Parental response and adolescent adjustment to the September 11, 2001 terrorist attacks

This study examined adolescents' adjustment following the attacks of September 11, 2001 (9/11). A Web-based survey was administered 2 weeks and 7 months postattacks to a national sample of adolescents (N = 104). A randomly selected parent also completed a survey at the 7-month assessment. Although exposure to the attacks was indirect, over half the participants felt threatened. Adolescents' posttraumatic stress symptoms were associated with their acute stress symptoms, parental distress, parental coping advice, parental availability to discuss the attacks, and reports that 9/11-related discussions were unhelpful. Adolescents' distress symptoms were associated with a history of mental health problems, acute stress symptoms, and parental unavailability to discuss the attacks.     

Alterations in affective processing of attack images following September 11, 2001

The events of September 11, 2001 created unprecedented uncertainty about safety in the United States and created an aftermath with significant psychological impact across the world. This study examined emotional information encoding in 31 healthy individuals whose stress response symptoms ranged from none to a moderate level shortly after the attacks as assessed by the Impact of Event Scale-Revised. Participants viewed attack-related, negative (but attack-irrelevant), and neutral images while their event-related brain potentials (ERPs) were recorded. Attack images elicited enhanced P300 relative to negative and neutral images, and emotional images prompted larger slow waves than neutral images did. Total symptoms were correlated with altered N2, P300, and slow wave responses during valence processing. Specifically, hyperarousal and intrusion symptoms were associated with diminished stimulus discrimination between neutral and unpleasant images; avoidance symptoms were associated with hypervigilance, as suggested by reduced P300 difference between attack and other images and reduced appraisal of attack images as indicated by attenuated slow wave. The findings in this minimally symptomatic sample are compatible with the alterations in cognition in the posttraumatic stress disorder (PTSD) literature and are consistent with a dimensional model of PTSD.     

Strategien des Rettungsdienstes – Konsequenzen nach dem 11. September 2001

The terrorist attack of the 11 September 2001 has demonstrated the necessity for managed health care strategies in cases of major disasters.A year after the attack, at the 1st International Congress for the 11 September 2001 in Hamburg, the consequences for the emergency services were discussed. In this contribution, thoughts on the strategies to be adopted, in particular by the medical services in relation to the care of those involved, coordination and cooperation with other emergency organisations (fire brigade, army, civil defence) will be considered. In addition, the practical consequences for the emergency services will be discussed.Our changed perception of possible danger requires new strategies for emergency preparedness and civil protection.     

Posttraumatic Stress Disorder,Gender, and Risk Factors: World Trade Center Tower Survivors 10 to 11 Years After the September 11, 2001 Attacks

Ten to eleven years after the September 11, 2001 terrorist attacks, probable posttraumatic stress disorder (PTSD) was evaluated in 1,755 World Trade Center (WTC) evacuees based on data from the WTC Health Registry. Characteristics of men and women were compared and factors associated with PTSD symptom severity were examined using the PTSD Checklist (PCL). Compared with men (n = 1,015, 57.8%), women (n = 740, 42.2%) were younger and of lower socioeconomic status. Ten to eleven years after September 11, 2001, 13.7% of men and 24.1% of women met criteria for PTSD. Results indicated that when considered with all other variables (i.e., demographic, socioeconomic and social resources, exposure to the attacks, life events), gender was not a significant predictor of PTSD symptom severity. Being younger on September 11, 2001, unemployed, less educated, and/or having higher exposure to the attacks, unmet mental health care needs, and less social support predicted higher PCL scores for both genders (βs = .077 to .239). Demographic characteristics and socioeconomic resources (ΔR ² = .113) accounted for the largest amount of variance in PCL scores over and above exposure/evacuation, mental healthcare needs, and social support variables (ΔR ² = .093 to .102). When trends of unmet mental healthcare needs were analyzed, the most prevalent response for men was that they preferred to manage their own symptoms (15.1%), whereas the most prevalent response for women was that they could not afford to pay for mental health care (14.7%). Although the prevalence of probable PTSD in women tower survivors was approximately twice as high as it was for men, this is attributable largely to demographic and socioeconomic resource factors and not gender alone. Implications for treatment and interventions are discussed.     

Mental and Physical Health Consequences of the September 11, 2001 (9/11) Attacks in Primary Care: A Longitudinal Study

The magnitude of the September 11, 2001 (9/11) attacks was without precedent in the United States, but long‐term longitudinal research on its health consequences for primary care patients is limited. We assessed the prevalence and exposure‐related determinants of mental disorders, functioning, general medical conditions, and service utilization, 1 and 4 years after the 9/11 attacks, in an urban primary care cohort (N = 444) in Manhattan. Although the prevalence of posttraumatic stress disorder (PTSD) and levels of functional impairment declined over time, a substantial increase in suicidal ideation and missed work was observed. Most medical outcomes and service utilization indicators demonstrated a short‐term increase after the 9/11 attacks (mean change of +20.3%), followed by a minor decrease in the subsequent year (mean change of ?3.2%). Loss of a close person was associated with the highest risk for poor mental health and functional status over time. These findings highlight the importance of longitudinal assessments of mental, functional, and medical outcomes in urban populations exposed to mass trauma and terrorism.     

Complicated Grief Among Military Service Members and Veterans Who Served After September 11, 2001

Minimal research is available on the prevalence and impact of complicated grief (CG) in military service members and veterans, despite high reported rates of loss in this population. The present study aimed to examine prevalence rates of CG in a sample of treatment‐seeking military service and members and veterans who served after September 11, 2001. Additionally, the study aimed to examine characteristics associated with CG as well as the association between CG and quality of life. In a sample of 622 military service members and veterans who served after September 11, 2001, 502 reported a significant loss (80.7%). Usable data were available for a total of 468 participants. Of these 468 participants, 30.3% (n = 142) met diagnostic criteria for CG, as defined by a score of 30 or more on the Inventory of Complicated Grief (ICG; Prigerson et al., 1995). We conducted a series of t tests and chi‐square tests to examine the differences between individuals who met criteria for CG and those who did not. The presence of CG was associated with worse PTSD, d = 0.68, p < .001; depression, d = ?1.10, p < .001; anxiety, d = ?1.02, p < .001; stress, d = 0.99, p < .001; and quality of life, d = 0.76, p < .001. Multiple regression analyses examined the independent impact of CG on quality of life. Complicated grief was associated with poorer quality of life above and beyond PTSD, β = ?.12, p = .017. In addition, in a separate regression, CG was associated with poorer quality of life above and beyond depression, β = ?.13, p < .001. Overall, our findings highlight the impact of CG on this population, and have implications for assessment and treatment.     

Patterns of Comorbidity Among Bereaved Family Members 14 Years after the September 11th, 2001, Terrorist Attacks

Studies of terrorism‐related deaths are few and mostly focus on short‐term effects. To characterize long‐term bereavement outcomes, including resilience/recovery and patterns of comorbidity, following the September 11, 2001 (9/11), terrorist attacks, we report mental health conditions and grief‐related impairment in 454 9/11 bereaved family members. In addition, the contribution of non‐9/11 lifetime traumas, pre‐9/11 mental health conditions, post‐9/11 interim life events, grief services, income adequacy, and social support were examined. Latent class analyses yielded three groups: healthy, comorbid without PTSD (comorbid/noPTSD), and comorbid with PTSD and impaired (comorbid/PTSD+I). Participants in the healthy group (66.1%) were least likely to meet thresholds for mental conditions, whereas those in the comorbid/noPTSD (21.3%) and comorbid/PTSD+I (12.6%) groups had higher probabilities of meeting depression, grief, and anxiety thresholds. These groups also endorsed more negatively valenced post‐9/11 interim life events than the healthy group: comorbid/noPTSD vs. healthy, odds ratio (OR) = 0.84, 95% CI [0.76, 0.94]; comorbid/PTSD+I vs. healthy, OR = 0.85, 95% CI [0.76, 0.96]. Comorbid/PTSD+I was the only group with elevated probabilities of meeting clinical thresholds for PTSD (.64) and grief‐related impairment (.94). This group was also more likely to include bereaved parents: comorbid/PTSD+I vs. healthy, OR = 12.96, 95% CI [1.97, 85.41]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 15.55, 95% CI [1.63, 148.41]); and to experience more non‐9/11 lifetime traumas: comorbid/PTSD+I vs. healthy, OR = 4.34, 95% CI [1.28, 14.70]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 6.54, 95% CI [1.53, 27.95]. Clinical and community programs should target this high‐risk group to identify individuals in need of services.     

Two New York City hospitals' surgical response to the September 11, 2001, terrorist attack in New York City

BACKGROUND: We describe the surgical response of two affiliated hospitals during the day of, and week following, the September 11th, 2001 terrorist attack at the World Trade Center in New York City. The city of New York has 18 state designated regional trauma centers that receive major trauma victims. The southern half of Manhattan is served by a burn center, two regional trauma centers, and a community hospital that is an affiliate of one of the regional trauma centers. This report accounts for the surgical response by a regional trauma center (Hospital A, located 2.5 miles from the World Trade Center) and its affiliate hospital (Hospital B, located 5 city blocks from the World Trade Center) on September 11th when two commercial jets crashed into the Twin Towers at the World Trade Center mall. METHODS: Hospital A maintained a concurrent log of patients received during the first 5 hours, the first day, and the first week after the disaster which was kept by the Surgical Triage Officer. The trauma registry completed and verified this data by September 18th. Hospital B collected its data by hand counting and verification by chart review. Both hospitals, A and B, had established disaster plans that were implemented. RESULTS: Nine hundred eleven patients were received by two affiliated hospitals from the World Trade Center attack. Seven hundred seventy six patients (85%) were walking wounded, sustaining mild inhalation and eye irritant injuries. One hundred thirty five (15%) were admitted with 18 (13%) of these undergoing surgery. Twenty two of the 23 transfers were from the community hospital to specialized orthopedic or burn centers. Of the 109 patients admitted to Hospital A, 30 were to the surgical service. The mean ISS score of these patients was 12. There were 4 deaths (within minutes of arrival at the hospital) and 6 delayed deaths (day 1-14). Excluding walking wounded and DOAs, the critical mortality rate was 37.5% overall. CONCLUSION: The September 11th, 2001, terrorist attack in New York City, involving two commercial airliners crashing into the World Trade Center, led to 911 patients received at two affiliated hospitals in lower Manhattan. One hospital is a regional trauma center and one was an affiliate community hospital. Eighty five percent of the patients received were walking wounded. Of the rest, 13% underwent surgical procedures with an overall critical mortality rate of 37.5%.     

Splenic embolization revisited: a multicenter review

BACKGROUND: Splenic embolization can increase nonoperative salvage. However, complications are not clearly defined. A retrospective multicenter review was performed to delineate the risks and benefits of splenic embolization. METHODS: A retrospective chart review of all patients undergoing splenic embolization from 1997 to 2002 at four separate Level I trauma centers was performed. Reviewed results included patient demographics, admission and follow-up computed tomographic scan results, angiographic technique, and patient outcomes including splenic salvage rate and procedural complications. RESULTS: A total of 140 patients were reviewed. The majority were young male patients involved in motor vehicle crashes. These patients had high abdominal computed tomographic grades of splenic injury and moderate Injury Severity Scores. The splenic salvage rate was 87%, which decreased with increasing injury grade. However, over 80% of splenic injury grades 4 and 5 were successfully managed nonoperatively. Significant hemoperitoneum did not affect success, but the presence of arteriovenous fistula was associated with a high failure rate, even with embolization. Salvage rates were similar between main coil and subselective embolization groups. Patients over 55 years of age did no worse than younger patients. Major complications included bleeding in 16 patients; 6 splenic abscesses, with 5 patients requiring splenectomy; and 1 episode of arterial injury requiring operative repair. CONCLUSION: Splenic embolization remains a valuable technique in splenic salvage, especially in higher grade injuries. Complications are common but do not seem to affect outcome.     

Aftermath of Terror: A Nationwide Longitudinal Study of Posttraumatic Stress and Worry Across the Decade Following the September 11, 2001 Terrorist Attacks

Research conducted in the early years after the September 11, 2001 (9/11) terrorist attacks in New York, Pennsylvania, and Washington, DC demonstrated adverse psychological outcomes among residents of the United States who were exposed to the attacks both directly and indirectly via the media. However, less is known about the impact of this collective trauma over time. Beginning at the end of December 2006, a longitudinal study of a nationally representative sample of U.S. residents (Cohort 2, N = 1,613) examined the long‐term effects of 9/11, with annual assessments administered every year for 3 years. We assessed rates of 9/11‐related posttraumatic stress (PTS) annually during the first 2 years of the study; during the second and third years of the study, we assessed fear and worry regarding future terrorism. Rates of PTS among participants were compared with those assessed annually in a nationally representative sample between 2002 and 2004 (Cohort 1); results indicated a relatively stable pattern of 9/11‐related PTS symptoms for 6 years following the attacks. Five to six years after 9/11, we found an association between 9/11‐related PTS and both direct, B = 8.45, 95% CI [4.32, 12.59] and media‐based (live television), B = 1.78, 95% CI [0.90, 2.65] exposure to the attacks. Six to 7 years post‐9/11, fear and worry regarding future terrorism were predicted by 9/11‐related PTS symptoms that had been reported approximately 5 years after the attacks, B = 0.04, 95% CI [0.03, 0.05]. The psychological legacy of 9/11 was perceptible among many U.S. residents throughout the decade that followed.     

Human Remains Identification,Grief, and Posttraumatic Stress in Bereaved Family Members 14 Years After the September 11, 2001, Terrorist Attacks

Returning human remains to family members after a loved one's death is thought to support grief adaptation. However, no known research has examined the effects that notifications of fragmented remains have on bereaved family members. We examined the number of notifications received, continuing questions about the death, grief severity, and posttraumatic stress (PTS) in family members bereaved by the September 11, 2001 attacks (N = 454). One notification was associated with fewer continuing questions compared to zero notifications, p = .037, or two or more notifications, p = .009. A model using notifications and continuing questions to predict grief severity showed there was no difference between receiving one and zero notifications, p = .244; however, receipt of two or more notifications was associated with higher grief severity compared to zero notifications, p = .032. A similar model demonstrated that receipt of any notifications was associated with PTS, ɳ_p² = .026, p = .006. Having continuing questions was associated with grief severity, ɳ_p² = .170, p < .001; and PTS, ɳ_p² = .086, p < .001. Additionally, participants who received one notification and chose not to receive more had fewer continuing questions compared to all other participants, and participants who received two or more notifications and chose no future notifications had higher PTS levels compared to all other participants. The results indicate that human remains notification is not associated with reduced grief severity but is associated with PTS. These findings should inform notification policy and guide families’ notification choice after traumatic deaths.