A survey of the mental health effects associated with the intensive media coverage of the September 11, 2001 terrorist attacks on the Pentagon and the World Trade Center revealed that 44% of the adult respondents who had watched television coverage of the events were considered to have a substantial stress reaction as determined by a modified PTSD checklist. 1 A substantial increase in the rate of new prescriptions for antidepressants and sleeping pills was also noted in the New York area at this time. 2 Another study addressed the prevalence of PTSD symptoms in residents of Manhattan 5 to 8 weeks after the September 11 terrorists attacks. 3 To our knowledge, new-onset psychotic symptoms have not been reported in connection with the September 11 tragedy. 4 We describe two cases of brief psychotic disorder in adults who experienced the terrorist attacks from afar through television coverage. The patients were brought in for assessment to a medical center in the Northeastern United States approximately 2 weeks after September 11.
Case Report 1
A 59-year-old widowed Haitian female, who had recently immigrated to the United States and had no prior psychiatric history, became increasingly distraught soon after viewing the television coverage of the terrorist attacks on September 11, 2001. She became extremely paranoid and delusional, stating that there would be further terrorist attacks that would kill everyone. She also became suspicious of her family, accusing them of trying to kill her; her behavior became disorganized with increased agitation, motoric hyperactivity, and decreased sleep. She was taken to an emergency room on September 23, 2001, where she was found to be paranoid, agitated, and delusional. The delusions related to voodoo practices. In the emergency room, she was treated with lorazepam 2 mg and risperidone 2 mg and admitted to inpatient psychiatry. At first, the patient remained suspicious and guarded and was amnesic for events that led to her admission. She was treated with olanzapine 5 mg/day for 5 days. Her symptoms resolved on this regimen and she remained in good behavioral control. A successful family meeting was held. At the time of her discharge on September 27, 2001, the patient was free of psychotic symptoms and had returned to her baseline level of functioning with no flashbacks, nightmares, or dissociative symptoms. She was discharged on olanzapine 5mg/day. Two months following discharge, her son reported that she was doing well in Haiti. She had discontinued the olanzapine.
Case Report 2
A 49-year-old married white male with a history of impulse control disorder (pathological gambling), learning disorder, and possible attention-deficit/hyperactivity disorder but no previous psychiatric hospitalizations became distraught after watching the television coverage of the September 11 terrorist attacks. He became extremely concerned about the safety of his wife, who is of Middle-Eastern descent and works in New York City. After about 10 hours, he was able to communicate with his wife over the telephone; however, he became gradually and progressively disorganized in his thinking and behavior. On September 26, 2001, he was evaluated in an outpatient psychiatric clinic after being arrested for openly stating that he had a bomb in his duffle bag before getting on a public bus. The patient did not remember stating that he had a bomb but remembered feeling like his head was going to explode. He was sent home with an appointment to return the following week. However, on September 28, 2001, he became grossly disorganized and went outside completely naked. According to the police report, the patient was quite combative and kept repeating the words “zero” and “New York.” He was admitted to the inpatient service where he was found to be hypervigilant with pressured speech. He refused to be touched by a Q-tip during the physical examination because he thought it was a weapon. His thought process was tangential and circuitous. His thought content was paranoid with ideas of persecution centering on his wife, whom he believed was in danger from others. His affect was labile and anxious. He stated that he had run into the street naked because he believed that if everyone was naked no one could be hiding guns. The patient’s family history included a mother with schizophrenia.
The patient was treated with olanzapine and the dose was gradually increased to 15 mg/day. He received lorazepam intermittently for symptoms of anxiety. Because of his mood instability, the patient was also started on valproic acid, with a gradual dose increase to 500 mg twice daily.
The patient stabilized and his thought processes gradually became better organized. He did not have any further episode of behavioral dyscontrol nor did he have any re-experiencing or dissociative symptoms. A family meeting was held with the patient’s brother and his wife. By October 11, 2001, the patient’s paranoia had completely resolved and he was transferred to the subacute unit, where he returned to his normal level of functioning The patient has been followed at our institution for over a year and was asymptomatic at the last office visit. He is being maintained on olanzapine 10 mg/day and valproic acid 750 mg/day.
These two cases met the criteria for brief psychotic disorder with marked stressor (see Table 1). 5 The specifier “with marked stressor” as applied to these two cases refers to the September 11, 2001 terrorist attacks experienced indirectly through television coverage. Both patients presented with a relatively sudden onset of positive psychotic symptoms: delusions, disorganized speech, and disorganized behavior following television viewing of the terrorist attacks. In both cases, the disturbance lasted less than 1 month and the two individuals eventually had a full return to their premorbid level of functioning.
The respective ages of the patients (49 and 59 years) make their presentation somewhat atypical, since the age of onset of brief psychotic disorder has usually been reported to be in the late 20s or early 30s. 5 Both patients had a relatively low level of education. Neither had a history of alcohol or substance abuse or a co-existing medical condition that could account for their symptoms, nor was there any evidence of malingering or factitious disorder.
The first patient had no previous psychiatric history and no family history of psychiatric illness. The second patient had a previous history of psychiatric disorders but had never been hospitalized and denied experiencing psychotic symptoms in the past. He did, however, have a family history of psychotic disorder.
Both patients responded well to acute treatment with a combination of an antipsychotic and a benzodiazepine. The first patient was discharged on olanzapine alone and the second patient on a combination of olanzapine and valproic acid.
The differential diagnosis in these cases included acute stress disorder and posttraumatic stress disorder. Although the time course of both presentations would be consistent with a diagnosis of acute stress disorder (a disturbance lasting for a minimum of 2 days and a maximum of 4 weeks and occurring within 4 weeks of the traumatic event), 5 the patients in these two cases did not meet full criteria for this disorder. There were no prominent dissociative symptoms and no persistent re-experiencing of the events. Both patients did present with amnesia, and the second patient also had a transient exaggerated startle response, but the prominence of their psychotic symptoms favors the diagnosis of brief psychotic disorder.
The time course of both presentations (lasting less than 1 month) precludes a diagnosis of posttraumatic stress disorder (the criteria for which require a duration of longer than 1 month), even though psychotic symptoms may be part of the clinical presentation of that disorder. In addition, these patients did not have persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, or persistent symptom of increased arousal, all of which are criteria for posttraumatic stress disorder.
The etiology of brief psychotic disorder is not well understood and requires further investigation. Researchers have proposed that the stress-vulnerability hypothesis may be applicable to acute and transient psychotic disorders. A positive family history of psychotic illness has been found to confer a high degree of vulnerability to these disorders. 6 Our second patient clearly qualified as vulnerable not only based on his family history of schizophrenia, but also in view of his pre-existing psychological problems. In the case of the first patient, although there was no family history or personal psychiatric history, cultural factors—i.e., recent immigration to an unfamiliar cultural milieu, poor socioeconomic status, and superstitious beliefs—may have made her more vulnerable to a transient psychotic disturbance. The relative importance of genetic versus environmental or cultural vulnerability remains to be determined; however, the role of intercurrent stressors such as interpersonal conflicts should not be minimized.
In both of the cases described here, superimposed upon the pre-existing vulnerability was exposure via television coverage to one of the most stressful life events of modern times. The magnitude of the event was clearly accentuated by the pervasive and persistent media coverage. Increased television viewing of national disasters, such as the 1986 Challenger space shuttle explosion 7 and the 1999 Oklahoma City bombing, 8 has also been documented to be correlated with severe psychological stress in viewers.
The present report has some limitations. Intellectual functioning was not formally assessed in these patients during their hospitalization. There was no systematic assessment of a representative population, so that we cannot postulate the prevalence of this type of reaction or of typical risk factors. We would therefore recommend that future research be done more systematically following large-scale violence or terrorist attacks. This might involve asking patients about their media viewing at the time of the initial psychiatric evaluation.
One can only speculate as to the mechanism by which stress induces psychotic symptoms even though there has been a great deal of hypothesis-driven research in other psychotic disorders (e.g., schizophrenia) investigating the association between stress and exacerbation or new onset of psychosis. More research is clearly needed to elucidate the psychological effects of extensive modern media coverage of disasters.
1. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of the stress reactions after the September 11, 2001 terrorist attacks
. N Engl J Med 2001; 345:1507–2.
2. Miller CM. Disaster and trauma. The Harvard Mental Health Letter. January 2002; 18:1–5.
3. Galea S, Resnick H, Ahern J, et al. Posttraumatic stress disorder in Manhattan, New York City, after the September 11th terrorist attacks
. J Urban Health 2002; 79:340–53.
4. Galea S, Ahern J, Resnick H, et al. Psychological sequelae of the September 11 terrorist attacks
in New York City. N Engl J Med 2002; 346:982–7.
5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association; 2000.
6. Das SK, Malhotra S, Basu D, et al. Testing the stress vulnerability hypothesis in ICD-10 diagnosed acute and transient psychotic disorders. Acta Psychiatr Scand 2001: 104:56–8.
7. Terr LC, Bloch DA, Michel BA, et al. Children’s symptoms in the wake of Challenger: A field study of distant traumatic effects and an outline of related conditions. Am J Psychiatry 1999; 156:1536–44.
8. Pfefferbaum, B, Nixon SJ, Krug RS, et al. Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing. Am J Psychiatry 1999; 156: 1069–74.