Thursday, September 01, 2011

Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11



All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at Psychologytoday.com).

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”


The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’
·      Psychological resilience “situations are viewed as challenges, not threats”:
·      Activating social networks, including confiding relationships
·      Adequate external supports
·      Challenging one’s self
·      Looking for meaning through involvement
·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.
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9 comments:

Sarebear said...

That appraisal thing strikes a chord with me, because I vividly remember at what point I personally felt threatened, although I live in Utah. For one, NYC was basically the backyard of where I grew up, in NY state, so I felt some connection.

I was horrified by the first plane, even more so by the second, but I still felt, it's localized, it's NY, they've gone after economic centers before (so I therefore felt safe since what's out here?)

Then, when I learned of the Pentagon, my thought was, "Oh my . . . no . . . they are after as many people as they can get, they want us to know that no one is safe!"

And from then on I felt it as an attack on me, even though I obviously wasn't anywhere near the attack. Probably sounds wierd, but that whole appraisal thing finally helps me understand why I felt the way I did, when I did, and stuff. Having more understanding of myself is good.

Thanks for helping me inadvertently. Now I don't feel so wierd for feeling the way I felt.

Sarebear said...

One other thing, though. This was 6 months before the 2002 Salt Lake Olympics, and there were all sorts of reports and even reported sightings of Middle Eastern men scouting locations near the place the Opening Ceremonies were to be held, to set up bombs or stuff, in the months after 9/11 and leading up to the Olympics.

Nothing was ever substantiated, but it brought the terrorism home in a way that people outside Utah might not have thought of; we were hosting a global event, so soon after 9/11, with so many dignitaries coming, well, we felt like a target. And to see the military providing some of the security for the games, patrolling the streets with their weapons and camo uniforms during the games . . . it's wierd to have your home city being well patrolled by the military. A bit scary too.

Sideways Shrink said...

My program director talked a lot about resilience the preceding summer while talking about grief, but I did not really get the connection. (Looking at some of her earlier research papers later, I surmised that she may have had several miscarriages as that was focus of her research.)
Then came 9/11 which was a truly odd morning. I found out the Saturday before that on the first try my husband and I had conceived at my old age of 33!
I was so happy and in shock at being so pregnant so fast (after thinking intensely about it in analysis for 2 years+) and running late as always when WNYC cut out shortly after 9AM. I was the first to greet my professor which was truly unheard of--I lived a block away and she lived on the Upper West Side. But besides the awfulness Dr. Hellerstein describes, of waiting at the hospital much later that day for the overflow of patients that would surely make it to us, a major trauma center at the opposite end of the island but who never showed up....
Oddest of all was that my 60 or 65 year old professor (who I knew had 2 adult children she and her husband had adopted from Japan) held the small group psychotherapy supervision as usual until 11 as students had driven in having heard the news on the radio about the twin towers telling us this news. At the end of class, she stated in her always calm voice, "My son works in Tower 2. I am going to call him to make sure that he is OK."
This is a drawn out way of illustrating that resilience which I have always associated with the ability the rebound, to bounce back, can on the surface, perhaps appear to be completely still. Of course, that could be an initial paralyzed/denial trauma response she was having. If her son hadn't been meeting with clients in mid-town and had simply disappeared with the other 3000+ people (God forbid) that would have been a real test of her own resilience.
Personally, upon completion of my residency I dragged my husband and baby back to the Pacific Northwest where I could test out my resilience by being around MY MOTHER!!
If I were in the same situation in the middle of anything with anyone where one of my children was in a building that had been bombed (demolitioned or hit by very inexperienced pilots and then the building happened to actually burn down from fast burning jet fuel despite the sprinkler systems)I would pause what I was doing with patient or student(s) and call them. My children have given so much to medicine already. It would be for me a sad irony not to forego my work and see if my child is alive. I know everyone is different in their trauma responses and I am not judging this woman who was one of the fairest professors I had in all of my training.

Anonymous said...

I don't know how anyone can compare different peoples' experiences when they didn't all experience the exact same thing. My sibling saw things occur I cannot even begin to fathom. There was no returning to normal when she was covered in the dust of human beings. There's a new normal, maybe, but things are never the same after something like that. Is she less resilient because she is still bothered by those memories? I don't think so.

WV = witch. Uh oh, is someone trying to tell me something?

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Dinah said...

Sideways: I took off the post, but Snoring Solutions is computer generated spam.

Shannon Pennington said...

Resilience by David Helletstein something which he is well researched and has delivered on. As a former career I.A.F.F. firefighterveteran with over 12 thousand active duty runs under my hydrant belt many as a heavy rescue specialist I can say that resilience or as I like to say Bounce is something we all need to understand. When we loose our Bounce/Resilience we get stuck to the pavement of life and are unable to move forward. Sometimes it happens like forrest gump said. Get connected to stress education at the web site firefighterveteran.com
Well written Dr Hellerstien
Shannon Pennington
Executive Director
North American Firefighger Veteran Network
F.I.R.S.T. S.T.E.P. H.O.P.E. and
F.I.R.E.S. within Suicide Prevention for the Fire Service

djhell said...

Thanks to all for your perceptive and thoughtful comments in response to my posting!

I agree that people's experiences and reactions to trauma do differ quite a bit. Some of it has to do with exposure--how close a person was. Anonymous mentions a relative who was actually at the WTC site, whereas Sarebear describes her reaction from across the country. Some of it has to do with personal style. Sideways Shrink describes the reaction of her professor, who seemed very detached even though her son was apparently in one of the WTC buildings. People do have very different reactions to traumas.
Also the degree to which they are able to recover from the traumas varies a lot. People who had previous traumas or losses have shown more difficulty recovering from 9/11 in some studies, for instance. Those who already had depression or other psychiatric disorders also tend to have a harder time bouncing back. And in contrast, people with more resiliency seem to be at lower risk for developing PTSD. Shannon Pennington describes how resilience is so importance for people who work in fields like rescue operations--since they are exposed to traumatic situations day after day, it is crucial for them to find effective ways of coping, of keeping their 'bounce'!

thanks again,
David Hellerstein, MD