Two women hold each other as they watch the World Trade Center burn on Sept.… (Ernesto Mora / Associated…)
For New York City resident Esperanza Muñoz, the attack on the World Trade Centers is not over 10 years later — not by a long shot. At odd moments, the stench of death still rises to her nose, and the 55-year-old woman slides into a haze of nausea and tears. She suffers headaches and is awakened several times a week by nightmares of headless bodies and shoes with bits of feet left inside. She dreads the sound of sirens or a passing plane.
Muñoz lives in the New York City borough of Queens, and can't — or won't — go into Manhattan, even to attend her support group for Latinas still scarred by the events of Sept. 11, 2001. She went to a meeting a few blocks from the site of the former World Trade Center once, six or seven years ago, but she became so panicked she had to leave.
Muñoz has a classic case of post-traumatic stress disorder, or PTSD, even though she is not a classic victim of the disorder. She has not survived a violent crime, warfare or even a clear sense that her life was threatened. She watched the fiery collapse of the World Trade Center towers from the roof of her apartment building in Queens, horrified but safe.
Two days later, the office and residential cleaning company that employed Muñoz assigned her to the blocks surrounding ground zero, where she picked up office mementos, charred debris and body parts from the ground almost every day for nearly four years. By 2009, the woman who had left a peaceful life in Colombia so she could send her son to college had twice attempted suicide.
When Al Qaeda terrorists violently seized control of four U.S. jetliners and crashed them, post-traumatic stress disorder was a diagnosis that had been in psychiatry's diagnostic manual for just 11 years. Most American mental-health professionals would rarely come across the disorder. Cases typically involved isolated patients — survivors of rape, child abuse, home fires or horrific automobile crashes. If soldiers, police officers and others whose jobs revolve around mayhem complained of nightmares, flashbacks and disabling anxiety, they were more likely to be accused of malingering than they were to be ushered into therapy.
But the events of Sept. 11 set in motion dramatic changes on all those fronts. Within months, PTSD was a widely observed condition. Afflicted firefighters, police and recovery workers were hailed as haunted heroes, not slackers. And a new generation of victims — military personnel deployed to two wars sparked by the terrorist attack — would soon bring the disorder home to nearly every community in America.
The sudden abundance of sufferers from the condition, and of research on them, has prompted the nation's psychiatrists to broaden their criteria for diagnosing the disorder in ways that would make room for people like Muñoz, whose exposure to the twin towers' fall was distant and whose symptoms took time to materialize. In the process, psychiatric leaders pondered for the first time how factors such as community cohesion, poverty and media coverage can affect the public's mental health when mass disaster strikes.
"9/11 changed the picture of PTSD, and transformed it from being simply a mental disorder that psychiatrists deal with to a public health issue," says Charles Figley, a pioneer in the study of the disorder who directs Tulane University's Traumatology Institute and Psychological Stress Research Program. Researchers have come to realize how well communities recover from mass violence or disaster is a barometer of their overall mental health, he adds.
For clinicians and researchers who had labored through the 1980s to understand PTSD, those affected by the events of Sept. 11 were a grim windfall — a population large and diverse enough to reveal important truths about the disorder.
The disaster gave researchers opportunities to study how trauma scrambles the brain (in medical terms, the onset of the disease). They could measure how often it appears in a typical population exposed to trauma (the disorder's prevalence) and how long it causes disruption and disability (disease progression). For the first time, the size of the population affected by a single trauma allowed researchers to discern which attributes or experiences make some people more vulnerable to the disorder (the term they use is risk factors) and which may be a source of resilience for others (protective factors).
"Before we had the current notion of PTSD, we tended to think that those who developed it were people with character disorders — there was a sort of 'blame the victim' quality to our thinking," says Dr. David Spiegel, director of Stanford University's Center on Stress and Health. Sept. 11, he says, has challenged much of that thinking.