By David M. Benedek and Elissa P. Benedek
Posted: Friday, February 1, 2002

ARTICLES
Publication Date: February 1, 2002

Illusions of Immunity

The tragedies of September 11, 2001 shattered most Americans' previous notions of the threat of terrorism in our homeland. Prior to these events, kidnappings, suicide bombings, and the murder of innocent civilians appeared to be problems of "third world" or war-torn nations from which we were uniquely immune. However, the sudden and unexpected murders of thousands of Americans in New York and hundreds more in Washington, D.C. and Pennsylvania by terrorists drove home the idea that Americans, too, must address these threats to our way of life and our civilization.

Our heightened state of alert following September 11th raised consciousness and fears of further attacks, including the potential for bioterrorism or other weapons of mass destruction. To some extent, these fears were realized with the anthrax letters of October. As members of the media and government leaders announced that anthrax led to severe illness and in some cases death of office workers in Florida, Washington D.C., New York, and Connecticut, government offices closed, mail service was disrupted, and varying states of fear, anxiety, and depression swept our nation. Even as public health officials and government leaders acted to contain this threat, citizens ruminated over their own safety, the safety of friends, family, and loved ones, and what danger would come next. The extent to which fear, anxiety, and terrorism-related depression affects our daily lives are questions to be answered by ongoing epidemiological studies. However, even without the "hard numbers," it seems that almost everyone experienced these symptoms to some degree, many may still be experiencing them today, and some may continue to do so in the months ahead. Many people are asking themselves if their reactions are "normal," or what can be done "to feel normal again." While no simple answer to these questions applies to everyone, knowledge of some basic principles of the psychological response to traumatic or stressful events may help Americans understand their current emotions and behaviors and provide guidance on the effort to "return to normal."

Psychological Reactions to Stressful Events

Although America has never before experienced the horror of mass murder on its own soil to this magnitude, previous studies of the aftereffects of natural disasters such as earthquakes or man-made disasters such as train derailments, both here and abroad, have taught us much about the psychological and behavioral responses to trauma—the Traumatic Stress response. The symptoms of fear and anxiety, including avoidance (staying away from the office or air travel), hyper-alertness, easy startle, sleep difficulties (even nightmares), irritability, and mood changes, have all been observed and well-documented in victims of other disasters. Often, these symptoms are temporary and resolve without any specific medical intervention. Of course, a single event such as a train accident is different from an ongoing fear of potential unknown disasters. Americans are now not only experiencing the predictable reactions to the September 11th attacks, but are simultaneously processing the ongoing threat and other as yet unrealized dangers, such as potential bioterror or chemical attacks, as we learn more about their potential for use by terrorists. What happens when one trauma is followed by evidence of ongoing attacks or threats of further attack?

Management of Fears: Known and Unknown

Can citizens do anything to reduce their own anxiety? Yes. Many stress management principles apply, whether the stress is from clearly identifiable events or relates to ongoing threats. First, we must recognize that previously unfamiliar or rare emotions of edginess, irritability, sadness, or ill-defined fear are not signs of "craziness." They are normal reactions to an abnormal situation. Second, we must realize that talking to others can be reassuring, and therefore we should reach out to those around us for support. Knowing that loved ones and trusted colleagues experience similar emotions can help us maintain a sense of our own normalcy and emotional health in trying times. Avoiding the temptations of alcohol or illicit drugs as a means of escape is critical, as the intoxicating effects and subsequent withdrawal from these substances tend to exaggerate rather than reduce symptoms. Continuing to use health stress management techniques that "worked" before September 11th—such as regular strenuous exercise, healthy eating and sleeping habits, and attention to hobbies, outside interests, and children—have been shown to reduce unpleasant emotions and dysfunctional behavior in persons experiencing high levels of stress. Conscious efforts to make decisions, even over trivial matters, serve to reduce the sense of loss of control that many are experiencing. Consultation with health care providers, particularly mental heath care providers or counselors, if one has questions about particularly distressing symptoms or symptoms not responding to self-help measures is appropriate. These professionals can instruct in other coping techniques and, in some instances, may prescribe medications for more severe or long-lasting reactions.

Maintaining an Appropriate Perspective

Finally, it is important to recognize that our country is not sitting back and "waiting for the other shoe to fall." Our government and military are taking strides to reduce the likelihood of future terrorism. They are becoming increasingly prepared to deal with possible future attacks, and it appears that our leaders and scientists are learning quickly. Remember that prior to this fall, we have never experienced a bioterror event in our country. Even though enough anthrax was released in our country to kill or infect millions of Americans, only a handful of persons were infected. Most of those affected were treated quickly enough to prevent death or severe consequences. This fact does not minimize the tragedy for those persons, their families, their friends, and their loved ones, or even for our nation. It only serves to remind us that our leaders and health system can work effectively to reduce threats to our physical and emotional health. Containing the infectious aspects of this agent (and others) appears considerably easier than containing their fear- and anxiety-producing aspects. Staying informed about new medical and scientific information about terror threats and protective measures will reduce the sense of mystery and related fears as the unknown becomes understood. Relying on trusted sources of information and verifying the accuracy of new reports will ensure that knowledge, rather than misinformation or hype, is disseminated. Although times have changed, our devotion to life, liberty, and the pursuit of happiness has not. Remembering that our nation and its leaders have successfully handled threats to our national values can help us remain strong and can instill and maintain hope for the future in troubling times.

David M. Benedek, M.D., MAJ, MC, USA
Chief, Forensic Psychiatry Service, Walter Reed Army Medical Center

Elissa P. Benedek, M.D.
Clinical Professor of Psychiatry, University of Michigan Medical Center; Private Practice Child, Adolescent, Adult Psychiatry

Note: The ideas and opinions expressed here are those of the authors and do not necessarily represent those of the US Army of Department of Defense.