delivery that
integrate mental health and primary care in community settings.
Within the first year after the terrorist incidents, a
number of data-based studies and scholarly reviews regarding their psychological
impact on Americans were published in the scientific literature. The findings
of these reports are informed and supported by studies regarding the aftermath
disasters and other terrorist events in the U.S. and other countries. They
all can inform future research and contribute to resource development.
The purpose of this review is to examine existing literature
regarding the psychological impact of the September 11 terrorist events,
as well as subsequent terrorist alerts and events, on adults, children
and health care providers in relation to:
a)
number of people affected and psychological and somatic symptoms during
the first six months after the events;
b) trends over
time with regard to psychological and somatic symptoms that emerged gradually
or changed after the initial six month time frame;
c) factors related
to psychological distress and resilience; and
d) natural disasters
and terrorist attacks in the U.S. or international settings.
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