September 11, 2001, psychiatric disorders, and broadening treatment options.

The September 11, 2001, attacks galvanized local and national resources in perhaps the most remarkable mental health research and services effort in history. A sense of urgency surrounding the New York City, Washington, DC, and Pennsylvania attacks seemed to pervade all aspects of the community, from those who served our community and its bereaved families, to government officials, to scientists involved in field research. After a large-scale disaster, the process of recovery can produce new resources and promote new alliances between individuals, groups, and institutions that ultimately benefit the entire community. At the same time, the field must take care that this single-minded focus does not inadvertently lead to neglect of the clinical dilemmas and unanswered research questions that were with us before September 11th, and remain with us 1 year later. This month's issue of CNS Spectrums therefore presents a balance of articles, that address the mental health consequences of September 11th as well as persistent treatment issues in refractory psychiatric disorders in adults and children. Dr Marshall presents a review of the first published scientific studies documenting the psychological consequences of the September 11th attacks. These epidemiological surveys are impressive for their size, sophistication, and rapidity of execution, and proof that, indeed, chance can favor the prepared mind. It is clear that there were significant mental health repercussions across the nation and, in particular, in the greater New York area. Most surprisingly, three major surveys have found that rates of posttraumatic stress disorder (PTSD) symptoms and full PTSD were positively correlated with television exposure on and after September 11th and in the 8 weeks following the attacks. An average of 4% of adults outside of the New York area met criteria for probable PTSD because of September 11th 7 million individuals. This is a remarkable finding and deserves closer study. There are also important implications for our understanding of the etiology of PTSD, since they offer proof that, in some persons and under some conditions, television coverage of a disaster can evoke the subjective experience of "fear, helplessness, or horror," particularly when the viewer perceives his or her own safety is threatened. Soon after the World Trade Center attacks, our institution was inundated with requests for training in empirically validated treatments for acute trauma. Unfortunately, this area of research is so new that manualized treatments were not even available in the public domain. We contacted Dr Bryant, and he graciously and immediately sent us his manual. In this issue, Dr Bryant reviews this important new area of research. It is our belief that disaster-preparedness in any community requires the presence of mental health professionals proficient in these highly successful, shortterm psychotherapy interventions. Social anxiety disorder is the most common anxiety disorder in the United States, and has been a major focus of study over the past 15 years. Problematic perceptions of others as critical and superior, and sensitivity to experiencing shame or humiliation, has traditionally been a focus of psychotherapy. In its more severe and persistent forms, this constellation represents social anxiety disorder. Over the last 2 decades, cognitive-behavioral techniques that address such problems efficiently have been manualized and shown effective in rigorous controlled studies. More recently, a number of different categories of medication have been shown efficacious in single-site and multi-center trials. However, the research literature provides almost no guidance if these first-line treatments fail or are not well tolerated. It is this problem that Simon and colleagues begin to address in their pilot study of citalopram, which resulted in promising preliminary findings for both kinds of prior treatment failures. Study of the use of medications in neurocognitively impaired children is still in its earliest stages. Because of the often intractable nature of these disorders, and their clear (though poorly understood) biological origins, families often hope for a medical approach to improving functioning and controlling maladaptive and potentially destructive behavior. Childhood autism is one of the most mysterious and debilitating of these, and is notable for the great gap between the scope of the public health problem and the availability of large, well-controlled trials of either somatic or psychosocial treatments. Dr Owley gives us a scholarly guide to this complex literature that will be particularly useful to pediatric pharmacologists, and perhaps families of such children. More importantly, Dr Owley describes the decision-making process of the pharmacologist, with a number of important guidelines and sensible caveats. Given the limited effectiveness of medication treatments to date, he provides a clear analysis of the role of the pharmacologist as one of several members on a treatment team.