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Learning to deal with 9/11 Trauma

September 7, 2006

Learning to deal with 9/11 trauma
Survivors work through fears using virtual reality

Stephen King, a retired safety chief for New York City's Fire Department, was just swallowing his morning coffee at his office at the Brooklyn Navy Yard when he saw an explosion rocket one of the two World Trade towers on that crystal-clear morning five years ago.

Nine minutes later, he was standing in fire gear in the lobby of the tower, working with colleagues to help people out of the building. Checking stairwells to keep the human flow in motion amid chaos, King was accidentally pushed by a woman on her way down. He fell backward, hitting his knee badly. That fall, he would come to realize, saved his life. He was working his way back to the lobby of the north tower when the south tower collapsed.

"You could feel the air-pressure building," King recalled. "The windows blew inward spraying bullets of glass." Then, his world went black with smoke.

A year later, King was sitting in a laboratory at Weill Cornell Medical College in Manhattan, being fitted with a headset and goggles, about to re-experience the shattering events of that day. For this firefighter, who lives in Deer Park, that day would be his last working day. He had surgery for his damaged knee and retired on disability.

But he couldn't retire from the sleepless nights and recurring events of that day. He'd been in weekly therapy for post-traumatic stress disorder at Cornell, but he'd hit a wall. He just wasn't getting any better.

His doctor, JoAnn Difede, an associate professor and director of the program for anxiety and traumatic stress studies, recommended another technique that they had borrowed from other traumas - a computer-generated virtual reality treatment. Difede and her colleagues reconstructed a program that would bring King, and others, into a simulated world that mimicked the events of 9/11.

The key to processing traumatic events, Difede said, is to expose patients to the trauma and slowly let them work it through. Such exposure therapy has been used in all types of traumas.

The World Trade virtual reality re-creates the scene of the attacks - starting with the beautiful, crisp late summer day in lower Manhattan, to the looming towers, to the plane flying close to them, to the first strike, then the next, followed by the black smoke and eventually the sounds of the day are embedded in the scene.

"It re-creates their world at that moment," Difede explains. The patients wear a helmet that gives the user visual and auditory information, and the computer simulation is so real that they could easily believe that they are down on the street watching the terrorist attack.

"You have the person re-create it," Difede said. "Exposure therapy extinguishes the cues that bring on the fear and anxiety and it ratchets down their reality. They see it, hear it and feel it, and we think that it allows them to rapidly and completely process the trauma. It's worked for people who failed other PTSD treatments."

Patients move at own pace

The first virtual reality treatment deals with the exterior of the World Trade Center. Patients go through the program at their own pace. The scientists are now comparing the reduction in patient symptoms to those people with PTSD who remain on a waiting list for treatment. They have just put together a second virtual reality program that deals with life that day inside the towers. Therapy studies are set to begin soon.

"When I first saw the program, I said this can't possibly help," said King. Then he put on the gear and headed into that sky-blue day, looking at the towers and hearing the engine of a plane somewhere in the background. He started shaking. Five minutes of the simulation was all he could muster that first day.

Finally, three months later, it was the technique "that brought me to the finish line. I was 95 percent better," King said. "It made all the difference."

The group is now enrolling patients into another arm of the study that will provide treatment with a drug called d-cycloserine that has, at least in animals, shown that it helps separate the mental connection between fear and the experience "and helps reconsolidate new memories," Difede said.

"It allows patients to take fragments of the experience and re-create a coherent narrative of the memory."

She said that they are still seeing people with post-traumatic stress disorder whose symptoms have grown more chronic and mixed with depression and substance abuse. "Many people are irritable and they forget why. They no longer relate it back to the events of that day," Difede said. She said that many doctors will give people antidepressants "without tracing the line back to the 9/11 trauma."

So far, two dozen patients have completed the virtual reality study. The first report on 14 of these patients, including King, will be published soon. Difede can't talk about the results until then but says: "We think it is successful." The treatment is completed in 12 sessions.

Scientists at Columbia University College of Physicians and Surgeons also have been treating survivors of 9/11 with psychotherapy and medicine, and studying the benefits of the treatment.

Dr. Randall Marshall, a trauma expert at Columbia University College of Physicians and Surgeons, said that there is good news, even for those still suffering five years later. People are finding relief when the right treatment is offered.

"Many people who remained symptomatic during this five-year window were marginalized and embarrassed about how they felt," said Marshall, who also directs the trauma studies and services at Columbia's New York State Psychiatric Institute. After the initial wave of treatments to help 9/11 victims, many spent their life savings on moving from one failed treatment to the next. Years after the initial trauma, many were getting therapy for everything but post-traumatic stress disorder, he said.

Self-destructive behavior

Many who finally arrived at Columbia shared the same types of post-9/11 stories - lives marked by self-destructive behavior, lost life savings, severe depression, divorce, unemployment and despair. One patient who finally ended up there lost everything after her company, in the throes of losing half of its office members when Tower One fell, put pressure on those still alive to finish up the work of their deceased colleagues.

"These are people who tried to put the pieces of their lives back together and couldn't," said Marshall, because no one was treating the actual problem: post-traumatic stress disorder, a psychiatric condition that has a specific and successful treatment. The symptoms can range from insomnia to nightmares, anxiety, depression, intrusive thoughts, and problems with memory, attention and motivation.

At Columbia, the scientists have studied almost 200 patients treated with a mix of cognitive behavior therapy and the antidepressant Paxil. It is a research study designed to test whether people do in fact recover from post-traumatic stress disorder. The study is ongoing and the scientists are still recruiting 9/11 victims.

Marshall says that most people have recovered with the tailored treatment, even after many years of symptoms and failed treatments. He's co-edited a book on disaster therapy - "9/11: Mental Health in the Wake of Terrorist Attack" to be published this month by Cambridge University Press.

People exposed to the traumatic events of that day have also taken advantage of Lifenet, a counseling and referral service for the Mental Health Association of New York City. Before 9/11, the hotline received 3,000 calls a month. Today, they average 7,000 calls a month.

For more information on the virtual reality treatment study: or 212-821-0783. The Columbia study runs 10 weeks. For more information on the Columbia therapy study: 212-543-5367. Both are free to 9/11 victims. Lifenet is 800-LIFENET or

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