August 25th, 2013

PTSD among Firefighters 12 Years Following the Collapse of the World Trade Center

First-responders are those rescuers that are first to arrive at any catastrophic event – whether “natural” (such as a flood or earthquake) or man-made (such as a terrorist attack).

The knowledge obtained by studying enduring psychological reactions among rescuers has far-reaching public health implications.

It is now the 12th year commemorating the WTC collapse on 9/11 that prompted me to revisit some of my discussion-points with Dr. Steven Friedman about the continued work with several firemen from the original group of referrals who have continued to suffer to the extent of remaining in treatment for an extended time-period.

During this 12-year period Dr. Friedman gathered a collection of vignettes of the FDNY, and the data is unique in probing the long-term psychological effects among a specific group of rescuers who were sent into the mayhem and chaos of the WTC on that awesome day.

During the rescue operation, and at enormous personal risk, they performed countless acts of heroism.

During the event, the firemen witnessed the death by burning of hundreds of trapped fellow citizens, as well as their own near-death experiences.

Following the event, they then were faced with the additional bereavement resulting from the loss of many close friends.

Those in the field of Public Health and National Safety should consider the potential risk to first-responders, since they are the first to arrive and provide rescue-functions to fellow citizens, often under perilous conditions.

Given the chaotic circumstances at the time, our assigned mission was to stabilize trauma victims and our observations lack the methodological rigor required by most academic journals.

Firefighters at Engine 54, Ladder 4, and Battalion 9 were among the first at the scene of the disaster, and bore the brunt of exposure to graphic trauma-imagery beyond the scope of normal measurement.

I will touch on some longitudinal observations of “life beyond rescue” for this cohort.

 Issues of Loss

For the firefighters who survived the collapse of the WTC, one of the most poignant issues was to deal with the loss of so many colleagues on a single day.

As one responder stated in his initial session, “How can anyone understand? On that day our battalion lost 30 to 40 guys that I knew very well. I was very close to them. We went through the Academy and served in the same house together. These were guys I would call if I wanted to see a movie or go out for a beer.”

The loss of so many colleagues on one day felt like a complete fracture of their social support system.

Many firefighters continue to feel a deep sense of loss.

One rescuer conceded that he had endured the experience completely unsupported, and had become progressively socially isolated.

The loss of close ones is known to play an additive negative role with worsening of PTSD, confirmed by studies of other traumatized populations (Savjak, N. “Multiple Traumatization.” PSIHOLOGIJA (2003): 32).

Among first-responder groups who have close fraternities resembling the firefighters of FDNY, a massive loss of good “attachment objects” may overwhelm the psyche’s self-soothing functions, further hampering the ability to synthesize this volume of traumatic material.

While cognitive behavioral therapy is the traditional treatment modality in trauma treatment, first-responders like these who experience catastrophic trauma combined with multiple interpersonal loss may require additional intense emotional support for their bereavement.

For other clients, shame and guilt was the dominant theme.

One fireman suffered from a recurrent flashback of running away after the initial collapse and failing to rescue a civilian who needed help.

Since this fireman had symptoms both of PTSD and major depressive disorder, one might also ascribe recurring unwanted thoughts as morbid ruminations or flashbacks, depending on whether the primary diagnosis was PTSD or major depressive disorder.

This distinction is important since P.T.S.D. and Major Depression are treated differently.

Unique Personality and Cultural Factors

It is important for the therapist to acculturate with the unique nuances of any distinct trauma-group, as these often provide the “hooks” for engagement into therapy with any traumatized group. This has already been published by others working with firefighters following trauma, and emerged in our group early in the recovery process (Kirshman, 2004).

An example of a distinct cultural nuance was well-captured by one of the firefighter victims in a trauma-recovery group as follows: “We are that group of true Americans that live and die by our beliefs. We are those simple folk that don’t have patience for analyzing a situation which calls for action.

Firefighters tend to be people who thrive in environments involving risks and challenges. They are not risk-aversive. They embrace action as a form of self-validation when others seek safety or even emotional flight; even in situations that others describe as dangerous and whose reflexive actions are risk-aversive.

Like other groups of self-responders, Firemen tend to be individuals who react instinctively, and have little patience for analytic self-reflection.

An important by-product of this action-orientated “extroverted” method of problem-solving, is that individuals with this temperament historically pay less attention to the psychological dimension of their experiences.

When trauma victims are less verbally or emotionally reflective (extroverted, rather than introverted), any form of psychotherapy tends to be alien to their usual coping experience and comfort level.

One firefighter reported that upon safely returning home, he realized that he had witnessed such a momentous day in American history that he wrote down all the events of the day in a diary, knowing that he would one day show this to his children.

When the therapist asked to see his diary, it consisted of less than two pages of unemotional factual detail.

This fireman continued to suffer high levels of arousal (with symptoms of insomnia, irritability, an inability to tolerate noise); as well as avoidance symptoms.

His response was typical of the temperament seen among first-responders: action-oriented and emotionally avoidant.

He could not accept any value in recalling memories of the trauma and reconstructing memory fragments into a “trauma narrative”.

Does this suggest that first-responders attract individuals who score higher on visuo-spatial than verbal performance but neglect or delay the emotional “working through”, which is the symbolic processing of trauma material?

In other words, by temperament, these first-responders prefer crises-management through an action-modality, (possibly indicating a higher performance- IQ at the expense of emotional intelligence).

Action-responders are more likely to perform efficiently in situations requiring “instrumental skills”, but delayed in their recovery from crises when the rescue effort ends traumatically.

These issues highlight the need for trauma therapists to be innovative in certain groups of traumatized first-responders.

In addition to issues around engagement, there is the challenge to evoke sufficient verbal expression to compile a trauma narrative in a client who is action-orientated.

An example of an innovative trauma-exposure technique known as “Virtual Reality Exposure” (VRE) was presented by Rothbaum at the Lake George Research Conference on PTSD in 1998.

Computer-generated visual-displays of specific trauma-scenes, were coupled with soothing audio-responses, delivered by earphones to a group of Vietnam Veterans suffering from chronic PTSD and alcoholism.

Significant symptom-improvement was noted following fourteen 90-minute exposures, during a seven-week period of “exposure-therapy”.

This form of Cognitive-Behavior Therapy should be considered as the primary modality in psychotherapy among trauma-survivors with PTSD when culture or temperament are antithetical to conventional psychotherapy.

The author gratefully acknowledges the contributions made by Dr. Steven Friedman, Ph.D. Professor of Clinical Psychiatry and Director of the Phobia & Anxiety Disorders Clinic, at the State University of New York, Downstate Medical Center, for his tireless efforts assisting the firefighters who survived the collapse of the World Trade Center.


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2 Responses to “PTSD-among-Firefighters-12-Years-Following-the-Collapse-of-the-World-Trade-Center”

  1. love it says:

    love it

    PTSD-among-Firefighters-12-Years-Following-the-Collapse-of-the-World-Trade-Center « BrianTrappler M.D. | General Psychiatry | Traumatic Stress Expert

    • btrappler says:

      The reason that this brief report was released was to provide lay-readers and professionals with an opportunity to visit the topic of the emotional consequences of being a first-responder
      to crises in real-time. These situations are almost never anticipated and elude the possibility for optimal research study design. The evidence obtained by clinicians is mostly empirically-based.
      The author nevertheless felt that the findings by the staff of the Anxiety Clinic at S.U.N.Y. Downstate deserve attention. As a public-health issue, the emotional outcome of first-responders to events such as natural disasters and acts of terrorism are important components of this emerging body of knowledge in the field of trauma.