On September 11th, American life changed. But most of us are still not sure what it changed into. As our definition of normal continues to evolve, though, one thing is clear: Americans are more anxious than ever. Before the terrorist attacks on the World Trade Center and the Pentagon, anxiety-related disorders cost the U.S. an estimated $42 billion a year in medical and work-related losses. Now mental health professionals can only make educated estimates of how many more of us will be affected in the near future, although they have begun studying the problem.

What the experts do know is that those most at risk—specifically for developing post-traumatic stress disorder (PTSD)—are people with direct, personal involvement in the tragedies. This high-risk group includes not only individuals exposed to life-threatening danger themselves but also those who watched the events unfold from a nearby vantage point or lost a loved one. PTSD typically manifests itself in flashbacks or nightmares that replay the traumatic event, an avoidance of reminders of the ordeal or a hyperalert state. For diagnosis, symptoms must persist for more than one month but they may surface immediately.

"Those who are going to go on to the acute and chronic forms of PTSD are very likely to exhibit symptoms in the hours to days after [the event]," says Charles Marmar, professor and vice chair of the department of psychiatry at the University of California at San Francisco and associate chief of staff at the San Francisco Veterans Affairs Medical Center. Marmar estimates that between 70,000 to 100,000 people in New York alone had the kind of exposure on September 11th that puts them at risk for developing PTSD.

The count is so high in part due to the nature of the attacks. Studies show that rates of PTSD are greater following events caused by deliberate violence than after natural disasters. "If an airplane had accidentally flown off course in a heavy fog in New York and taken down one of the towers," Marmar explains, "it would have been very traumatic but probably less traumatic than knowing that somebody, or some group, wanted to kill everybody in those buildings." It is this relationship to violence that may explain the higher rates of PTSD observed in women. Compared with men, women are more likely to suffer trauma after a physical or sexual assault.

Although PTSD is the most severe reaction to a traumatic event, countless people—including many far from New York or Washington, D.C., on September 11th—have experienced heightened anxiety during the past two months. As unwelcome as their fear might be, most of it is entirely natural. The human nervous system has, over time, developed an array of stress reactions—among them, adrenaline rushes, increased respiration and greater blood flow to major muscle groups—to ensure our survival in dangerous situations. Now people in no immediate mortal danger, with nothing to fight or flee, are feeling these reactions first hand in response to a series of extraordinary events.

Individuals with previously diagnosed panic or anxiety disorders are likely to suffer from more frequent attacks and magnified symptoms, according to Lorna Wienstock, a psychotherapist who specializes in the treatment of anxiety-related disorders. But, she says, "many people are walking around in a state of generalized anxiety. People feel a sense of dread and apprehension. They feel more vulnerable." For most, such feelings are normal, but clinicians can not define what exactly constitutes a normal reaction because no two people are alike. Experts suggest that trying to return to some semblance of ordinary daily life is vital.

That's not easy given the ongoing nature of the terrorist threat and the following catastrophes. "If you're afraid of something that you know what it is, you can avoid it, or diminish it in some way," explains Jeff Rosen, an associate professor of psychology at the University of Delaware. "This, there's nothing to diminish." If people find they are unable to leave their homes as a result of anthrax anxiety or credible-threat consternation, their symptoms have become disabling and professional help may be required, the doctors suggest.

Some researchers go so far as to assert that the long-term psychological ramifications of chemical or biological terrorism may be more damaging than any physical effects. Writing in an editorial in the British Medical Journal, Simon Wessely of the Guy's King's and St. Thomas' School of Medicine in London, Kenneth Craig Hyams of the Department of Veterans Affairs in Washington, D.C., and Robert Bartholomew of James Cook University in Australia caution against inappropriate reactions to presumed threats that serve to heighten the threats' impact.

"Even if the short-term consequences of an attack with chemical or biological weapons turn out to be less than some of the apocalyptic scenarios currently being aired by the media," they write, "the long-term disruptions may be worse than anticipated." Indeed, the trio suggests that the purpose of such weapons "is to wreak destruction via psychological meansby inducing fear, confusion and uncertainty in daily life."

Studying the Response

Because the events of September 11th are so unprecedented, pertinent research literature is limited, although studies have investigated reactions to the Oklahoma City bombing and traumatic national disasters such as earthquakes. Now researchers at the Stanford University Center on Stress and Health are trying to gauge the range of possible outcomes of enduring traumatic stress. On September 22nd, they launched a study via the Internet to assess people's responses to the attacks on America.

"Although it is widely documented that natural and man-made disasters and other traumas are often associated with considerable post-event distress, little is known about normal responses to extremely abnormal situations," says lead investigator David Spiegel, a professor of psychiatry and behavioral sciences. "And even less is understood about adaptive coping in the face of traumatic stress." So far the scientists have received more than 5,000 responses from across the country and from locales as varied as Australia and Israel, says Cathleen Desjardins, a doctor and lawyer working on the project.

In the first section, the study asks participants multiple-choice questions designed to evaluate their exposure to the recent terrorist attacks and their reactions. Initially created to investigate the impact of September 11th, the study has now taken on the added complexity of addressing ongoing and broader national threats. "We're going to be looking at when participants have given their input," Desjardins says, "what has happened up to that date and what may have been happening on that day in terms of anthrax reports."

The second and third parts of the study include longer, narrative questions and will attempt to assess such things as personal experiences, physical health and social well-being, as well as coping strategies that might be particularly beneficial in dealing with terrorism anxiety. Utilizing the Internet, Desjardins explains, allows the investigators to reach a wider variety of participants both geographically and demographically in terms of background and exposure to traumatic events.

Although the idea of collecting data through a web site might raise questions regarding the veracity of the responses, Desjardins is confident that the Internet's benefits in terms of economics and reach outweigh its risks. "We don't believe that someone would take the time it takes to do the survey, about 20 minutes, to make one item of fraudulent data," she says. "Usually people who are creating fraudulent input don't want to put that kind of effort into it."

What you can do

It is certain things will never be the same, but mental health professionals call attention to the human ability to adapt. "We've been kind of privileged in not living in a state of fear that a lot of the rest of the world does live in," Rosen says. "But we will get used to it. We'll be able to live in this state and be productive and go back to what we really need to go back to, which is family, work and all the routine parts of life." Strategies for easing the transition, doctors say, include exercise, talking about feelings with friends and family, keeping to routine eating and sleeping schedules and continuing with the small pleasures of life, such as going for walks, listening to music or watching movies.

The experts also suggest limiting your exposure to news coverage. "Obviously, we all want to be informed citizens," Ellen Leibenluft, a physician at the National Institute of Mental Health, says. "But the other thing is to titrate the amount of brain time people spend on this." If you find news fasting too much to bear, Erica Wise, a clinical psychologist and associate professor at the University of North Carolina at Chapel Hill, has this advice: read or listen, but don't watch. "It does seem that the visual medium is a little more intense," she cautions. "[With radio, anxious people] are less likely to have exposure to images that are going to be things that they see again and again in their minds."

Repeated images of space-suit-clad officers help viewers to overestimate the general level of danger, psychologists say. The unknown aspect also feeds fear. Even though the average American is still more likely to die in a car accident than to contract anthrax, the continual focus on outcome rather than probability means anthrax is at the forefront of the American consciousness now. And with the ever-increasing perceived threat of anthrax exposure, there have been increasing numbers of reports of people wanting to safeguard a personal supply of Cipro, an antibiotic used to treat anthrax.

Both the American Medical Association (AMA) and a recent editorial in the British Medical Journal have cautioned against hoarding or using antibiotics unnecessarily. The medications are not without side effects, the AMA cautions, and must be used only when necessary to avoid a growing likelihood of antibiotic resistance. What is more, they add, "the federal government has stressed that antibiotics for the treatment of anthrax are stockpiled in several areas of the nation and they can de delivered to any airport within 12 hours."

In their editorial, Anthony Hart of the University of Liverpool and Nicholas Beeching of the Liverpool School of Tropical Medicine write that "the important thing is to ensure that prophylactic treatment is given only to those who really need it, and to discourage its mass use by an understandably alarmed public. To induce antimicrobial resistance on a mass scale would be an even greater triumph for the terrorists."