9-11 United in Courage & Grief

It will be years before the full psychological and physiological impact on those who have witnessed these events--either in person or second-hand through television images--will be known. There has never been an event quite like this one, which has touched so many.

On this page you will find general information on the most common normal reactions--physiological and psychological following a tragedy and signs and symptoms indicating it is time to seek treatment. Also included is a section on Coping After Crisis. There is more information regarding the most common acute reactions, Acute Traumatic Response, Acute Grief Response, and Acute Stress Disorder. Finally there is a section that explores Complicated Mourning or Unresolved Grief paying attention to the most common long-term sequalae--Major Depression and Post Traumatic Stress Disorder--including ways of recognizing these disorders. An extensive bibliography of articles used to write this page as well as additional articles of interest found on the Internet is provided.

Introduction
During the acute phase of a reaction to a traumatic event, the presenting signs and symptoms can mimic many medical emergencies. If there is any doubt as to whether the symptoms you might be feeling in the aftermath of the tragedy are physical or psychological seek professional treatment. The information in this section is provided for educational purposes and cannot substitute for a professional evaluation by a physician or mental health practitioner.

There is a realistic concern by those in the medical and mental health communities that it will be years before the full psychological and physiological impact on the millions who witnessed these events will be known.

Prior to this event we have been a nation that denies and ignores grief. For the first time in a very long time, we have been faced with an event of such proportions that we, as a nation, are no longer able to ignore the pervasive grief response--too many people were killed or injured in the attacks, too many were watching as the events unfolded, too many people are impacted. We are a nation united in grief.

One way of helping in the aftermath of this tragedy is to normalize grief through education. If people understand that what they and others are feeling and experiencing is a normal response is to such an abnormal event--it will help improve the recovery process.

Common Normal Responses Following a Tragedy
There are a number of common reactions that occur following disasters. Most people who directly experience a major trauma have severe problems in the immediate aftermath. Thousands, if not millions, experienced this tragedy by watching it unfold on television. The feelings and reactions that one experiences in the aftermath of this event are likely to be the same ones as many other people are experiencing. These common responses include:

• Sadness
• Loss of interest in previously enjoyable activities
• Plans for the future no longer matter
• Tearful at unexpected moments, crying more easily or wanting to cry all the time
• Anger, rage
• Fear
• Anxiety
• Numbness
• Avoidance of situations that remind you of the trama--places, time of day
• Guilt because you are all right and others are not
• Difficulty falling asleep, staying asleep, or having nightmares
• Changes in appetite - eating too much or not being hungry
• Problems concentrating or difficulty in school
• Feeling helpless
• Negative view of the world
• Re-experiencing the trauma - nightmares, flashbacks
• Wanting to be alone more often than usual, or not wanting to be alone at all
• Moodiness, impatience or irritability
• Feeling jumpy, jittery, or shaky
• Startling with loud noises
• Increased use of alcohol or drugs following the traumatic experience can slow down the recovery process

• Stomachaches
• Headaches
• Increased allergies
• Rashes
• Colds and flu-like symptoms

People may responds to differently to the same traumatic event. Everyone feels stress and responds to stress in different ways. Some may not appear to have been affected. Not everyone has a reaction to a disaster. Some people have delayed reactions that do not show up for days, to weeks or even months later. Others never have a reaction at all. Everyone has their own coping mechanisms. We should take care not to compare our reaction with the reactions of others, or judge their reactions or even lack of reactions.  One helpful way of aiding in recovery is by education on what is a "normal response to an abnormal event" and by becoming more aware of the changes undertaken and the emotions experienced since the trauma.

In general, these feelings and reactions should disappear within four to six weeks or less as life continues and attention becomes focused on other things. Many people then feel much better within three months after the event, but others recover more slowly, and some do not recover enough without help. However, when a death is considered "traumatic" e.g. a death that is sudden or unanticipated, violent or destructive, random and/or preventable or when their are multiple deaths, this predisposes the grief process to be at a higher risk for complicated mourning. Complicated Mourning is a delayed or incomplete adaptation to loss or failure in the process of mourning. These types of losses are the ones that often require counseling and professional help from someone knowledgeable about traumatic losses to help the grieving cope with the loss. (More on Complicated Mourning later in this page)

Major Depression and Post Traumatic Stress Disorder are potential sequalae of complicated mourning, that can also
result from being a secondary victim of the incident--from watching the events unfold on television. The diagnosis of depression or PTSD is only made after experiencing symptoms for several weeks to months after the initial event,  we will just be starting to see people who will be diagnosed with these disorders in the aftermath of this tragedy.

Long ago we were taught to ignore grief rather than enter into it. Simply to hang on mindlessly until it is over. But this old perception cannot bear the weight of profound experience. Neat categories cannot accommodate the muddle of mature emotion. To get through grief, we let go rather than hand on, watching for the inner counselor who will guide us, ever mindful of the process that will slowly, patiently lead us where we need to go.

• Within the first 24 to 48 hours, participate in strenuous exercise coupled with relaxation. This will help alleviate some of the physical reactions.
• Try and keep busy. It is worse to just sit and do nothing.
• Write a letter to President, Congress expressing how you feel.
• Write a letter of thanks to the police, firefighters and emergency personnel.
• Make a Donation.
• Give Blood.
• Hang a Flag.
• Wear Red, White and Blue.
• Get educated as to what is a normal response. Don't tell yourself that you have lost your mind.
• Spend time with children, spouse, life partner, friends and co-workers.
• Do something you enjoy.
• Talk to people—talking is the one of the most healing thing you can do. Talk it out.
• Tell your story over and over, if necessary, for the reality of the events to sink in and to help diminish the pain.  Each time the story is told and someone else listens, a bit more healing occurs.
• Try not to cover up your feelings by withdrawing or by using alcohol.
• Reach out to others. Spend time with others. Do not isolate yourself. Ask other people how they are doing.
• Listen to other people's stories and help in their healing process.
• Find things to do that feel rewarding or refreshing.
• In time of crisis spiritual beliefs often help people to cope.
• Offer support and comfort to those  you know who have suffered a loss.
• Be patient and kind with each other. Fuses may be even shorter when dealing with crises and others may be feeling as much stress as you.

The response to a traumatic event should be viewed as a normal response to an abnormal event. The magnitude of the events that occurred on September 11, 2001, the traumatic nature of the death and the destruction, the suddenness and senselessness of the attack make it more likely that people who witnessed the events will have some response--physical (Physiological), emotional, cognitive or behavioral to this abnormal event. Depending on the perception and experiences of the event, people may experience one of the following responses or a combination of the following normal responses to this event:

• Acute Traumatic Response
• Acute Grief Response
• Acute Stress Disorder

Note: Not every response is evidenced by every person.

Acute grief is a definite syndrome characterized by the following psychological and somatic symptoms:

1. Sensations of somatic distress that occur in waves lasting for 20 minutes to an hour characterized by:

• Tightness in the throat
• Choking
• Shortness of breath
• Sighing
• An empty feeling in the stomach
• Lack of muscular strength
• Intense subjective distress described as tension or pain

 
2. Intense preoccupation with the image of the deceased, as in waking dreams, accompanied by feelings of
    vagueness and unreality.
3. Guilt feelings; the survivor reviews behavior before the death for evidence of negligence and failure.
4. Emotional distancing in relationships with others, accompanied by erratic responses of irritability, hostility and
    anger.
5. Disoriented behavior such as restlessness, insomnia, absentmindedness and an inability to concentrate or to
    initiate and maintain normal daily activities.

Common presenting signs and symptoms of Acute Stress Disorder include: generalized anxiety and hyperarousal, avoidance of situations or stimuli that elicit memories of the trauma, and persistent, intrusive recollections of the event via flashbacks, dreams, or recurrent thoughts or visual images. The symptom of dissociation, which is a perceived detachment of the mind from the emotional state or even the body, is a critical feature for the diagnosis. Dissociation also is characterized by a sense of the world as a dreamlike or unreal place, it may be accompanied by poor memory of the specific events, which in most severe form is known as dissociative amnesia.

Acute Stress Disorder is a diagnosis made by a mental health professional. There are specific diagnostic criteria which must be met before this diagnosis can be made.

A.   The person has been exposed to a traumatic event in which both of the following were present:
       1. the person experienced, witnessed, or was confronted with an event or events that involved actual or
           threatened death or serious injury, or a threat to the physical integrity of self or others
       2. the person's response involved intense fear, helplessness, or horror

B.   Either while experiencing or after experiencing the distressing event, the individual has three (or more)
       of the following dissociative symptoms:
       1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
       2. a reduction in awareness of his or her surroundings (e.g., "being in a daze")
       3. derealization
       4. depersonalization
       5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

C.   The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images,
      thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on
      exposure to reminders of the traumatic event.

D.  Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, people,
      conversations, activities, places).

E.  Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration,
      hyper vigilance, exaggerated startle response, motor restlessness).

F.  The disturbance causes clinically significant distress or impairment in social, occupational, or other
      important areas of functioning or impairs the individual's ability to pursue some necessary task, such as
      obtaining necessary assistance or mobilizing personal resources by telling family members about the
      traumatic experience.

G.  The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4
      weeks of the traumatic event.

H.  The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
      medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and
      is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

Nature provides the exact dosage for dealing with the constant strikes of pain we experience. Usually there is no real need for outside medication. Your body in its perfect wisdom gauges your requirements and numbs you accordingly. You will feel cold, but your bodymind will not allow more pain than you can tolerate. To disrupt the natural safeguards may only postpone the initial pain in your mourning process.

There is a realistic concern that due to the extreme traumatic nature of the events of September 11, 2001, that over time we will see a great potential for long-term psychological sequalae--for those directly involved in the events, as victims or as providers, and for those who were witnesses to the events; this is yet another byproduct of the terrorist acts.

Tragic events can be much more difficult to recover from quickly, or even at all. Much depends on the nature of the tragedy experienced or witnessed e.g. unnecessary or accidental death, rape, loss through natural disasters, death during war-time, unnecessary acts of violence. A death is considered to be "traumatic" it if is sudden or unanticipated, violent or destructive, random and/or preventable, when their are multiple deaths, or if there is no body available for viewing or burial; these factors predispose the grief process to be at a higher risk for complicated mourning. These types of losses are the ones that often require counseling and professional help from someone knowledgeable about traumatic losses to help the grieving cope with the loss and prevent Complicated Mourning or Unresolved Grief.

Complicated Mourning is a delayed or incomplete adaptation to loss or failure in the process of mourning. Unresolved Grief is a halting of the grief process, which becomes chronic unless treated.

11 Issues Inherent in Sudden, Unanticipated Death that lead to Complicated Mourning
These issues explain the reasons why sudden, unanticipated deaths lead to complicated mourning.

1.   The capacity to cope is diminished as the shock effects of the death overwhelm the ego at the same time
      new stressors are added e.g. heightened personal threat and vulnerability
2.   The assumptive world is violently shattered without warning and the violated assumptions e.g. the world
     as orderly, predictable, and meaningful, the self as invulnerable—cause intense reactions of fear, anxiety,
      vulnerability and loss of control.
3.   The loss does not make sense, and cannot be understood or absorbed.
4.   There is no change to say good-bye and finished unfinished business with the deceased, which cause
      problems due to the lack of closure.
5.   Symptoms of acute grief and of physical and emotional shock persist for a prolonged period of time.
6.   The mourner obsessively reconstructs events in an effort both to comprehend the death and to prepare
      for it in retrospect.
7.   The mourner experiences a profound loss of security and confidence in the world which affects all areas
      of life and increases many kinds of anxiety.
8.   The loss cuts across experiences in the relationship and tends to highlight what was happening at the
      time of the death, often causing these last-minute situations to be out of proportion with the rest of the
      relationship and predisposing to problems with realistic recollection and guilt.
9.   The death tends to leave mourners with relatively more intense emotional reactions, such as greater
      anger, ambivalence, guild, helplessness, death anxiety, vulnerability, confusion, disorganization, and
      obsession with the deceased along with strong needs to make meaning out of the death and to determine
      blame and affix responsibility for it.
10.  The death tends to be followed by a number of major secondary losses because of the consequences of
       lack of anticipation e.g. loss of home because of lack of financial planning.
11.  The death can provoke post traumatic stress responses e.g. repeated intrusion of traumatic memories,
       numbing of general responsiveness, increased physiological arousal.

• A depressive syndrome of varying degrees of severity
• A history of delayed or prolonged grief
• Symptoms of guilt, self-reproach, panic attacks, and somatic expressions of fear such as choking sensations and hyperventilation
• Somatic symptoms representing identification with the deceased, those of the terminal illness
• Physical distress under the upper half of the sternum accompanied by expressions such as
• "There is something stuck" or "I feel there is a demon inside me."
• Searching behavior - trying to locate the deceased symbolically or actually
• Recurrence of depressive symptoms and searching behavior on holidays or anniversaries
• A feeling that the death occurred yesterday, even though the loss took place months or years ago
• Unwillingness to move the material possessions of the deceased
• Change in relationships e.g. replacement of deceased with someone else
• Diminished participation in religious and ritualistic activities
• The inability to discuss the deceased without crying or the voice cracking, particularly when the death occurred over a year ago
• Recounting themes of loss

• Severe depression
• Hypochondriasis
• Psycho-physiologic reactions
• Alcoholism
• Drug Dependency
• Psychotic States
• Inhibited or Absent Grieving

Recognizing these symptoms in yourself or in others is the first step toward recovery and finding appropriate treatment. The symptoms to watch out for:

• Recurring thoughts or nightmares about the event.
• Re-experiencing the event through vivid memories or flash backs.
• Having trouble sleeping or changes in appetite.
• Experiencing anxiety and fear, especially when exposed to events or situations reminiscent of the trauma.
• Being on edge, being easily startled or becoming overly alert.
• Feeling guilty about surviving the event or being unable to solve the problem, change the event or prevent the disaster.
• Feeling depressed, sad and having low energy.
• Experiencing memory problems including difficulty in remembering aspects of the trauma.
• Feeling "scattered" and unable to focus on work or daily activities.
• Feeling overwhelmed by what would normally be considered everyday situations and diminished interest in performing normal tasks or pursuing usual interests.
• Having difficulty making decisions.
• Feeling irritable, easily agitated, suspicious, or angry and resentful.
• Feeling fearful and a sense of doom about the future
• Feeling emotionally "numb."
• Withdrawing, disconnecting. Avoiding social situations
• Feeling different from others.
• Spontaneously crying, feeling a sense of despair and hopelessness.
• Feeling extremely protective of, or fearful for, the safety of loved ones.
• Not being able to face certain aspects of the trauma, and avoiding activities, places, or even people that remind you of the event.
• Relying increasingly on alcohol or drugs to get through the day.

The symptoms of depression include feeling sad and blue, not enjoying activities once found pleasurable, having difficulty doing things that used to be easy to do, restlessness, fatigue, changes in sleep, appetite or weight, inability to make decisions, feelings of worthlessness, and thoughts of death or suicide.

Common Symptoms of Depression

• Persistent, sad, anxious or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness or helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, a feeling of fatigue, being "slowed down"
• Difficulty concentrating, remembering or making decisions
• Restlessness or irritability
• Insomnia, early-morning awakening, or oversleeping
• Changes in appetite or weight
• Unexplained, persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain
• Thoughts of death or suicide; suicide attempts

Signs That May Be Associated with Depression in Children and Adolescents
The diagnostic criteria and key defining features of major depression in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in the youth for several reasons. The way symptoms are expressed varies with the developmental stage of the child. Children and adolescents may have difficulty in identifying and describing their internal emotions or moods; they may act out and be irritable with others, because they are unable to communicate how they are feeling; this behavior is often interpreted as misbehavior or disobedience.

• Frequent vague, non-specific physical complaints e.g. headaches, muscle aches, stomachaches or tiredness
• recent absences from school, poor performance in school
• talk of or efforts to run away from home
• Outbursts of shouting, complaining, unexplained irritability, or crying
• Being bored
• lack of interest in playing with friends
• Alcohol or substance abuse
• Social isolation, poor communication
• Fear of death
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Reckless behavior
• Difficulty with relationships

If the symptoms and behavioral disturbances of the Acute Stress Disorder (see above) persist for more than 1 month, and if these features are associated with functional impairment or significant distress to the sufferer, the diagnosis is changed to Post Traumatic Stress Disorder. Post Traumatic Stress Disorder is further defined in DSM-IV as having three distinct subforms: acute (< 3 months’ duration), chronic (> 3 months’ duration), and delayed onset (symptoms began at  least 6 months after exposure to the trauma).

Post Traumatic Stress Disorder is characterized by the following:

• Immediate response to a tragedy involving intense fear, helplessness, or horror
• Continuously re-experiencing the event with images, dreams, flashbacks, nightmares and/or a sense of reliving the experience, especially when they are exposed to events or objects reminiscent of the trauma
• Avoidance of any reminders or thoughts of the ordeal
• Emotional numbness
• Depression
• Feelings of intense guilt
• Symptoms of increased irritability such as outbursts of anger, difficulty sleeping, trouble concentrating
• Symptoms of Acute Stress Disorder that last for more than one month and/or impairing functioning in social, occupational, or other areas of life

Among those who may experience or have experienced PTSD are military troops who served in Vietnam and the Gulf Wars; rescue workers involved in  the aftermath of disasters like the Oklahoma City bombing; survivors of accidents, rape, physical and sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of the 1994 California earthquake, the 1997 South Dakota floods, and hurricanes Hugo and Andrew; and people who witness traumatic events, including watching the events on television. Family members of victims also can develop the disorder. PTSD can occur in people of any age, including children and adolescents. The highest rates of post traumatic stress disorder are found among women who are victims of crime, especially rape, as well as among torture and concentration camp survivors. Overall, among those exposed to extreme trauma, about 9 percent develop post traumatic stress disorder. An estimated 5.2 million American adults (ages 18 to 54) or approximately 3.6 percent of people in this age group in a given year, have PTSD.

Symptoms of this disorder usually occur within the first three months after the trauma, although there can be a delay of months or even years before symptoms appear. Length of symptoms vary from person to person. Approximately half of the people affected by PTSD tend to recover within 3 to 6 months. However many people report their symptoms lasting for longer than 12 months after the trauma. For many the disorder may persist for years, dominating a person's life.

For a more information on Post Traumatic Stress Disorder or to take a quick Screening Quiz for Post Traumatic Stress Disorder start with the information from the National Institute of Mental Health, Post Traumatic Stress Disorder (PTSD), A Real Illness at http://www.nimh.nih.gov/anxiety/ptsdri1.cfm

Disclaimer:
If there is any doubt as to whether the symptoms you might be feeling in the aftermath of the tragedy are physical or psychological seek professional treatment. The information in this section is provided for educational purposes and cannot substitute for a professional evaluation by a physician or mental health practitioner. It is not designed to be a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.

Additional Articles
Department of Health and Human Services http://www.mentalhealth.org/cmhs/EmergencyServices/after.htm
Mental Health Aspects of Terrorism - http://www.mentalhealth.org/cmhs/EmergencyServices/terrorism.htm
National Depressive and Manic-Depressive Association. Coping with a Traumatic Event. http://www.ndmda.org/Posttraumatic_Stress.htm
National Institute for Mental Health. Response to Terrorist Acts Against America
http://www.nimh.nih.gov/outline/responseterrorism.cfm
National Institute of Mental Health. The Invisible Disease: Depression http://www.nimh.nih.gov/publicat/invisible.cfm
National Institute of Mental Health. The Effects of Depression in the Workplace http://www.nimh.nih.gov/publicat/workplace.cfm
National Institute of Mental Health. Reliving Trauma - PTSD http://www.nimh.nih.gov/publicat/reliving.cfm
National Center for Post Traumatic Stress Disorder. Disaster Mental Health: Dealing with the Aftereffects of Terrorism http://www.ncptsd.org/disaster.html
Mental Health Report of the Surgeon General, Chapter 4 - Anxiety Disorders. http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html
Screening for Mental Health, Inc. When Depression and Other Illnesses Co-Exist http://www.mentalhealthscreening.org/brochure/index.htm

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In Memory of all those lost and forever missing from the events on September 11, 2001, the day our world changed.
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