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The Long-Term Reactions to Traumatic Events

November 2001

"I find myself going over to the window and looking at the skyline, again and again. I just keep thinking of those people in that building." -- Audrey

"It just keeps replaying the scene in my mind. Like a big magic trick, I see those planes going into the building and disappearing... then I start crying." -- Allen

"I find myself crying at the strangest times now. I stare at my 9-year-old daughter and think about her future. Then I watch her play and just start crying." -- Veronique

"I've lost over 20 friends to HIV/AIDS, and this just does the same for me. I'm just reliving the grief from that all over again. I think about taking care of myself and I feel guilty about that... really guilty." -- Anthony



In the moments and days after the World Trade Center attack, we all shared such common emotional reactions to this horrific event like fear, shock, helplessness and a profound change in the way in which we viewed our world. While these are all reactions that fall within the normal range of what we can expect to experience, now that we are more than a month away from the disaster, the persistence of these emotional states can profoundly cause one to have severe difficulty in overall functioning.

Furthermore, for people who have had previous traumatic exposures (e.g., car accidents, extreme social ridicule or combat) and for those who function with the chronic stress of an illness or poverty, there is an increased risk for post-traumatic stress disorder (PTSD). Therefore, groups that are "at-risk" might include: persons with HIV/AIDS; members of ethnic or racial minority groups; lesbian, gay, bisexual, or transgender persons; and the economically poor and homeless people. Persons with prior psychological histories of depression, mental retardation and psychosis are "at-risk" as well. Children, with their limited understanding and coping resources, struggle with attempting to make sense of traumatic events, so they often suffer from trauma and act out by exhibiting challenging behaviors rather than expressing themselves with words. All of these groups present with a risk of developing PTSD.

Mental health professionals describe PTSD, according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) as follows:

  1. The person has been exposed to a traumatic event.

  2. The event is persistently re-experienced.

  3. There is an avoidance of anything associated with the event and a new sense of numbness in response to other stressful events.

  4. There is a new persistence of an increased arousal to the environment.

  5. There is impairment in social, occupational and emotional functioning.

If a person experiences at least three of the aforementioned symptoms for longer than one month, the diagnosis of PTSD can be made, although only by a qualified, licensed, mental health professional. Here is a simple test you can take to see if you might be "at-risk" for PTSD:

  1. Are you continuing to replay the events of September 11 in your mind and reacting emotionally as if they are happening today?

  2. Are you continuing to avoid places and events associated with the traumatic event such as subways, cities, tall buildings, etc.?

  3. Are you more easily startled and scared by loud noises or sirens, and subway service interruptions in a way that you were not prior to the traumatic event?

  4. Do you feel emotionally numb and unresponsive to your environment in a way that is different prior to the attacks?

  5. Are you continuing to have difficulty in sleeping, eating, working, or concentrating on your work or family responsibilities?

  6. Have you become socially withdrawn and remained this way since September 11?

  7. Has your ability to take care of yourself (i.e., adhering to treatment regimes for people with chronic illnesses like HIV/AIDS) been effected by the events?

  8. Are you one of the "at-risk" groups mentioned above (e.g., economically poor, HIV-positive, a sexual minority, a racial minority, previous trauma history)?

If you found yourself answering "yes" to any of the questions above, it is recommended that you speak to your doctor about getting a referral for the services of a qualified mental health counselor. In many cases, these services are part of your health care plan, whether private or Medicaid/Medicare. These are entitlement services that are designed to be used specifically in situations like national disasters. Consult a referral source or hotline for the names of mental health providers that are qualified to assist people with PTSD.

Part of the healing process for the nation starts with our focused efforts on healing our family members, our neighbors and ourselves. Please share the information in this article with your loved ones and communities. Healing our pain starts with discussing our experience and recognizing that "we are not alone."

"I thought that I was the only person who was doing these strange things like calling my boyfriend ten times a day at work to see if he was OK, or not going to visit my friend who lives on the 21st floor. I was becoming a shut-in... no subways... I would just stay in Queens. I'm getting back to normal now... little by little." -- Ramon

Should You Seek Mental-Health Care?
In addition to post-traumatic stress disorder, other mental health conditions may be complicated by the experience of the tragedy of September 11. Below are some common signs and symptoms for three common psychological conditions: drug and alcohol dependence, clinical depression, and anxiety. These signs and symptoms are derived from the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association. Please note that there are many other psychological conditions which can affect people and which also may warrant consultation with a mental health professional.

If you feel that you may be experiencing mental health concerns, please seek out appropriate treatment and care. Start however you're able, maybe by talking to a knowledgeable friend or family member, your primary care physician, a member of the clergy, or a community-based agency such as Body Positive. If you need further assistance seeking help, consider calling the toll-free Body Positive telephone Helpline (1-800-566-6599) between Monday and Friday from 10 am to 6 pm.

Drug and Alcohol Dependence

If you have had three or more of the following symptoms in the past twelve months, you should seriously consider seeking professional assistance for possible drug and/or alcohol dependence.

Do you find that you have developed "tolerance" for the substance(s) you use? Tolerance means either that you need a greatly increased amount to get as high as earlier or that using the same amounts produces less of an effect.

Have you experienced "withdrawal" symptoms (i.e., physical reactions to the absence of the substance) or have you used other substances to relieve or avoid withdrawal?

Are you using more alcohol or drugs or using them over a longer period than you intended?

Do you persistently try, or try and find yourself unable, to cut down or control your use?

Do you spend a great deal of time obtaining the substance, using it, or recovering from its effects?

Are you reducing, or giving up important social, occupational, or recreational activities because of substance use?

Do you continue using alcohol or drugs even though you know they are causing physical or psychological problems for you?

Clinical Depression

If you have experienced four or more of the following symptoms during the same two week period, you should seriously consider seeking professional assistance for possible clinical depression. This is particularly the case if you think that the symptoms are not clearly related to HIV or some other physical condition.

Has your mood been depressed most of the day, nearly every day, during a two week period? This can be either in terms of how you feel or in terms of what others have commented on.

Have you had markedly less interest or pleasure in all, or almost all, activities most of the day, nearly every day, during a two week period? Again, this can be either in terms of how you feel or in terms of what others have commented on.

Have you experienced significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or the decrease or increase of your appetite nearly every day?

Have you been sleeping too little or too much?

Have you felt unusually restless or sluggish?

Have you felt fatigued or had a loss of energy nearly every day?

Have you had feelings of worthlessness or excessive guilt every day?

Have you had trouble thinking or concentrating, or felt unable to make up your mind about things, nearly every day?

Have you had thoughts of death (not just fear of dying) or of suicide?


If you have experienced the following symptoms either over a long period (such as over six months) or for a shorter duration with greater intensity, you should seriously consider seeking professional assistance for possible problems relating to anxiety. This is particularly the case if you think that the symptoms are not clearly related to HIV or some other physical condition.

Have you felt excessive anxiety and worry, occurring more days than not, about a number of events or activities?

Do you find it hard to control the worry?

Do you feel at least three of the following symptoms: restlessness or feeling keyed up; being tired easily; having trouble concentrating or feeling your mind go blank; being irritable; feeling tense; having difficulty falling or staying asleep or having restless, unsatisfying sleep?

Dominic J. Carbone, Ph.D. is a developmental psychopathologist and Chairman of the Board of Body Positive.

Back to the November 2001 issue of Body Positive magazine.

This article was provided by Body Positive. It is a part of the publication Body Positive.
See Also
Guide to Conquering the Fear, Shame and Anxiety of HIV
Trauma: Frozen Moments, Frozen Lives
More on Coping With Stress and Anxiety