Like most Americans, Kristina Lozano remembers exactly where she was when the planes hit the World Trade Center on the morning of Sept. 11, 2001.
"The first time the first plane hit, I was actually in homeroom, where they take attendance," says Lozano, who was 16 then and attending Murry Bergtraum High School, just blocks from the twin towers. "By the time the second plane hit, I was in English class."
She remembers the school building shaking and being hit by debris. Soon, her school was evacuated. With no trains running, and many roads blocked off, Lozano tried to find a way back home on foot with a friend. The two teenagers eventually found themselves taking one of the bridges to Brooklyn.
"I remember running on the Manhattan Bridge with my friend Sonia and someone actually saying there's another plane coming, which set everyone to run," Lozano says.
In the weeks and months that followed, Lozano struggled to sleep and felt easily anxious. "Any little noise that was loud, like maybe an airplane passing by, [I remember] being a bit paranoid."
She also began to lose interest in things she once loved such as sports. "I began to really doubt myself, my abilities, just in terms of performing in school. And not really caring as well," she says. "I was living almost on autopilot."
Many people in New York City and neighboring areas who witnessed the disaster experienced symptoms of trauma in the months that followed. Researchers studying the health of survivors, recovery workers and witnesses such as Lozano say the event led to increased rates of mental health problems such as depression and post-traumatic stress disorders.
And while the majority of people have recovered in the years since — a testament to human resilience — a sizable share of survivors still experience symptoms to this day.
"This disaster of 9/11 in New York City has had long-term impacts on both the responders and civilians," says Mark Farfel, director of the World Trade Center Health Registry, which has tracked the health of more than 70,000 people directly exposed to the attacks who voluntarily enrolled in the registry in 2003 and 2004.
The registry provides ongoing research on this group, surveying its members every few years about their health — its research has shed light on factors that erode — or enhance — people's ability to bounce back from trauma.
According to data gathered by the registry, about a 10th of enrollees have continued to struggle with symptoms of PTSD.
"Each time we do a survey, it's between 8% and 10% that have sufficient symptoms to indicate post-traumatic stress disorder," says Robert Brackbill, director of research at the registry.
But among people who had a closer experience of the disaster, such as occupants of the buildings, or rescue and recovery workers, the rates are even higher — about 17% to 18%, he adds.
Studying the emotional impacts of a disaster
Researchers at Columbia University led the first effort to track the mental health of people who witnessed the attacks, surveying them in the weeks after the disaster and following them for three years.
"First, we dida study of Manhattan, and then we were able to get funding to do a study of New York, southern Connecticut, eastern New Jersey," says Dr. Sandro Galea, dean of the School of Public Health at Boston University who was at Columbia University at the time. The studies surveyed the general population in these areas, which included survivors, rescue workers and those who witnessed the attacks that day.
"What we found in the beginning was about a doubling of the baseline rate of depression, post-traumatic stress disorder in the general population," Galea says.
People with PTSD can experience a range of symptoms related to the traumatic event, such as nightmares of the event — they are often easily startled and anxious about something bad happening.
"They're haunted by what happened, and the haunting nature comes out in reexperiencing symptoms, in nightmares and flashbacks," says psychologist Barbara Rothbaum at Emory University, who specializes in treating people with PTSD and other anxiety disorders. "People [also] feel emotionally numb and distant from others. I've had people tell me, 'I know I love my family, but it's hard for me to feel it. It's hard for me to feel the joy.' "
Galea and his team also found that people who had a closer experience of the 9/11 attacks — say those who worked in the buildings, or people who lost loved ones — were at a higher risk of having PTSD and depression.
They also found that most people with symptoms went on to recover within six months of the attack. "But there was about a third who continued to have symptoms," he adds.
His research, as well as studies by the World Trade Center Health Registry, have revealed some of the other risk factors for longer term symptoms of mental illness.
Those risk factors are the presence of other traumas or chronic stress in people's lives. So people who had experienced traumas or hardships before or since the attacks, those without a job, or with lower income, or housing insecurity were far more likely to continue to struggle with mental illness over the years compared with others.
And studies of those enrolled in the World Trade Center Health Registry also show that most people with symptoms are often struggling with multiple physical and/or mental health conditions.
"A hallmark of 9/11 conditions is that unfortunately, many of these conditions co-occur," Farfel says. "So, for example, PTSD often occurs with depression, and that magnifies the impacts of the disaster."
Similarly rates of substance use is also high among those with PTSD, Brackbill says.
"A lot of times what they're doing is self-medicating," Rothbaum says. "So they're smoking a lot of marijuana to try to get to sleep tonight. They're drinking a lot to try to get to sleep tonight. But then obviously that can turn into a problem of its own."
Getting help
Around 400,000 people directly affected by the attack on the twin towers are eligible to be enrolled in the World Trade Center Health Registry. Enrollees can be referred to the World Trade Center Health Program, which provides free monitoring and health care to those the disaster directly affected.
"That program is open, and anyone who's not currently receiving care through the World Trade Center Health Program can make an application," Farfel says.
And yet, he says, the registry is still finding people who have symptoms but haven't sought care. And the stigma of mental illness is a big barrier to seeking help, he adds.
"Treatment really can help," says Rothbaum, who has worked with many post-9/11 veterans, who returned from combat and struggled with PTSD, as well as refugees from war-torn regions.
"I think that people should have a treatment that's been proven effective and we've got a number of choices for that."
Those evidence-based treatments include medications such as Zoloft and Paxil, along with certain kinds of talk therapy, such as prolonged exposure therapy, which involves talking about the traumatic event or events, and attempting to do things that an individual has avoided since the trauma.
For Lozano, enrolling in the World Trade Center Health Registry did pave the way for seeking help.
"I sought help in college," she says. "I got therapy, and therapy was a huge eye-opener for me."
That's when she was diagnosed with anxiety and depression and started to work on her recovery.
Today, she works as a life coach. With the 20th anniversary of the attacks, she says she feels emotional but is no longer anxious or depressed.
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