Remembering 9/11: Insights on Collective Trauma, Resiliency, and PTSD

Firemen and rescue workers conduct search and rescue at Ground Zero.

CLINICAL CONVERSATIONS

More than 20 years after the events of September 11, 2001, survivors and first responders are still grappling with the psychiatric sequalae, including posttraumatic stress disorders (PTSD). According to a recent study that tracked PTSD symptoms in World Trade Center first responders, approximately 10% of participants have experienced a worsening or persistence of symptoms after 2 decades. In addition, the researchers found that many years passed before patients experienced a lasting change in symptoms, despite the availability of free treatment. The study, published in Nature Mental Health, is one of the longest and largest studies to track PTSD symptom trajectory for since exposure.^1,2

In recognition of this solemn anniversary, Psychiatric Times spoke with Christina Ni, MD, about her experiences addressing the mental health consequences of September 11, and the lessons clinicians can draw from her work.

Christina Ni, MD

Psychiatric Times: What was it like to be a psychiatric clinician treating individuals in the aftermath of 9/11?

Christina Ni, MD: 9/11 impacted almost everyone in different ways. There were people directly involved who were physically there, and then there were people who enlisted in the military after 9/11 in response to the attack and had mental health consequences from their time serving. People experience vicarious trauma from loved ones who were directly involved.

The different ways that people experienced trauma were eye-opening and indicated the extensive nature of treatment/care that would be needed to address all these different forms of mental health symptoms.

Psychiatric Times: What were some of the key unique clinical characteristics and challenges of the 9/11 trauma?

Christina Ni, MD: Patients who experienced 9/11 directly and experienced PTSD differed from those who experienced PTSD from other events, in that 9/11 was a mass exposure with thousands, even millions impacted. So, there is more of a shared sense of trauma vs individual trauma. This extends to how the US has commemorated 9/11, with news coverage, public memorials, anniversaries, as this frames the trauma as more of a community shared trauma vs single-event trauma. There is a community grief and fear component, feeling that America was no longer secure, and grief over the lost lives of loved ones.

Other issues with 9/11 trauma were physical sequelae—physical injuries, exposure to toxic air, etc. Patients not only had PTSD, but lifelong physical ailments like asthma that would progress to chronic obstructive pulmonary disease and gastroesophageal reflux disease.

Psychiatric Times: What were your experiences of working with veterans who enlisted after 9/11?

Christina Ni, MD: People who enlisted in the military directly because of 9/11 and subsequently experienced trauma from their military service had less of a baseline fear toward unpredictability. They tended to have more engrained, learned behaviors from the military.

When we had in-person visits, I had to get patients from the waiting room and walk them back to my office down a long, narrow hallway with no windows. Many veterans strongly disliked that setup where there was no clear escape and no windows to see what was going on outside. Many veterans made it clear that they preferred that I walk in front of them – they did not feel comfortable having anyone walk behind them. Often, they would sit in the corner of the room, facing the door and any threats. They would ask to have the window open and often even the door open, even when it came at the cost of compromising their privacy. These veterans had hypervigilance more directly related to their specific experiences while serving.

One veteran described the challenge of walking into the VA hospital; he had to walk through 2 sliding doors, and the second sliding door that opened would cause a rush of air to blow on his face. This reminded him of improvised explosive device (IED) blasts, and it was always triggering. He chose to walk all the way to the other side of the building to avoid this sensation.

I think that for the people who made a voluntary choice to join the military directly due to the events of 9/11, they exhibited more resilience because of the principles of why they joined. There was a mental framework of “this is why I joined, and this is why I’m experiencing these difficult situations,” which provided a framework for them to operate within that resulted in greater resilience. Often, they would tell me that they felt that they were contributing to something and this was meaningful to them.

Psychiatric Times: As you mentioned, trauma was experienced by individuals beyond those at ground zero. What did you see?

Christina Ni, MD: I treated many patients who had family members, friends, and loved ones who were directly impacted by 9/11. Treating these patients and listening to their stories made me question the current DSM 5 criteria for PTSD, which specifies that to officially qualify for a PTSD diagnosis a person must have direct exposure to an event that poses risk of death or serious injury. It made me think that the DSM needs to be revised. There was a high level of trauma in some of these patients, even though they did not directly experience the 9/11 attacks. They still exhibited hallmark PTSD symptoms including nightmares, intrusive/distressing thoughts, avoidance of anything that might be tied to the event, both emotional and physical distress at exposure to the event, such as movies, anniversaries, newspaper articles, etc.

Psychiatric Times: How did the events impact patients in general?

Christina Ni, MD: It’s interesting how much of a close connection there is to personal life events that become entwined into their mental health condition. There was a veteran who worked for the Air Force in an elite division overseeing fighter jets; this patient was part of an active combat group. It was critical to have the exact parameters inputted, if the numbers were wrong it could mean life or death. The veteran spent years doing this work and meticulously checking, double-checking, and triple-checking his work.

After serving successfully, he retired, but then he struggled with full-blown obsessive-compulsive disorder in civilian life to the point where he could not hold down a job. He engaged in behaviors like repeatedly returning to speed bumps to check that he did not run over a person, which would make him late for work. For this patient, the high consequences of errors in his military life triggered something within him that made him feel like he needed to constantly check various tasks at the cost of living a functional life.

His condition was so severe that he could not live in a productive manner after the military. As a result, he was sent from the DC area where he was living to an intensive psychiatric treatment center in San Diego. There he seemed to improve on the highest dose of an antidepressant, but he subsequently experienced sexual dysfunction. Although he and his wife wanted to have a child, attempting to stop the medication made his symptoms so unmanageable that they made the difficult decision not to have children so he could go back on his medications.

This type of interface is truly unpredictable, and when it comes to burgeoning mental illness, the types of connections that are formed become extremely powerful. This goes back to basic neuroscience and how brain circuitry forms. The more we as humans pay attention to a thought—whether it is a positive or negative thought—the more the brain will provide resources and energy supporting that thought. For negative neural circuitries, this is where deep-seated problems arise. When there is not adequate mental health intervention, patients can spend hours of each day, every day, devoted to certain ideas and they become increasingly entrapped by the world they create.

I think it’s important to continue de-stigmatizing mental health and increase access. Then, issues can be more easily discussed and, if warning signs arise, friends and family members can intervene and get the person to mental health care right away. This way the patient can be monitored and the coincidental and noncoincidental events that occur can be reframed for the patient so it doesn’t become a full-fledged part of their pathology. This is where treatments like therapy, medications, and interventional psychiatry (eg, transcranial magnetic stimulation) can help by breaking up this process, decoupling the events/triggers, and helping direct the patient to rewire their brain differently.

Psychiatric Times: What have you learned about the long-term, chronic nature of this trauma?

Christina Ni, MD: From the patients that I have treated, most of the first responders with 9/11-related PTSD seemed to show more resilience and were more engaged in mental health treatment toward meaningful recovery. I often wondered if this was part of the nature of being a first responder: that people who become first responders are a self-selected group who find meaning and purpose in this type of work and who are more resilient to begin with to continue working in this field. Additionally, they have encountered traumatic situations in the past and have found what works to successfully process events.

The patients whose symptoms have persisted tend to have a greater mental health burden, with other comorbid conditions like anxiety, depression, OCD, or personality disorders, which make it more difficult to achieve recovery. The anniversary of 9/11 is particularly triggering to patients and having strong social support as well as strong mental health care through family and friends to decouple the triggering event from the emotional/physical reaction is important.

The presentation of PTSD seems to evolve in patients, beginning with classic PTSD symptoms, eg, intrusive thoughts, avoidance, hypervigilance. In later years with chronic PTSD (typically 5 years or more), patients continue to experience those symptoms and struggle with entwined depression, anxiety, insomnia, and ruminations. Patients with poor social support, inadequate access to mental health care, physical injuries, and other life stressors like finances and work also tend to fare worse. It seems that the less functional/productive the person is in family life, work, and their community, the more they continue to suffer from chronic PTSD.

What I have learned from long-term, chronic nature of PTSD:

• Not all people follow the same trajectory. Some show symptoms immediately; some have emerging PTSD symptoms that manifest later with a delayed onset
• Sometimes symptoms wax and wane depending on other life circumstances.
• It is important to treat the whole person, with diet, exercise, therapy, medications, interventional psychiatry treatments, and to get families involved in support groups. Substance use has been an issue and getting patients into rehabilitation programs early is important. Addressing issues like housing, food access, sleep, and physical health are all important to help patients heal from PTSD.
• PTSD/grief support groups have been helpful for some patients.

Psychiatric Times: What advice for clinicians do you have as we reflect on the anniversary of 9/11?

Christina Ni, MD: After a collective tragedy, a psychiatrist’s role should not be limited to symptom management, but they should get to know the patient, how they function and interface with their worlds, and truly walk alongside the patient toward long-term recovery. The path to long-term recovery is to help patients integrate the trauma into their lives and process the events, while conscientiously ensuring that they are caring for their physical health, social/family lives, work/school, diet, sleep, exercise. Also, collective trauma doesn’t exist in isolation, and it is important for patients to connect with a community of others who share their experiences.

In thinking about patients who recovered and demonstrated resilience—including those patients who initially struggled but were able to adhere to treatment plans—it really highlights the strength of survivors, victims, and the mental health care professionals who support them. I am reminded that although some treatment arcs might take decades, patients are able to come out with recovery, healing, and functional lives.

Having said that, it might take time, jumping through hoops, and repeated discussions before patients become receptive. For example, one patient spent a full year coming to appointments, often sitting in silence and refusing to participate, but he continued to show up. Frequently, he would leave after a few minutes of silence. After a year, he slowly became receptive to pediatric doses of medication. Then, we were able to increase medications to a therapeutic dose. Later he became open to individual therapy and then group therapy. It took time and a lot of repetition of unsuccessful appointments, but eventually he trusted me and engaged in treatment. As a result, he went from living in his van and cutting off ties with his family to reconnecting with his family, finding steady work, and even starting a little garden in his backyard.

When I think of the tragic events and horrific experiences that people go through, the only way for me to come to peace with it is to think about all the people who are willing to help, who are willing to stick through years of mental health that doesn’t seem to be improving.

If the patient is willing to continue, then I’m willing to continue walking alongside them on their journey. I try to think about what humans can overcome and how resilient they can be, and how they can contribute so much beauty and positivity to the world.

Dr Ni is board-certified psychiatrist and Interventional Psychiatry Medical Director with Mindpath Health in Southern California.

References

1.Mann FD, Waszczuk MA, Clouston SAP et al. A 20-year longitudinal cohort study of post-traumatic stress disorder in World Trade Center responders. Nat. Mental Health. 2025;3: 789-802.

2. Ni Christina. On 9/11 and Trauma Treatment, a Reflection With Christina Ni, MD. Psychiatric Times.September 11, 2025. Accessed September 11, 2025. Psychiatrictimes.com/view/on-9-11-and-trauma-treatment-a-reflection-with-christina-ni-md