The Psychology of 9/11, Ten Years Later

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Patricia J. Watson, senior educational specialist, National Center for PTSD, assistant director of terrorism and disaster programs, National Center for Child Traumatic Stress, assistant professor at Dartmouth Medical School, Department of Psychiatry, Dartmouth College, Hanover, N.H.

Claire Cammarata, clinical director, New York City Fire Department Counseling Services Unit, adjunct lecturer, NYU School of Social Work, New York, N.Y.

Sandro Galea, Gelman professor and chair, department of epidemiology, Mailman School of Public Health, Columbia University, New York, N.Y.

Roxane Cohen Silver, professor, department of psychology and social behavior, Department of Medicine, University of California, Irvine, Irvine, Calif.

Immediately after the Sept. 11 attacks, many first responders and other victims received psychological care. Ira Flatow and guests look at the psychological effects of 9/11, and what researchers have learned since then about caring for victims of psychological trauma.

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IRA FLATOW, Host:

This is SCIENCE FRIDAY. I'm Ira Flatow. This Sunday will mark the 10th anniversary of the 9/11 attacks. We all have a story about that day, what we were doing when we heard the news. We could all watch the events unfold on TV, seeing a plane hit, the towers falling, a live, televised terrorist attack on a scale that Americans have never before experienced.

Thousands were killed, of course, and millions were left to struggle with the psychological aftereffects. An army of counselors and mental health experts have tried for the past 10 years to not only soothe the mental anguish of the victims and their families, but to document, study and understand the long-term health effects that may linger with firefighters, police and the public.

By one count, more than 150 research papers have looked at the mental health of 9/11 survivors. And now 10 years later, what have counselors and researchers learned? What would they do differently? What have we learned about how people cope and how people did cope, and even grow after a traumatic incident?

FLATOW: 1-800-989-8255, 1-800-989-TALK. You can tweet us @scifri, @-S-C-I-F-R-I, or go to our website at sciencefriday.com and leave some comments.

Let me introduce my panel. Roxane Cohen Silver is a professor in Department of Psychology and Social Behavior at UC Irvine. She edited a special issue of the journal American Psychologist that looked at the 9/11 attacks, and she joins us from the studios of KUCI. Welcome to SCIENCE FRIDAY, Dr. Silver.

ROXANE COHEN SILVER: Thank you.

FLATOW: You're welcome. Sandro Galea is a Gelman Professor and chair in the Department of Epidemiology at the Mailman School of Public Health at Columbia University in New York. Thank you for being with us today, Dr. Galea.

SANDRO GALEA: Thank you for having me.

FLATOW: Claire Cammarata is a licensed clinical social worker and a clinical director for the New York City Fire Department Counseling Services Unit. She's also an adjunct lecturer at the NYU School of Social Work, and she's here in our New York studios. Thank you for being with us.

CLAIRE CAMMARATA: Thanks for having me.

FLATOW: Patricia J. Watson is a senior educational consultant for the National Center for PTSD. She is also assistant director of terrorism and disaster programs at the National Center for Child Traumatic Stress, and assistant professor at Dartmouth Medical School. Welcome to SCIENCE FRIDAY, Dr. Watson.

PATRICIA J: Thank you very much.

FLATOW: Let me - there's so much to talk about. Let me talk about the immediate weekend that's coming up. This weekend people are going to be living and reliving the 9/11 attack all over again. Dr. Silver, for people who've lived through it, experienced it or watched the videos over and over and over again the last 10 years, is this weekend and seeing all the stuff that's going to be on the media, the act of reliving the event and feeling associated with it, is it going to help people cope, or is it going to make it worse for some people?

COHEN SILVER: I think that we can respectfully commemorate the day 10 years ago, the thousands of lives that were lost. We can appreciate the heroism of many people in the aftermath of 9/11, and I think we can do all of that respectfully this weekend.

I think that we can do that without reliving, without reactivating the feelings if we are not continuously exposed to the graphic images of that day. So I think that we can do - we can have a commemoration, and we can have a respectful memorial, and we don't need to see the pictures again.

FLATOW: Are you suggesting we not look at them?

COHEN SILVER: I'm a researcher, and in my research, I would say that we see no psychological benefits from watching the graphic images. I personally will not be watching them.

FLATOW: If any of you want to jump in and add your comments, please feel free to do so. Dr. Watson, or Dr. Silver, let's talk about some people retreated in the days immediately after 9/11. Some people were encouraged to talk about their feelings, to share what they went through as part of something called critical incident stress debriefing. Can you tell us what that is about?

WATSON: Yes. Critical incident stress debriefing was a model that was used primarily with first responders following traumatic incidents, and it involves usually a group setting, where people sit and talk about what happened, what they saw, what they felt, what their reactions were, what was hard for them. And then there's a bit of sort of guidance about stress management.

And it was with all the best of intentions that this model was used after 9/11 and after other disasters. But some of the research literature and expert consensus suggested that it might not be the best model for a post-disaster or post-terrorism situation for many reasons, one of which is people - it's such a chaotic environment, people have many basic needs that need to get met. They need to have resources, and oftentimes people needed downtime. They need to be focused on what needs to happen for them to get their feet back on the ground.

And we also know from some of the literature, looking at immediate reactions after traumatic stress, that when the heart rate goes up and when people have higher anxiety levels, it can actually lead to longer-term problems.

So the goal, in many ways, has been to move away from a model that imposes that people should talk to more of a model that's very much tailored to the individual and to the circumstance. So that model has to fill the gap. One model is what's called psychological first aid, which is very much tailored to what's happening for the person, getting their needs met, providing them resources.

If they choose to talk and they want to talk, absolutely, the person should be supportive and listen, but not to impose that they should talk before they're ready to talk.

FLATOW: Dr. Cammarata? You're shaking your head about this.

CAMMARATA: Yeah. I agree with Dr. Watson. I think at the fire department, we've been very fortunate to have a very strong peer program, so that we were able to actually visit the members at their - at the site, at their firehouse and just check in with them, what it is that they needed at the time, rather than imposing any particular kind of treatment or intervention.

FLATOW: Mm-hmm. There are studies that I'm reading that have shown - and I think you're one who can talk about this - that the onset of the disorder PTSD was very often delayed among firefighters and emergency responders because their work - their experience and their training allowed them to suppress the emotions, but something later on in their life could trigger it and bring it back.

CAMMARATA: Well, I think a big factor was working at the site until June of the following year, and I think that allowed the members to use more of an active style of coping. I think once the site was closed, they were somewhat robbed of that opportunity, and I think that caused a bit of a delay in some of the more formal traumatic stress symptoms.

FLATOW: How well were - and I'll ask all of you - how well were mental health officials prepared to deal with an event like this? Dr. Silver, any - or Dr. Watson?

COHEN SILVER: I think Dr. Watson, perhaps, maybe.

WATSON: From what we saw after 9/11, providers were actually extraordinarily well-prepared in some ways, because they - this occurred in a community, particularly in the New York community, where you have a very strong resource base of providers. And because it was a large urban community, you had people who were trauma experts there who were willing to go out and do mass trainings, to teach the most updated techniques on how to treat traumatic stress and loss and traumatic grief.

And the national community responded with an outpouring of support and funding to bring people across the nation together to figure out, you know, how do we do the best to treat people. So we were extraordinarily lucky in that way.

And I think that there was funding released, as well, for research to take a look at what was helping people and what makes the most sense for people at different time phases after an event like this.

FLATOW: Mm-hmm. 1-800-989-8255 is our number if you'd like to be involved in the conversation. Dr. Galea, you were part of a study looking at PTSD rates across a number of studies. Who was more susceptible to getting PTSD, from your results?

GALEA: Well, we know from our findings and from those of many others that the people who are most exposed to a trauma are more likely to get PTSD. So if we did it in different groups, for example, within rescue workers, the rescue workers who got to the scene first or those who were there longest were more likely to get PTSD, compared to those who were there later or spent less time.

And we have - we did a study where we looked at survivors of the towers, and we found that those survivors of the towers who encountered more injured people, encountered more traumatic events on their way out were more likely to have PTSD.

And in the general population, the people who were living closer to the World Trade Center - who were south of Canal Street, for example - were more likely to have PTSD than those in the rest of Manhattan or in the rest of New York City.

FLATOW: Is it possible for people who don't even live in New York or in Washington or in Pennsylvania to get PTSD from the repeated seeing of these videos over and over and over again?

GALEA: That's actually a very interesting scientific question. It's a matter of some controversy. The - there have been studies, some done by our group, some done by others, that suggest that those who are vulnerable - who are vulnerable because of something else - so, for example, somebody who has had PTSD in the past, or potentially people who have some sort of genetic vulnerability - may have PTSD triggered by watching specific images.

So I would consider the groups at risk of PTSD because of images to be a very particularly vulnerable group. There is a nice paper in today's literature, actually, summarizing the findings on this. And I think the papers are consistent across about a dozen papers, showing that the group of individuals who have something else to make them vulnerable may develop symptoms of what we call PTSD simply through the watching of repeat images.

And I think Dr. Silver made the point about the repeat images on the anniversary, and I think it's a very good point. I think there is a possibility that those images will be associated with problems in people who are vulnerable, and it's also likely that those images can trigger recurrence of PTSD among those who have already had it.

FLATOW: All right, we're going to take a break and take some calls. Our number: 1-800-989-8255. You can also tweet us, @scifri, @-S-C-I-F-R-I. Talking withRoxane Cohen Silver, Sandro Galea, Claire Cammarata and Patricia J. Watson about the 9/11 psychological effects. You might want to share some experiences. We'd like to hear from you, but you know as always, we can't take any - treat personal problems. So don't, you know, try to narrow in too focused on what might be going on there, because it's unethical for us to talk to you about that.

So - but we will talk about everything else. So stay with us. We'll be right back after this break.

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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.

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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. We're talking this hour about the mental health effects of 9/11 with my guests, Roxane Cohen Silver, Sandro Galea, Claire Cammarata and Patricia J. Watson. Our number: 1-800-989-8255. And Dr. Cammarata, can you give us some idea of - how did you know what to do working with the NY Fire Department when these calls first came in? You were still a social worker with the New York City Fire Department then.

CAMMARATA: At the time, yes.

FLATOW: At the time.

CAMMARATA: Yes.

FLATOW: How did you know how to handle all that stuff?

CAMMARATA: Well, I mean, we were lucky that we had a preexisting counseling unit, a pre-existing peer team. Just a few months prior to 9/11, we had lost three firefighters. So we had just sort of went through a much smaller-scale disaster. So that helped tremendously.

But I don't think a lot of us did know what to do right afterwards, and I think that was a blessing in disguise, because it caused us to sit back a little bit and see what people needed, rather than rushing in, assuming what people needed.

FLATOW: What makes a terrorist attack different from, let's say, other natural disasters, like a tornado or a tsunami or other big disasters that affect, you know, hundreds or thousands of people. Dr. Silver?

COHEN SILVER: Yes. There are many unique aspects of terrorism. And particularly, you have a clear, malicious intent, somebody who seeks to do harm in general by elevating anxiety and fear in the population. So the goal of terrorism is inherently psychological.

That means that, in addition to any effort - any successful destruction of buildings or successful murdering of individuals as a result of the terrorist attack, the real goal is to scare people. And I think that makes it unique from other disasters.

However, terrorism, like natural disasters, are uncontrollable. They seem random. They're often unpredictable. And so there are many features that these disasters share. But the fact that there is a malicious intent to do harm and to create fear and anxiety is what makes terrorism unique.

FLATOW: Mm-hmm. 1-800-989-8255. Teresa in Santa Rosa, California. Hi, Teresa.

TERESA: Hello. Thank you for taking my call. I was hoping to have the opportunity to talk about this time, which is very - it's very kind of mixed blessing at this time of year. But I wanted to acknowledge the flight attendants and the pilots. It seems like oftentimes when you hear stories about 9/11, people refer to the firefighters and the policemen.

But I was a flight attendant at the time, and I had the, I guess, unfortunate opportunity to be flying over the World Trade Center. We were in a plane trying to land in Newark as the World Trade Center was coming down and exploding.

But more than that, I just wanted to have opportunity to bring some remembrance to the flight attendants and pilots that we lost on the planes during that time.

FLATOW: Well, thank you for calling. Is there any research, Dr. Galea, on the flight attendants, all flight attendants thinking that those were my brothers and sisters on those planes?

GALEA: I don't know that there's been any research specifically on flight attendants. There has been the research on workers who are involved indirectly in events like this. And we do know that workers who are exposed to sort of the horrors of terrorism or of disasters indirectly are themselves at risk of, let's say, post-traumatic stress disorder or psychopathology. But I am not aware, maybe Dr. Silver is, of other...

COHEN SILVER: No, I'm not aware of any research specifically on that, either. It's an excellent question, and I think it is - I appreciate your bringing that to our attention.

FLATOW: You know, what's interesting is I'm reading through all the papers that all of you have written in. So many of your papers say there's so much we still don't know. I mean, there's so much research in - and even in methodology of how to do the research that we still haven't figured out yet or haven't attempted to do yet.

GALEA: Well, the disasters in general - and terrorism in particular - pose particular challenges for research. It's - these are events that happened completely unexpectedly. The research is - typically, it's large operations, and they take years to prepare. And when they do happen, they disrupt the typical infrastructure. So mounting research projects becomes tremendously difficult.

So, as a result, there remains much to be done. I actually think that the science has progressed tremendously in the past 10 years, in large part due to some work, very good work that was done after September 11th. I think we know a lot more now than we did 10 years ago, but I think the papers are correct. There remain a lot of open questions.

COHEN SILVER: And also one needs funding, and it's very challenging to get funding in the immediate aftermath to launch a study. Dr. Galea and I both launched studies in the early aftermath of 9/11, and we have spoken with a few others that have done so, as well. And we all talked about the incredible challenges of not only setting up a project, but getting it out into the field quickly so that you can do a methodologically sophisticated project, so that the conclusions that you draw are valid ones.

FLATOW: So have you been specifically turned down for your requests for funding?

GALEA: Well, getting - when one is in the business of applying for research funding, one is turned down routinely.

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GALEA: But that's - one does not take that personally. I think - but I think Dr. Silver's point is valid. It's - because these events are challenging to launch research projects, it - the problems compound. You are trying to launch something quickly. You're trying to get funding quickly, and you really have no margin of error in getting the funding.

So it - the - it is - there's no question that it is harder to launch research projects under conditions of post-disaster than they are normally.

FLATOW: 1-800-989-8255. Dr. Cammarata, let's talk about the firefighters for a moment. And post-9/11, compared to other trauma survivors or the general population, how do the rates of PTSD rank among firefighters?

CAMMARATA: Well, in the general population, I believe there is an average about eight percent of post-traumatic stress disorder. But - and I think it was a study that was in 2006 that was on the retired and active members that were actively involved in the rescue and recovery rates downtown. They found 12 percent among those members to have symptoms of PTSD or to meet the criteria for the full disorder.

I think a lot depends on the population, though, within the fire department: those who were there at the time of the attacks, those who were there at the time of the collapse or the buildings or those who worked at the morgues. So there's many different groups within the entire department.

FLATOW: Do you see new firefighters, who never claimed to have PTSD before, now coming in and saying I don't know what's going on, I think I have it?

CAMMARATA: I have personally never had that experience, but I have had clients that have not come in until recently. And in my opinion, I feel like they've just sort of muddled through somehow, and then have recently gone through a situation that just exacerbated the symptoms that they had, whether it be another incident at work, like a fatal fire, whether it be the threat of a hurricane or something like that.

FLATOW: Well, that's what we were talking about before: Something new can trigger an old feeling or something that happened before. And then that's why there's a danger of watching the film - the video of it again this weekend.

CAMMARATA: I think a lot has to do with the threat of safety, of one's personal safety. I think that really is a main factor.

FLATOW: 1-800-989-8255. Let's go to Jane in Beaufort, South Carolina. Hi, there.

JANE: Hi there. It's Beaufort, South Carolina. Thank you for having me.

FLATOW: Excuse me.

JANE: I'm a licensed, professional counselor, and I'm trained in EMCR, cognitive process, as well as prolonged exposure. And I was wondering if there's any research, you know, comparing those types of - three different types of therapy with the victims, you know, with either acute stress disorder or post-traumatic stress disorder.

FLATOW: Dr. Watson?

WATSON: Yes, there has been research that has compared cognitive behavioral theory and cognitive processing therapy and exposure therapy and EMDR. And generally, taking into account a lot of methodological issues, they both - they all three show progress, that people recover and that the treatment is effective.

And what you hear is there are some studies that show that EMDR is a type of exposure treatment, and when you take away the bilateral movements across the midline, you still have the same effects. So there's a question about whether it's that much different. Other people say, yes, it is, and that it's more well tolerated than some of the other types of cognitive behavioral intervention.

So the same thing with exposure and cognitive processing treatment - there are studies that show that exposure tends to be more effective for the fear-based types of elements, but that cognitive processing might be better for guilt and anger and shame and that type of thing. So you'll see different results. But in general, the results are fairly good across all three of those types of treatments.

FLATOW: George in Santa Barbara, hi. Welcome to SCIENCE FRIDAY.

GEORGE: Thank you very much. My question has to do with the firefighters and their exposure about - and as you can hear in the background.

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FLATOW: Right on cue.

GEORGE: (unintelligible) ambulance going by. The delayed effect of the firefighters going in there, like their suicide rate is much higher than it was - I was a firefighter for, like, 30 years. And guess what, you know, it may occur sometime later. One of my good friends from - I'm a Vietnam vet. And 25 years later, he's driving on his vacation and had to pull over to the side of the road. He - and his wife says, what's wrong, and he's crying because he said, I couldn't save my men. There's some signs that come along with it, or is there something that you guys look at when it starts, like, five, 10 years later, five years later or down that line?

FLATOW: Good question. Thanks. We'll see if we can get an answer for you.

GALEA: Well, there - I think that there is no question that - as I mentioned earlier, repeat trauma is associated with psychopathology. And we do see this, that particularly trained personnel will have earlier trauma then go on to have subsequent trauma, which then manifests as post-traumatic stress disorder. The - I - we have seen cases where five, 10 years down the road, people will develop symptoms of post-traumatic stress disorder due to something that's quite trivial, in fact, at that time. But really what's happening is the symptoms are manifesting now as a result of a serious trauma years previously. And I think the caller is describing really a good example of that in the context of a firefighter.

FLATOW: Can you give us a definition of PTSD?

GALEA: Well, post-traumatic stress disorder is a complex of symptoms and is essentially the same reaction that one has when you're scared of something, only it persists for a very long period of time. So you have symptoms where you keep re-experiencing the event, you keep re-living it, you keep having nightmares, you keep having memories of it. You start avoiding what reminds you of the event, and you become what we call hyper-vigilant, which is you're very jumpy. And if everybody thinks about what you feel like when you're scared, it's a pretty dramatic feeling. PTSD is that set of symptoms, but continuing on chronically for weeks and weeks and months and even years.

FLATOW: Hmm. I'm Ira Flatow. This is SCIENCE FRIDAY from NPR, talking about mental health effects of 9/11. Let's see if we - a lot of people want to ask interesting questions. David in Boise, hi, welcome to SCIENCE FRIDAY.

DAVID: Hi. Thank you. I have a question for your guests regarding the emergency dispatchers that handled all of the thousands of calls. I'm a paramedic and been a paramedic for about 32 years. I also train dispatchers. And we have statistics from 9/11 within, like, the first 18 minutes after the first attack, 50 dispatchers got, like, 30-some-thousand calls, excuse me, I'm sorry, 3,000 calls, and they had about 55,000 calls total in that one dispatch center. And I was wondering if any studies had been done about the dispatchers experiencing stress from that situation.

FLATOW: Good question. Sandro, any...

GALEA: I am not aware of any studies that have been done, but I think the caller's point about dispatchers being overwhelmed is an essential point in our disaster preparedness. We just finished a full day meeting yesterday, bringing together scientists and policymakers around thinking of the next 10 years what should we do. And one of the big issues that emerges is our capacity to cope with future events and our limitations in the number of people who we have working in dispatch and how much pressure they're under is, I think, a critical rate (unintelligible) not to mention, of course, something that puts tremendous pressure on these people who are on the front lines.

FLATOW: Mm-hmm. Dr. Watson, what do we know about how young people have responded to 9/11? We talked a lot in the days after 9/11 about how we should talk to kids about what was happening. Ten years later, do we know how they responded?

WATSON: Knowing about children and researching about children can be more challenging, in some ways, because of funding and also ethical and difficulties with intervention research. However, we do know that depending on the developmental age, cognitively children responds very differently depending on how old they are. For instance, the younger children very much take their cues from their parents. And we know that part of the work that the National Child Traumatic Stress Network has tried to do over the last 10 years has been to find ways to educate parents about what to do with children at the different age, developmental ages.

We know that developmental milestones sometimes get interrupted in a way that doesn't necessarily happen with adults. So, for instance, right around this time of year, school is starting, things might have gotten put off. If there's any kind of ritual that a child misses, it can be a sticking point for them and then every year that becomes a trigger for them. Children, younger children, we heard anecdotally, when they were watching the images on the TV - because the parents would have the news programs on, understandably so. But we heard that children were sometimes confused and thought that multiple planes were flying into buildings all over the country because they kept seeing it happen over and over again on the news.

And so what we've tried to do is educate parents that they need to monitor and restrict, you know, exposure to these types of things with kids or be able to talk with them. We've tried to have school-based interventions as well for teachers and schools that can access groups of children and just give them education about what this means and how to cope with it. There's - usually with children there's a multi-pronged approach that involves some schoolwork and some work with parents and that type of thing.

COHEN SILVER: I'd like to just comment on this a little bit. I was involved in writing a review of the dozens and dozens of studies that have been done in the aftermath of 9/11 on children. And as Dr. Watson says, these are challenging studies to do. But I would say that the good news is that in general, with the exception of those children who were directly affected by the attacks - that is, they lost a loved one or they were at a school that - in which they could see the attacks occur outside their school window - with the exception of these directly impacted children, in general most children were quite resilient in response. Over time the symptoms abated.

FLATOW: All right. We're going to take a break, come back and talk lots more about the mental health effects of 9/11. Our number: 1-800-989-8255. You can tweet us, @scifri. Stay with us. We'll be right back.

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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. We're talking this hour about the mental health effects of 9/11 with Roxane Cohen Silver, Sandro Galea, Claire Cammarata, and Patricia J. Watson. Our number: 1-800-989-8255.

Dr. Cammarata, let's talk about something that's really interesting, and I had not heard about - post-traumatic growth. Is that good news?

CAMMARATA: It is. It is, but it oftentimes is confused or dismissive of the post-traumatic stress that can co-exist. So I think it's important to note that assessing for or addressing post-traumatic growth is not minimizing the trauma of the experience, the sadness, the suffering, but it's been a very interesting topic for me and one that I'm curious about and want to study further.

FLATOW: What is it?

CAMMARATA: Well, the idea is that after being exposed to a traumatic event, that an individual may have the opportunity to actually grow from the experience in different ways and areas of personal strength and their relationship with others and their spirituality.

FLATOW: Mm-hmm. They realize that they have given - been given a second chance, perhaps?

CAMMARATA: Mm-hmm. And that the trauma was grand enough to really shake up their world and give them an opportunity to possibly reorganize things, in a way.

FLATOW: Is there any percentage of people or any number you can give us about how - who is affected or who has experienced that?

CAMMARATA: Well, Tedeschi and Calhoun are really the ones who studied the concept of post-traumatic growth. One of the theories is that the trauma has to be seismic. It has to really impact the individual on a grand scale in order to have the potential for growth.

FLATOW: Are there types of personalities or coping strategies that make some individuals better able to survive and thrive after a trauma?

CAMMARATA: Mm-hmm. It's definitely thought that people who have a more optimistic personality or higher self-esteem are more prone to post-traumatic growth. In my study, that showed those who used emotional support, humor, but also those who used denial and disengagement also had higher levels of post-traumatic growth. But again, they also had high levels of post-traumatic stress as well, so they run parallel.

FLATOW: Dr. Silver, you've studied this, have you not?

COHEN SILVER: Mm-hmm. We looked at whether or not people across the country were able to see any social benefits from the attacks. So we didn't look merely at personal growth, but whether or not people saw that there were changes in society that they saw as positive. And in fact, we did find that many people were able to see something positive that happened after 9/11. As you may remember, there was an outgrowth - there was an outpouring of philanthropy. People gave charitable donations, gave blood, and there was a coming together. People saw benefits in the support of their communities and in the positive pro-social behaviors that they saw in their neighbors and friends.

FLATOW: Mm-hmm. Did you also find, as Dr. Cammarata talked about, that people who are more spiritual did cope better?

COHEN SILVER: We conducted some research showing - that did show that individuals who found religion as helpful in the aftermath of the attacks saw that as beneficial. And in fact they experienced more positive emotion over the years afterwards. Of course that doesn't mean that we should impose that on others, but we did see that those individuals who were more religious, who reported being more spiritual, did find that to be helpful, and they did adjust better over time.

GALEA: Ira, I would jump in for a second and agree with Dr. Cammarata that sometimes in the discussion around post-traumatic growth, we have - it has been confused with thinking that post-traumatic growth is a balm against post-traumatic stress disorder. And that is not the case. Research shows clearly - I'm in agreement with what both Dr. Cammarata and Dr. Silver have said, that there are - that there is evidence that there is a positive social good that emerges for some people from these events.

However, that does not mitigate the post-traumatic stress disorder that the bulk of people have. I think there are two different axes. I think some people do find meaning. I think these large-scale events do have a positive effect on some aspects of social bonding and on shifting social norms to the positive. But it doesn't minimize the potential harm that does occur to a substantial minority of the population that merits attention.

COHEN SILVER: I completely agree with that point.

FLATOW: Mm-hmm. 1-800-989-8255. Dr. Galea, let me ask you about - do these mental health effects, are they related to possible physical effects?

GALEA: Yeah. It's a terrific question. I think they are. The evidence suggests that they are. And increasingly, we are beginning to realize that. The - we are beginning to realize, increasingly, that the symptoms that I described, what we call, let's say, post-traumatic stress disorder, are not symptoms in isolation. They reflect an underlying pathophysiologic mechanism likely, in some respects, mediated by immune function that also is associated with the development of other disorders, including autoimmune disorders, for example, and cardiovascular disorders.

So we know that mental disorders and physical disorders after trauma go together. And, increasingly, we are beginning to realize that these are not two separate streams of research. They are representing different manifestations of the same spectrum of pathophysiology. And this is an important realization for us, because it won't direct us to finding the cause, and also, from a clinical point of view, I think helps us realize that when a patient presents - after a traumatic event, let's say with PTSD - she may well be at a greater risk of physical disorder.

And, conversely, if a patient presents to an emergency department with reports of, let's say, an asthma attack after a traumatic event, that kind of - that patient is at a substantially higher risk of PTSD.

FLATOW: Hmm. And possibly, could depression be involved here, too?

GALEA: Well, depression and PTSD after traumatic events frequently go together. In fact, it is a minority of PTSD patients, after these kinds of events, who do not also have some other psychopathology, with depression being most common, followed by use of substances, typically alcohol. So there are these complexes of what we call comorbidity, both with a number of mental disorders going together, as well as with mental disorders and physical disorders going together.

FLATOW: In the few moments I have left here, I want to ask - just throw out this question, and you're all welcome to answer it, and that is: What about the future? What do we need to know more about? And what should we be studying?

GALEA: Well, I'll tell you my two cents. I think we are - as we become more sophisticated in understanding the consequences of trauma, we are getting better at combining the impact of context of what happens outside us, the trauma and the biology that explains the symptoms that are happening. I think we are getting better, and we need to get better at understanding how trauma gets under the skin so we can understand the social processes and the biologic processes together. And I think that will lead us to a clearer sense of the nature of these disorders, of course, so that we may intervene and make them better.

COHEN SILVER: I think we need to do more research to identify what kinds of interventions might be most helpful for different aspects of the population. We heard, in some of the callers, people were highlighting that there have been workers that perhaps have been understudied relative to firefighters and recovery workers. We need to see how we might best treat individuals who encountered these kinds of traumas as part of their daily work activities, in addition to individuals who suffer direct loss and in addition to the more general population who may merely witness these kinds of events on the television screen.

CAMMARATA: I hope to see a continuation of studies in PTSD and the pathology that's related to trauma, but at the same time, to not ignore the resilience of these survivors.

FLATOW: Mm-hmm. Well, I want to thank you all for taking time to join us today. Roxanne Cohen Silver of the UC Irvine, Sandro Galea of Columbia, Claire Cammarata of NYU School of Social Work, and Patricia Watson at Dartmouth Medical School, thank you for taking time to be with us today.

WATSON: Thank you.

GALEA: Sure.

CAMMARATA: Thank you.

COHEN SILVER: Thank you very much.

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