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From the spectacular blue sky, a pale-pink shirt cuff flutters down next to Sarah Bunting. She watches as it drops to the pavement and tries to compose her thoughts. But her thoughts will not be composed.
Then she hears a cavernous groan. It is the sound of a skyscraper dying. The massive white dust cloud billows toward her.
Sarah stood five blocks from Ground Zero when the towers fell. She wasn't a first responder or a volunteer who came to help. She didn't live nearby or work in the area. She wasn't physically harmed that day and didn't know anyone who was. She was just a passerby, a 28-year-old Web producer who happened to be in town from Ontario.
And yet, in the months and even years that followed, she would lose her train of thought when planes flew overhead, jump at the sound of trucks clanking over metal plates, and for no obvious reason suddenly find herself feeling scattered. Even today she can't bring herself to get rid of the sediment-encrusted black heels that tortured her feet as she trudged uptown that long-ago Tuesday morning. It felt wrong to just wash them, as if all it took to cleanse trauma from her life was a damp cloth. But she couldn't just throw them away either. In the end, she stashed them in a shopping bag in the back of a closet, and like so much else from that hideous day, they've burdened her ever since.
Only recently has research begun to reveal what many people intuitively knew: You didn't need to have suffered a personal loss on 9/11 in order to have been traumatized by the attack. In the two-month aftermath, post-traumatic stress (PTS) symptoms were reported by fully 17 percent of the U.S. population outside New York. Even six years later, nearly one in four passersby, witnesses like Sarah, still suffered from PTS symptoms—a ratio even higher, amazingly, than that for first responders, according to a study conducted by the World Trade Center Health Registry.
The findings fly in the face of conventional wisdom, which holds that you can't suffer from post-traumatic stress disorder (PTSD) unless your exposure to the harrowing event was direct and immediate. But on the 10th anniversary of 9/11, the research is bringing a disturbing truth to light: If you witness a traumatic event—whether it's a terrorist attack, an accident, or a crime—your risk for PTSD may be higher than previously imagined. The question is: What can you do about it?
When you walk into a restaurant—any restaurant—you know what to expect. The experience conforms to an established routine: Someone seats you, you order, the food arrives, and then the waiter hands you a check.
Part of what distinguishes traumatic events from ordinary ones is that they have no template, says Edna B. Foa, Ph.D., director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. It's partly this absence of precedent that explains the shock people felt after September 11. "If you don't have a template for interpreting information, then it takes a lot more cognitive effort for your brain to assign a meaning to it," says Foa.
In the worst cases, your mind simply shuts down, says Rosemary Masters, J.D., L.C.S.W, director of the Trauma Studies Center of the Institute for Contemporary Psychotherapy. "There's a sense of detachment," she says. "The brain goes into pure survival mode."
Which may explain Sarah's muted response. "My reaction was to have no reaction," she says. "My mind was immediately like, You're not going to be able to handle this right now, so we're just going to muffle everything—climate control."
That same day, Michelle Ciulla, then a 32-year-old magazine executive, was working about two miles north of Ground Zero. She was standing on the roof of her West Village office building when the towers fell. Someone handed her a pair of binoculars, and suddenly, like a curse, hell leaped into focus: She saw the silhouette of wreckage falling. No—not wreckage. People. "I've always really regretted looking through the binoculars," says Michelle.
In the days that followed, she wandered her Brooklyn neighborhood. She wiped her car free of the half-inch of ash that the winds had carried over the East River. She endured the awful smell and chatted blankly with neighbors at her local bodega. And everywhere she went, she saw flyers for missing people.
"There was this one woman whose family plastered the neighborhood with her picture," she says. The woman was young and Italian, with beautiful dark hair. Just like Michelle.
She used to be a heavy sleeper. But ever since 9/11, Michelle wakes up five times a night. The daylight hours, meanwhile, are overcast by an impending sense of doom. "It's a feeling that something cataclysmic is going to happen that will change life forever," she says.
For most people, this kind of reaction fades within three to 12 months of the distressing event, says Masters. That's how long it generally takes for your brain to mesh a disturbing incident into the tricky weave of memories that make up who you are. "What causes PTSD [as opposed to PTS symptoms] is the failure of the brain to integrate a traumatic experience," she explains. If the experience isn't assimilated, the brain can't make sense of it and continues to regard it with alarm. That fear is then triggered whenever you encounter something that reminds you of the experience—loud noises, for instance, or emergency vehicles.
This is why, say, after a car crash, you may find yourself dazedly repeating over and over the story of what happened. "In effect, you're trying to kick-start the normal integration process by repeatedly telling your brain that the event is over and there's an appropriate meaning for it," explains Masters.
Sometimes the trauma leaks out in nightmares, a classic symptom of PTSD (see "Internal Injuries," at right, for other signs). While ordinary nightmares often have bizarre, fantasy-like content, PTSD nightmares are usually graphic, video-like replays of the traumatic event, says Kelly Bulkeley, Ph.D., former director of the Dream Studies Program at John F. Kennedy University.
The dream that terrorized Michelle night after night was stuck between an exact replay of 9/11 and a mercilessly distilled version of it. "It was like a black void," she says. "I could see people standing in front of me, kind of staggered, spread out. And the people farthest away just started exploding into flames. And it was coming toward me. I couldn't move.Ã¢â‚¬Â¦And I'd wake up right before I exploded."
The nightmares have faded, but even today, Michelle still frets about terrorist attacks on the subway. Yet she has never sought help. "I don't feel like my experience was bad enough," she says. "I felt like my feelings were an overreaction. There were people who were really suffering, and I just needed to get hold of myself."
"It's a very, very common finding," says Patricia Watson, Ph.D., senior educational specialist for the National Center for PTSD. "No matter what trauma they witnessed, people often don't seek treatment because they compare their lives to the lives of others who, from their perspective, are much worse off."
In fact, in a recent review of PTSD research, Watson found that it took 10 years on average for someone with PTS symptoms to seek treatment. The effects of this kind of delay are potentially devastating. "For instance, people start to withdraw," she says. "They lose jobs. They miss pleasurable and rewarding activities because they're stuck in their house. They start to drink more or do other addictive things to try to manage their anxiety or their depression." Research shows that not coping effectively with the trauma can increase your risk for PTS symptoms.
Being far away from the event doesn't preclude an emotional response. In fact, the actual physical distance from a terrifying incident makes less of a difference than you'd think. And it doesn't even matter, according to a wealth of new data, if you're watching it on TV.
Patricia Frost (not her real name) was a 32-year-old music publisher living in Midtown Manhattan, four miles from Ground Zero. Like so many others, she spent the whole day watching news coverage. "It's a hell of a thing to see on television," she says. "To try to connect that it's actually happening in real life is not easy. But then the news plays it over and over again, so it connects it for you. The news programs won't let you forget it."
On 9/11, the typical American watched 8.1 hours of television. In the week that followed, the typical New Yorker saw the towers fall an average of 29 times. Nearly 20 percent of New Yorkers saw footage of people jumping more than seven times. And research has shown that New Yorkers who saw the most coverage of the attacks were 66 percent more likely to develop probable PTSD than those who watched minimal television.
"September 11 was probably the first 24-7 live mass disaster," says Sandro Galea, M.D., Dr.P.H., of Columbia University's Mailman School of Public Health. "I think the next national tragedy will [have even more coverage]. People will be seeing it not just on TV—it will be on their iPhones and their computers." The most important thing, Galea says, is to be aware of the traumatizing power of this kind of coverage. "If the images are disturbing," he says, "they should not be watched repeatedly."
In the days following 9/11, Patricia felt as if she couldn't help herself. She fell asleep to the TV's apocalyptic mutter and woke up to its hysteria. Then she engulfed herself in the stories of friends—and even strangers—who were directly exposed to the attacks, all in an effort to puncture the blankness she felt and come to grips with what had happened.
"The deeper I got, the worse it got," she says. Eventually, at the insistence of her fiance, she unplugged the TV. But it was too late. Patricia had changed.
Her first panic attack struck within a month of 9/11, on the subway. "I thought I was going to pass out," she says. "My heart was pounding and I felt nauseous. I had tunnel vision." Every few days it would happen again. "I was just like, I don't feel well, I'm sick, or maybe I haven't eaten enough today." It didn't occur to her that she was having a reaction to witnessing a trauma.