9/11 Changed How Doctors Treat PTSD

New research in the 20 years since the September 11th attacks has led to better therapies for those diagnosed with trauma disorders

9/11 attacks
Firefighters walk towards one of the towers at the World Trade Center before it collapsed on September 11, 2001. Jose Jimenez/Primera Hora/Getty Images

Before September 11, 2001, many people thought of trauma and post-traumatic stress disorder (PTSD)—if they thought of them at all—as things that happened to soldiers in faraway war zones.

But after the entire nation watched the Twin Towers crumble on television, it became clear that trauma could hit much closer to home. And you didn’t need to be physically involved to feel the effects, either.

In the aftermath of the attacks, a significant minority of New York residents experienced PTSD symptoms. The World Trade Center Health Registry, which tracks health effects of the attacks, shows that about 16 percent of participants (volunteers who either lived, worked or attended school near the World Trade Center or were involved in rescue and recovery efforts after the disaster) experienced probable PTSD five to six years after 9/11.

In the 20 years since the terrorist attacks, there’s been dramatic innovation in the treatment of trauma and PTSD, a disorder caused by exposure to traumatic events, with symptoms including disturbing thoughts, nightmares, flashbacks and physical distress. The disorder has been recognized since antiquity—symptoms are described in ancient texts from the Bible to the Epic of Gilgamesh—and became familiar as “shell shock” after World War I, when it was treated with techniques ranging from Freudian psychoanalysis to lobotomies. But it wasn't until 1980 that it appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM) under its current name. While many trauma patients will have symptoms in the aftermath of their experience, only a fraction will go on to develop the more severe and long-lasting PTSD. About 50 to 60 percent of all people will experience a major traumatic event in their lifetimes; an estimated 7 or 8 percent will develop PTSD.

“[9/11] really increased our understanding of trauma and PTSD—how both can impact large groups and communities of people in both the short and long term,” says Priscilla Dass-Brailsford, a professor of psychology at Georgetown University who studies trauma and PTSD. “Before this, we barely had well-developed crisis protocols in the aftermath of disasters. But after 9/11 a lot of institutions began to prepare protocols that could be used in a crisis.”

These new crisis protocols include “psychological first aid”—a term that refers to psychological treatment in the immediate aftermath of a traumatic event. This first aid involves actively listening to those who have experienced trauma and assessing their needs, much the way an ER nurse triages injuries. Some may want to talk, while others need time and space. Some will need concrete resources—like a new house to replace one destroyed in a hurricane—to recover. The first aid model largely replaced the 1970s model of “critical incident stress debriefing” that was still widely used in 2001, which involves gathering people in groups to talk immediately about their experience. Research has since suggested that these debriefings are not helpful, and can actually increase stress.

For those who do go on to develop PTSD, better longer-term therapies are now available as well. In the wake of 9/11, counseling and psychology programs started to make courses in trauma treatment mainstream, and a whole generation of mental healthcare providers graduated with an understanding of which therapies work best for trauma patients. These therapies include cognitive behavioral therapy (CBT), a type of talk therapy that helps patients identify negative thought patterns, and exposure therapy, where a patient is exposed to a (safe) situation that reminds them of their trauma. While neither of these therapies are new—both were developed around the mid-20th century—providers now better understand how to apply them to trauma.

The general public also now has a much greater understanding of trauma, Dass-Brailsford says. If an agency or school experiences a traumatic event like a homicide, it’s much more common to bring in trauma-focused therapists in the aftermath to conduct interventions. Celebrities like Ariana Grande and Lady Gaga are open about their PTSD in the media. Words like “trigger” and concepts like the importance of anniversary dates are now part of the cultural discourse. A recent study of American adults found that “most people demonstrated good general knowledge of PTSD.”

Paula Schnurr, executive director of the National Center for PTSD, a part of the U.S. Department of Veterans Affairs, says even more exciting developments are coming down the pike. She and her colleagues have been studying ways of making PTSD therapy more convenient and accessible for a larger number of people. Traditional therapy involves seeing a therapist in an office for an hour or so a week for many months. This kind of commitment can be difficult to keep, Schnurr says, and the Covid-19 pandemic has only made it harder.

To reduce this burden, a number of studies have looked at compressing a traditional multi-month course of therapy into as little as a week of intensive treatment. Another new study looks at delivering therapy via asynchronous text messaging. The patient communicates by text with the therapist, who then replies a set number of times every day.

“It really helps to make the treatment much more accessible and engaging,” Schnurr says.

Other studies look at drugs and devices for enhancing talk therapy. One Veterans Affairs study showed that patients who received cannabidiol (CBD) during exposure therapy progressed faster than patients receiving exposure therapy alone. Another study led by VA researchers looked at transcranial magnetic stimulation (TMS), a noninvasive procedure that uses magnets to stimulate the brain, which has been shown to help treatment-resistant depression. Patients who had TMS along with therapy also fared better than those receiving therapy alone.

Yet another line of research involves looking for biomarkers, or objective physical indicators, for PTSD. While many biomarkers, like increases in certain hormones or inflammation, are known to be associated with PTSD, the key, Schnurr says, will be targeting the right ones, in the right combinations, to be useful for diagnosis and treatment.

“This is still very much an emerging science,” she says.

One person who’s betting on this nascent science is neuroscientist Jennifer Perusini, CEO of Neurovation Labs, a New York biotech company. Neurovation Labs is working with the U.S. military on finding biomarkers for PTSD. They’re currently focusing on a protein called GluA1, noting that rodents exposed to trauma have higher levels of the protein in their brain’s fear centers. Once the levels of GluA1 are lowered, the rats cease to show PTSD-like symptoms.

Perusini’s company has developed a radio tracer that binds to GluA1 molecules and allows them to be seen on PET scans. Her team hopes to begin clinical trials in the next 18 months. If the screenings work, they could then potentially develop drugs to target the proteins.

For Perusini, the interest in trauma and PTSD is personal. “I am a lifelong New Yorker, and I lived through 9/11,” she says. “Where I grew up in Rockland County, we had such a high number of first responders lose their lives.” The same month the towers fell, Perusini lost both her mother and her grandfather. “So I just started becoming acutely aware of people’s coping mechanisms,” she says.

Some people seemed to rebuild and thrive after traumatic experiences, she says, while others lost their way. “I really wanted to know what was going on in the brain,” Perusini says. She went on to study behavioral neuroscience in college, then earned a PhD in the same subject from UCLA, where she worked in a lab researching fear and anxiety in rodent brains. In 2016, she launched Neurovation Labs, which expanded on her doctoral research on the neural mechanisms behind PTSD.

Both Dass-Brailsford and Schnurr emphasize that most people exposed to trauma will not go on to develop PTSD. But for the ones who do, the outlook for treatment is more optimistic than ever.

“The most important thing, and the most exciting thing to me that has happened since 9/11 is that we can say with confidence that PTSD is not a lifelong disorder,” Schnurr says. “We can treat it, and we can offer a message of hope.”