Traumatic Stress and Medical Illness: Lessons from 9/11
 
Traumatic Stress and Medical Illness:
Lessons from 9/11

David Spiegel, M.D.
Juck, Lulu and Sam Willson Professor and Associate Chair,
Department of Psychiatry & Behavioral Sciences
Stanford Unversity School of Medicine
Stanford, USA

Lisa Butler, Ph.D., Janine Giese-Davis, Ph.D. Jay Azarow, Ph.D.

Abstract

The terrorist attacks of September 11, 2001 subjected the entire nation to both physical threat and psychological stress. We posted our questionnaire package designed to assess distress, risk and resiliency in depth on September 28, 2001 on the internet. We obtained responses from 7582 participants, residing in 39 countries and all 50 states (and Washington, D.C.), with California and New York most represented (51% [n = 3692] and 7% [n = 505], respectively). About 17% (n = 1221) live in or proximal to states where the attacks occurred. We obtained six-month follow-up data from approximately 4,000 subjects. We constructed a hierarchical regression equation, entering demographics, social support, coping styles, and emotion regulation as independent variables. The model accounted for 40% of the variance in distress at baseline, and 28% at six-month follow-up. Significant factors associated with higher baseline and six-month distress were extensive media exposure, smaller social network size, poorer quality and quantity of social support, and coping strategies that involved avoidance, substance abuse, and self-blame. These data indicate that a substantial portion of the distress in response to the 9/11 attacks can be related to exposure, social support, and especially coping variables.
These findings will be compared with data from our ongoing studies of the effects of stress and support on metastatic breast cancer patients, focusing on the psychological and somatic effects of affect management. We have recently reported confirmation of earlier findings of significant reductions in distress among metastatic breast cancer patients randomized to a year of supportive-expressive group psychotherapy. Here we report that decreases in suppression of emotion mediate these decreases in distress. Ninety-six of 125 women provided follow-up data. Women in the treatment group showed a significant decrease in mean Courtauld Emotional Control Scale (CECS) scores (measuring emotional suppression) over 12 months when compared to the women in the control condition. Using ANOVA we observed a significant relationship between decrease in suppression on the CECS and decrease in PTSD symptoms on the Impact of Event Scale (IES) [t(3,93)=4.0, p<.0001]. We also found that increasing emotional self-efficacy on the Stanford Self-Efficacy for Serious Illness Scale (SSESI) was associated with decreasing IES scores [t(3,61)=4.08, p<.0001]. These findings confirm earlier observations that suppression of emotion is associated with higher distress among cancer patients, despite their tendency to under-report their distress. Furthermore, the ability to sustain the expression of negative emotion in the group setting was found to be correlated with a more normal diurnal pattern of cortisol as measured in saliva. Abnormalities in this pattern predict shorter survival. Thus there is reason to believe that direct expression of emotion in response to stress may improve psychological function and help to restore physiological allostasis, buffering the effects of stress and enhancing social support.