On the Anniversary of 9/11: A Thank You and Reminder of Price to First Responders

The scope and nature of the terrorist attacks on September 11th blew the lid off of what we know about trauma. Well over 150 scientific studies had been published on the potential negative health effects of this devastating event.

One of the groups that experienced the highest “dose” of exposure to the horrors and toxins of 9/11 and thus carry the biggest health burden are the first responders — those who came to the former World Trade Center to engage in search, rescue and recovery efforts. These brave men and women helped evacuees flee, dug through debris for survivors, and witnessed up close human death and dismemberment.

Research findings from responders’ annual monitoring visits indicate that the effects are even worse than we thought. Approximately one in seven or nearly 13% of World Trade Center responders appear to have some kind of cognitive impairment. Some even screened positive for possible dementia. In fact, those with current post-traumatic stress disorder (PTSD) and major depression had a two-fold increase in cognitive impairment than those without these mental disorders.

It was the PTSD symptoms of re-experiencing that carried the most bang for the impact. The repeated, disturbing, and unwanted dreams and memories of 9/11 and the strong physical and emotions reactions (heart pounding, trouble breathing, sweating) when reminded of the trauma were most consistently predictive of responders’ responses to a short-form cognitive test many years later. And these effects were still there after controlling for other variables that could have possibly accounted for the relationship, like education, related head-injuries and medications.

The possible link between PTSD and cognitive impairment in combat veterans had been talked about for years. And, several large methodologically stringent studies confirmed those fears. For example, in a sample of over 180,000 veterans, those with PTSD were more than twice as likely to develop dementia over a six-year follow-up.

Similarly, in an innovative design, researchers looked at over 10,000 veterans age 65 and older and categorized them according to PTSD status (yes or no) and receipt of a Purple Heart medal (yes or no). The veterans with PTSD had almost twice the odds of developing dementia compared to the other groups. This indicated that it was the PTSD that was the greater risk factor for dementia rather than solely exposure to combat-related trauma.

There was always some caution, however, against generalizing evidence on the relationship between PTSD and cognitive impairment based on veterans to a wider population. Until now.

For sure, the cognitive impairment measure in the World Trade Center responder study was a simple, short neuropsychological test. It wasn’t verified by extensive testing or observations in everyday settings. But, make no doubt about it, the results are extremely important, and particularly shocking as the average 9/11 responder was only in their early fifties.

The relationship among trauma, PTSD, and cognitive impairment is complex. And the ways that cognitive impairment can negatively affect those with PTSD is likely equally so. Cognitive impairment may lower the threshold for emotional reactions to trauma “triggers” for PTSD symptoms, leading to an increase in felt or expressed distress for survivors. It also seems likely that those with more moderate to severe forms of cognitive impairment won’t benefit as much from psychotherapies as they’re typically learning-based.

It provides some consolation to the Vietnam veterans I treat as a trauma psychologist, that they put PTSD on the map. I tell them that prior to their service, the mental health field knew relatively little about the consequences of trauma, and that by their determination, their refusal to suffer in silence (although many did) helped to catapult PTSD into our official psychiatric classification system in 1980. But if the Vietnam veterans and the women’s movement put trauma and PTSD on the map, then 9/11 kicked it out of the ballpark and over the fences of the world. Not only did trauma enter the U.S. collective consciousness in a very real and personal way after 9/11, it soaked into the public awareness worldwide.

May these research findings from the World Trade Center responders translate into the monitoring of cognitive function in all PTSD populations. And may the strong and mighty first responders of 9/11 know that we have this among many other things to thank them for.