by Michael D. Anestis, M.S.
The events of September 11, 2001 will forever been remembered as one of the most challenging, traumatic moments in our nation's history. The impact of that day was felt globally in a variety of manners, but understandably, much attention was focused on outcomes for those who were actually living in New York City at the time of the attacks. An important consideration when examining outcomes immediately following a traumatic event is that humans have a normative acute stress response that, on average, will fade with time. This response in and of itself is not a sign of mental illness or evidence that the individual will definitively eventually meet criteria for post-traumatic stress disorder (PTSD). In fact, the DSM-IV-TR requires that a month transpire between the traumatic prompting event and a diagnosis of PTSD in order to diminish the likelihood that individuals will be misdiagnosed with the disorder. That being said, the impact of terrorist events in general and 9/11 in particular have been shown to exhibit robust maladaptive effects upon the mental health of exposed individuals. In a recent meta-analysis, DiMaggio and Galea (2006) found that, in individuals exposed to terrorist events, rates of PTSD range from 12-16%. This is significantly higher than the rate typically found in community samples. For instance, in a sample of 5,877 individuals from communities across the United States, Kessler and colleagues (1995) found an overall lifetime prevalence rate for PTSD of 7.8%. With respect to 9/11 in particular, a study conducted 2 months after the attacks found that individuals living south of Canal Street, and thus in close proximity to Ground Zero, had a higher rate of PTSD than did individuals living between Canal Street and 110th Street (20.0% compared to 6.8%; Galea et al., 2002).
The obvious take-home point from these findings is that close proximity to trauma increases vulnerability to PTSD symptoms. While intuitively obvious, empirical understanding of this phenomenon is nonetheless useful. Recent research, however, has taken this point further in an attempt to determine vulnerability to severe responses after traumatic events. In other words, we understand that being close to a traumatic event increases our likelihood of developing PTSD, but of those who are close, who is most vulnerable?
One particular study along these lines, published in 2008 by Frank Farach and Doug Mennin of Yale University and Rita Smith and Matthew Mandelbaum of New York University, was able to examine this phenomenon in a truly unique manner, as the authors happened to collect their first round of data in a longitudinal study on September 10, 2001. The day before the attacks, the authors collected data from a sample of 229 undergraduates regarding symptoms of generalized anxiety disorder (GAD) and depression. 69 (30.1%) members of the original sample met criteria for analogue GAD. In other words, they endorsed significant symptoms of GAD as measured by the Generalized Anxiety Disorder Questionnaire for the DSM-IV (GADQ-IV; Newman et al., 2002) but were not given a diagnostic interview that would allow for an official diagnosis (see our Assessment Tools page for more information). After the events of 9/11, the authors petitioned their Institutional Review Board to allow for follow-up data collection on this sample and were then granted the opportunity to assess these same individuals both at 4-months and 12-months post-9/11. This presented a unique opportunity to use the psychological well-being of individuals a day before 9/11 to predict how they would respond to the attacks in the subsequent year. A total of 44 participants completed all three assessment periods (18 analogue GAD, 25 controls). This obviously reflects a rather small sample size, but the unique nature of this data and the careful statistical analyses of the authors render the findings highly valuable nonetheless.
Ultimately, the authors reported several interesting findings. First, even when controlling for the degree to which individuals were exposed to the attacks, symptoms of GAD on 9/10 predicted loss of psychological resources (e.g., social support, sense of control), disability in multiple domains (work, social life, family), level of worry, and general mood and anxiety symptoms at 12-month follow-up. Surprisingly, GAD symptoms on 9/10 did not predict PTSD symptoms at 12-month follow-up, which runs counter to prior longitudinal studies of major disastors (e.g., La Greca, Silverman, & Wasserstein, 1998). 
Perhaps more interestingly, both the degree to which individuals reported avoiding their emotions at 4-month follow-up and the degree to which individuals reported fearing their emotions at 4-month follow up mediated the relationship between pre-9/11 GAD and the same outcomes listed above (e.g., loss of psychological resources) at 12-month follow-up. In other words, when the authors statistically took into consideration the effect of avoiding and fearing emotions on these problematic outcomes, the relationship between pre-9/11 GAD and the problematic outcomes disappeared. The easiest way to interpret this is that individuals with GAD tend to experience emotions in a particularly problematic way that increases their vulnerability to harmful outcomes after a traumatic event. When individuals without GAD approach their emotions in this same manner, this impacts their vulnerability in an identical way. So, because more people with GAD than without GAD fear and avoid their emotional experiences, GAD serves as a risk factor to clinically relevant responses to trauma, but responding to emotions through fear or avoidance is problematic regardless of whether or not an individual has GAD.
So what does this article tell us? The findings are, to an extent, preliminary because the sample size was small, but the data drive home the point that avoiding our emotions when we are upset or responding to our emotions with fear leaves us vulnerable to a variety of problems in the face of stress. In this particular case, the stress was of an extreme magnitude, but the same principle can apply to more day-to-day stress as well. When we avoid our emotions rather than processing them and acknowledging them as a temporary and aversive but informative human response, our ability to navigate stress is diminished. What is frustrating about this is that, by avoiding emotional responses, we oftentimes feel as though we are taking a pragmatic approach towards problem solving when, in reality, we are quite clearly diminishing our ability to find adaptive solutions. This is very similar to the phenomenon of rumination.
So what do we do when we find ourselves overcome by worry and emotional avoidance? There are several options. Cognitive behavioral therapy has demonstrated promising results in the treatment of generalized anxiety disorder, as well as several other forms of mental illness (e.g., depression). Our EST Clinics page lists a variety of locations that offer such services. Mindfulness has demonstrated impressive abilities to increase the degree to which individuals accept their emotional experiences and remained focused on the moment rather than falling victim to ruminative cycles likely to induce and prolong negative emotional experiences. For stress due to the current economic climate, Robert Leahy has seven steps an individual can take to better handle their emotional responses. Ultimately, what studies are demonstrating time and again is that, by developing a pattern of responding to emotions through fear or avoidance, individuals increase their vulnerability to mental illness, increased stress, decreased social support, and a variety of other highly undesirable outcomes. Learning to better address and minimize the impact of emotions is therefore vital in order to decrease our vulnerability in times of stress.
For more information on how to decrease your vulnerability to fearing and avoiding emotions, we recommend the following products:
Books:
The Worry Cure: Seven Steps to Stop Worry from Stopping You
The Miracle of Mindfulness
Anxiety Free: Unravel Your Fears Before They Unravel You
Generalized Anxiety Disorder: Advances in Research and Practice
DVD:
Peace Is Every Step-Meditation In Action: The Life and Work of Thich Nhat Hanh
Feel free to consult our online store or to contact us for further recommendations.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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