As the anniversary of the attacks that killed about 3,000 people approaches, many Americans are having nightmares, flashbacks, tearful outbursts and needless quarrels as their minds subconsciously dredge up the horror of that day, psychologists say.

The terms "anniversary reaction" and "grievers' firsts" refer to time cues that re-trigger feelings surrounding a traumatic event. The cue can be anything from the season of the year in which the trauma occurred, to a specific day, date or hour.

The anniversary of the terror attacks that destroyed the World Trade Center's twin towers and part of the Pentagon brings a danger of throwing New York, the entire country and even other parts of the world into emotional turmoil.

"There could be mass depression," said Dr Michael Nuccitelli, of the SLS Health psychiatric facility in Brewster, New York, whose patients include families of the World Trade Center victims.

"We are going to experience grief as a nation -- parallel to the fact that there was mass shock. As a nation, we couldn't believe it happened," he said.

Witness to the Attack

On that clear September morning, Dr Alan Hilfer was driving on the West Side Highway on his way work at Maimonides Hospital in Brooklyn when he had "the great misfortune," as he put it, of seeing the first hijacked jetliner smash into one of New York's most prominent landmarks at 8:46 a.m.

"It was a beautiful day and the sun roof was open," the psychologist said. "I heard a plane flying very low over my head and then what I thought was a sonic boom. I looked up and saw the World Trade Center explode. Other drivers and I pulled over and just stood and watched the paper floating down. I can still see it. It will be burned in my mind forever."

He was already driving away when the second hijacked airliner struck the other 110-storey tower about 20 minutes later.

Dealing with Grief

Hilfer said the experience changed him.

"I will never, ever, be as complacent or unaware or take for granted the things I did before," said Hilfer, who not only had to help patients, but handle his own grief as well.

"My colleagues and I used to meet informally and privately for discussions, but those meetings have tapered off," Hilfer said. "In general, I've been so amazed by people's courage, kindness, and resilience that it has re-energized me."

Many people dread reliving the day and some are finding they can no longer put off seeking professional guidance.

"A mother who lost her daughter in the World Trade Center called me in tears. She is already anticipating the anniversary," said Anie Kalayjian, visiting professor of psychology at Fordham University. "Her nightmares are increasing. She's having flashbacks and her work is being affected."

Kalayjian has been researching the psychological effects of the terror attacks on students, mental health workers and corporate employees who worked in the area.

She believes the strong emotional response is involuntary, but may be prevented proactively with support groups, anniversary gatherings and memorials to help process feelings.

The Journal of the American Medical Association, in its August 7 issue, cited a new Web-based National Study of Americans' Reactions to September 11, which found that post-traumatic stress disorder was significantly higher in New York at 11.2 percent than in Washington, DC at 2.7 percent, and major cities including Boston, Philadelphia, Chicago, Houston, and Los Angeles at 3.6 percent. In the rest of the country it was 4 percent. The data was collected between October 12 and November 12, 2001, from 2,273 adults.

"The tragedy created a developmental ripple effect," said SLS Health's Nuccitelli. "It has accelerated people's decision making."

In a relatively short period after the event, many couples either renewed their commitment or decided to divorce.

"One couple thinking about having children made a decision within a month to go ahead. Another took 11 weeks to agree that they don't want to bring a child into this horrible world," he said.

Last September 11 upstate New Yorkers Debra and Julian Keiser were preparing to celebrate their daughter Amy's 14th birthday. This year, there will be no party.

"Maybe a week before or after," said Debra. "It's just too sad."

In the nation's heartland, Kansas antiques dealer Dagni Anders and her husband, Dale, an engineering specialist for Cessna Aircraft, are going ahead with plans to mark their 37th wedding anniversary, but with a twist.

At their Wichita church with a new pipe organ, a master organist will present a patriotic concert. "That should be a fitting way to recognize both our anniversary and the more recent events of September 11," she said.

A residual effect for New Yorkers in particular is a "startle response," meaning they are more sensitive to loud noises such as thunder or fireworks.

But that should diminish over time, psychologists say.

Kalayjian believes the world community will experience the anniversary reaction to some extent.

"The feeling of sadness will be overwhelming," she predicted.

Just after the attacks, she said she got 200 e-mails a day offering condolences.

"I've traveled a lot since it happened," she said. "People in Germany -- from 12-year-old kids to 60-year-old women -- were telling me what they were doing or eating at that exact moment, what they were holding in their hand. Their memories were very explicit, which is indicative of a major impact."

To be sure, Kalayjian said the feelings of sadness will be mixed with some anger and some helplessness.

"Some people are scared of being sad and would rather be angry," she said. "But that is an unhealthy way of coping."

"One of the downsides of grief is that we can become self-destructive," Nuccitelli agreed. "People should be careful about doing too much of anything - gambling, alcohol or drug use.

"As we get closer to the day, we'll see more people reacting. The feelings will build day by day, and take several weeks to diminish."

Hilfer suggested people who anticipate being affected should ignore the media as much as possible for a week before the anniversary and for a few days after.

(China Daily August 12, 2002)