Weeks before enduring psychological impact is revealed Seven days after the terrorist atrocities at the World Trade Center and the Pentagon, the physical toll is becoming clear - but experts say it will be weeks before the enduring psychological impact of the loss and devastation begins to be revealed.

Although 201 bodies have now been pulled from the rubble of the World Trade Center, 5,422 people are still missing in New York. At the Pentagon, the remains of 97 people have been retrieved, and 23 remain unaccounted for. Search and rescue operations continue, but hopes of finding more survivors have faded.

Relatives of the dead or missing and emergency service personnel will be experiencing the greatest psychological trauma, but New Yorkers and Pentagon workers less directly affected by the attacks are also likely to be suffering, says Alastair Ager, director of the Centre for International Health at Queen Margaret University College in Edinburgh, UK.

"Many emergency workers, in particular, will be suffering signs of stress - perhaps having flashbacks, trouble sleeping and general irritability. But the evidence suggests that that is a very normal response to very abnormal circumstances," says Ager, an expert in trauma following disaster. "For the majority - 80 or 90 per cent - that will last for perhaps three or four weeks."

Doctors and counsellors should be on guard to pick up people for whom the images and memories remain or intensify about one month after the disaster, he says. "That will be one of the intervention points to pick up people at risk of developing post-traumatic stress disorder."

Even people around the world watching pictures of the tragedy on television could be at risk from more long-term psychological problems, he adds.

Depression danger

Strategies for reducing the likelihood of long-term disorders do exist, says Ager. Emergency service personnel will be engaged in regular group meetings to recall and discuss concrete experiences over the past week. "People will be talking about what they saw, how the felt and how they reacted. There are some indications that this can help people recover more quickly."

But as well as classic post-traumatic stress disorder, Ager thinks depression could also be a problem. "There is a danger that post-traumatic stress disorder could become a catch-all diagnosis. But previous studies of people who have experienced a disaster suggest that symptoms of depression are much more prevalent."

For many people around the US, the terrorist attacks will have destroyed their assumptions of safety and security, Ager adds. "People around the US may well be feeling uneasy because the things they banked on as certainties have been shattered."

However, he stresses: "Just because you have had your assumptions shattered does not mean you end up with a clinical psychiatric diagnosis." For people watching and re-watching the unfolding events on television, the psychological impact is very hard to predict, he says. "There is some evidence of vicarious traumatisation - that people can become traumatised by seeing things at arm's length. But there is also some evidence that this can be exaggerated. Whether or not the traumatisation can be long-lived or deep is controversial."

Counselling and clinical support will be on offer to help people diagnosed with psychiatric disorders, Ager says

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-- Rich Marsh (marshr@airmail.net), September 20, 2001