The Intentional Self-Medication of 9/11-Related PTSD Symptoms with Alcohol: 15 Years after the Disaster

The self-medication hypothesis may explain the co-morbidity of affective and substance use disorders. Research shows increased prevalence, frequency, and intensity of binge drinking and post-traumatic stress disorder (PTSD) among those directly exposed to the 9/11 terrorist attacks on the World Trade Center (WTC), however, little is known about PTSD symptomology and intentional self-medication with alcohol (ISMA) among this group. We used WTC Health Registry data (N = 28,935) to describe the relationship between ISMA and specific symptom clusters of probable 9/11-related PTSD, the number of PTSD symptom clusters endorsed, and binge drinking intensity. Multivariable logistic regression models were used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CI). ISMA was most strongly associated with the hyperarousal PTSD symptom cluster (AOR = 2.04 [1.88, 2.21]) and the endorsement of one (AOR = 1.80 CI [1.65, 1.95]), two (AOR = 2.51 CI [2.28, 2.77]), or three (AOR = 2.84 CI [2.55, 3.17]) PTSD symptom clusters, indicating a clear dose–response relationship. A significant number of 9/11-exposed persons continue to experience PTSD symptoms and engage in ISMA as a potential coping mechanism. Repeated screenings for self-medicative alcohol use among survivors of mass traumas with PTSD symptoms is of public health importance.


Introduction
Post-traumatic stress disorder (PTSD) was the most common mental health sequela of the September 11th, 2001, terrorist attacks on the World Trade Center (WTC) in New York City [1]. The disaster exposed thousands of people, including volunteer and professional rescue/recovery workers, lower Manhattan residents, area workers, and passers-by, to a myriad of physical and psychological hazards of varying intensity and duration on the day of 9/11 and in the ensuing weeks and months. Exposure to 9/11 had a significant long-term impact on the physical and mental health among directly exposed populations. Research shows that it resulted in an elevated PTSD prevalence, depending on the population, of 3.8% to 29.6%, immediately after the event and in the years since [2].
Increased alcohol consumption is a short-term effect that has been frequently observed in populations exposed to man-made disasters [3], natural disasters [4] and terrorist attacks [5,6]. For instance, Keyes et al. [7] found that alcohol consumption increased in population samples directly exposed to 9/11 in the months after the event, and over the longer term for those with higher exposure levels. Another study also demonstrated an increased prevalence, frequency, and intensity of binge drinking among those directly exposed to the 9/11 attacks [8] and the among survivors of Hurricanes Katrina and Rita [9]. Comorbidity of PTSD and increased alcohol use is well documented in trauma-exposed populations is [10][11][12][13][14][15][16]. For example, a meta-analysis of substance use and misuse following mass traumas found that, among disaster-exposed individuals, post-disaster drinking was two to six times more likely for those with symptoms of PTSD, compared to those without PTSD symptoms [6].
There are several reasons proposed as explanations for the well documented association between psychological distress and substance abuse. One of the most widely supported theories that describes the increased comorbidity of depression and anxiety-related disorders, such as PTSD, and substance use is the self-medication hypothesis. This theory posits that individuals who experience affect dysregulation or mood-disorders use substances, such as alcohol, to alleviate or cope with their resulting symptoms. In relation to PTSD, the self-medication hypothesis has typically been studied in the context of specific clinical populations [17] or amongst veterans [18]. However, the literature on the self-medication of PTSD symptoms amongst civilian populations exposed to mass-traumas is still nascent. A study assessing the psychiatric impact on survivors of the Oklahoma City bombing found that those who had PTSD and comorbid mental health conditions were the only individuals in the study to use medication or alcohol as a coping mechanism [19]. However, the time frame of this study's findings are limited to six months after the disaster, thus the associations of delayed cases of PTSD and other longer-term mental health effects with self-medication could not be considered. Another study using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-II) found that close to 20% of individuals with PTSD used substances to relieve their PTSD symptoms [20,21]. However, the PTSD and the self-medication measure used in this study were not tied to a specific traumatic event, thus the authors could not comment on whether there was a common link between the respondents' reported self-medication behavior and PTSD symptoms. Furthermore, research that examines the self-medication hypothesis in non-institutionalized, civilian populations is limited to relatively small analytical sample sizes and little is known about the intentional self-medication with alcohol (ISMA) of PTSD symptoms and symptom clusters that resulted from 9/11. Findings pertaining to the relationship of alcohol use and specific PTSD symptomology are also mixed. One study observed that in a sample of civilians seeking treatment for substance use disorders, the frequency of avoidance-cluster PTSD were elevated significantly for individuals with alcohol use disorders [22]. However, another study performed on a similar sample observed that alcohol dependence was most highly correlated with the hyperarousal PTSD symptom cluster [23].
To address these gaps in the self-medication and PTSD literature, data from the World Trade Center Health Registry (WTCHR), a longitudinal cohort study of 71,427 individuals, were used to examine the factors associated with ISMA among the persons directly exposed to the 9/11 attacks who exhibited 9/11-related PTSD symptomology. The use of this cohort provided a unique opportunity to study the self-medication hypothesis within a substantial civilian population sample with an elevated prevalence of PTSD symptomology compared to the general U.S. population.
The goals for the present study were to look more granularly at the association between ISMA and PTSD by (1) examining the association of ISMA with the type of PTSD symptomology endorsed, (2) examining the association of ISMA with the number of concurrent PTSD symptom clusters endorsed, and (3) approximating the relationship of the intensity of ISMA to PTSD severity by describing the relationship among ISMA, the intensity of binge drinking, and PTSD symptom cluster endorsement.

Materials and Methods
This study's sample was derived from the World Trade Center Health Registry (WTCHR), a longitudinal cohort study of individuals directly exposed to the 9/11 disaster in New York City. Enrollees in the cohort belonged to one or more of five study eligibility groups: rescue/recovery workers and volunteers, lower Manhattan residents, area workers, school students/staff, and passers-by.

Data Analysis
Chi-square tests for dichotomous variables and bivariate logistic regression for the one continuous variable used in the analysis (i.e., social support) were used to assess their associations with ISMA.
We used multivariable logistic regression to model the relationships between the three PTSD symptom clusters (avoidance, re-experiencing, hyperarousal) and ISMA. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were computed with those who did not endorse PTSD symptomology and did not report ISMA as the referent. We also performed multivariable logistic regression to model the relationship between the number of PTSD symptom clusters endorsed and ISMA.
A separate descriptive analysis examined the relationship of ISMA, binge drinking, and the number of PTSD symptom clusters endorsed. Chi-square tests were used to assess the associations between the proportions of enrollees reporting ISMA and the different binge drinking groups (i.e., none, low-and high-frequency) stratified by the number of PTSD clusters endorsed (0-3). All analyses were performed on SAS (SAS Institute, Cary, NC, USA) Enterprise Guide, version 9.4.

Description of Analytic Sample
The largest proportions of the study sample were men (60.0%), non-Hispanic white (71.1%), aged 45-64 years (61.0%) and reported at least some college education or technical degree (29.4%, Table 1). Rescue/recovery workers comprised 45.4% of the study sample. One fifth of enrollees (20.6%) reported the ISMA of 9/11-related PTSD symptoms at W4. Those excluded from our analysis (N = 5568) were enrollees who responded, "not at all," to all PCL items and those who were missing items on the PCL. Demographically, this excluded group did not differ substantially from our analytical sample (data not shown) except for sex: 65.7% of the excluded sample were women and 34.3% were male. Table 1. Sociodemographic characteristics of (edited out for blind review) who endorsed at least 1 post-traumatic stress disorder (PTSD) symptom, stratified by intentional self-medication with alcohol, 2015-2016 (N = 28,935). ISMA was more common among men, those aged 18-34 years and 35-44 years, and among those with higher levels of education (Table 1). Among those who reported ISMA, the mean social support score and the prevalence of life satisfaction was lower. As the number of sources of social integration increased, the prevalence of ISMA decreased (Table 2). Of the enrollees with probable depressive disorder, over one-third reported ISMA and of those who reported having a history of an alcohol and/or drug problem, more than half reported ISMA. Table 2. Mental health and social characteristics of (edited out for blind review) who endorsed at least 1 PTSD symptom, stratified by intentional self-medication with alcohol, 2015-2016 (N = 28,935). All associations tested at the bivariate level were statistically significant for all variables (p < 0.001), except for the survey eligibility group (p = 0.578).

PTSD Symptomology and ISMA
Almost a quarter of enrollees (23.7%) endorsed the avoidance symptom cluster, 38.8% endorsed the re-experiencing cluster and 38.8% endorsed the hyperarousal cluster (Table 2). We observed that a greater proportion of enrollees reported ISMA in all instances of symptom cluster endorsement compared to those who did not endorse any clusters. The avoidance/numbing cluster had the highest proportion of enrollees who reported ISMA: 35.7% of enrollees who endorsed the avoidance/numbing cluster reported ISMA, while 27.1% of enrollees who endorsed the re-experiencing cluster and 32.3% of enrollees who endorsed the hyperarousal cluster reported ISMA. In the adjusted model, those who endorsed hyperarousal had two times greater odds of ISMA (OR = 2.04, 95% CI [1.88, 2.21]), compared to those who did not endorse the cluster. Compared to those who did not endorse the specific cluster, individuals who endorsed the avoidance/numbing cluster had 1.4 times greater odds of ISMA (OR = 1.37, 95% CI [1.25, 1.50]) and those who endorsed the hyperarousal cluster had only a slightly greater odds of ISMA (OR = 1.11, 95% CI [1.03, 1.19]) ( Table 3). Table 3. Adjusted odds ratio (AOR) with 95% confidence intervals (CI) between the endorsement of 9/11-related PTSD symptomology and intentional self-medication with alcohol among (edited out for blind review), 2015-2016 ( N = 26,535).

Variable
AOR

Number PTSD Symptom Clusters Endorsed and ISMA
One sixth (16.6%) of enrollees endorsed all three PTSD-symptom clusters at W4, whereas 47.7% endorsed zero clusters, 22.0% endorsed one cluster and 13.7% endorsed two PTSD symptom clusters (

Binge Drinking, PTSD Severity, and ISMA
The prevalence of high-frequency binge drinking increased as the number of PTSD symptom clusters increased, but only for those who reported ISMA (Figure 1). The prevalence of high-frequency binge drinking amongst those who reported ISMA was lowest amongst enrollees who did not endorse any of the three PTSD symptom clusters (19.9%) and increased with each subsequent level of PTSD cluster endorsement. In this sample, a quarter (25.1%) of those endorsing one PTSD symptom cluster, 25.9% of this sample who endorsed two PTSD symptom clusters, and 32.9% of those endorsing all three PTSD symptom clusters, reported high-frequency binge drinking. The prevalence of high-frequency binge drinking remained relatively constant as PTSD symptom clusters increased for those who did not report ISMA: proportions ranged from 2.0% to 3.0%. All associations in this sub-analysis were statistically significant (p < 0.001). support. social integration, general life satisfaction, depression status, and history of drug or alcohol problem. * p < 0.001. ** p = 0.078.

Binge Drinking, PTSD Severity, and ISMA
The prevalence of high-frequency binge drinking increased as the number of PTSD symptom clusters increased, but only for those who reported ISMA ( Figure 1). The prevalence of highfrequency binge drinking amongst those who reported ISMA was lowest amongst enrollees who did not endorse any of the three PTSD symptom clusters (19.9%) and increased with each subsequent level of PTSD cluster endorsement. In this sample, a quarter (25.1%) of those endorsing one PTSD symptom cluster, 25.9% of this sample who endorsed two PTSD symptom clusters, and 32.9% of those endorsing all three PTSD symptom clusters, reported high-frequency binge drinking. The prevalence of high-frequency binge drinking remained relatively constant as PTSD symptom clusters increased for those who did not report ISMA: proportions ranged from 2.0% to 3.0%. All associations in this sub-analysis were statistically significant (p < 0.001).

Figure 1.
Prevalence of high-frequency binge drinking by the number of post-traumatic stress disorder (PTSD) symptom clusters among (edited out for blind review) who did and did not report intentional self-medication with alcohol, 2016 -16 (N = 28,935); * p < 0.001.

Number of PTSD Symptom Clusters Endorsed
Did selfmedicate Did not selfmedicate Figure 1. Prevalence of high-frequency binge drinking by the number of post-traumatic stress disorder (PTSD) symptom clusters among (edited out for blind review) who did and did not report intentional self-medication with alcohol, 2016 -16 (N = 28,935); * p < 0.001.

Discussion
This study examines the topic of ISMA and specific PTSD symptomology and intensity in a post-disaster context among one of the largest disaster-exposed U.S. cohorts with more than 15 years of data. It is one of the few studies to consider the interplay between ISMA, PTSD severity, and PTSD symptomology from a population health perspective [20,29,39]. We observed a strong association between ISMA and the hyperarousal and the avoidance/numbing PTSD symptom clusters, a dose-response relationship between ISMA and 9/11-related PTSD symptom intensity, and a robust association between ISMA and high-frequency binge drinking. Given the complex nature of the interplay between individual PTSD symptoms and alcohol-related behavior, it would be advantageous to continue to apply this line of questioning to larger, more generally representative population samples.
We observed that ISMA was highly associated with specific PTSD symptom clusters, particularly for those who endorsed the hyperarousal and avoidance/numbing clusters. This finding is consistent with PTSD and alcohol-coping literature [20,[40][41][42][43]. An important aspect of the self-medication hypothesis is that the substances used by those who self-medicate are not chosen randomly, however, they rather reflect the interplay between the particular psychopharmacological effect of a given substance and the nature of the negative affect for which one seeks relief [44]. Alcohol may be perceived by some to temporarily relieve psychic tension [45,46] and can create the illusion of relief from rigid defenses and feelings of isolation [47]. The PCL-S items, or individual PTSD symptoms, within the avoidance/numbing cluster, such as, "Feeling distant or cut off from other people", and items within the hyperarousal cluster, such as, "Being super alert or watchful or on guard", closely align with the hypothesis that individuals who self-medicate with alcohol do so for the perceived effects to temporarily alleviate feelings of tense emotional states. Our findings are consistent with this aspect of the self-medication hypothesis. Future research may be warranted to consider the relationship of ISMA to the specific PCL-S items within the symptom clusters.
We also observed a positive dose-response relationship between the odds of self-medicating and the number of PTSD symptom clusters endorsed: as the number of PTSD clusters endorsed increased, the likelihood of reporting ISMA increased. Central to the self-medication hypothesis is the assertion that those who experience painful affective states or psychopathology are potentially pre-disposed to the maladaptive use of substances as a means for the temporary relief of related symptoms [44,47]. This was reflected in the present findings in that they demonstrate a clear association between the alcohol use and the severity of a potentially painful affective state: those with the more severe PTSD had a greater prevalence of ISMA. Our interpretation is limited by our self-reported data on potentially sensitive topics, including the severity of PTSD symptoms and alcohol use, which may have led to under-reporting. Because of this, our study may have been subject to social desirability bias, a phenomenon applicable to self-reported data, whereby enrollees may report inaccurately in order to represent themselves in a positive fashion [48]. However, because we were able to measure the number of PTSD symptom clusters endorsed, we were able to expand on the work of Leeies et al. [20], who determined the prevalence for self-medication of PTSD symptoms amongst a general U.S. population sample, but who, given restrictions stemming from their study design, were not able to assess the interplay of self-medication and PTSD severity.
We also found binge drinking and ISMA to be highly associated. When parsed out by the number of PTSD symptom clusters endorsed, the enrollees who reported ISMA consistently had the highest proportions of high-frequency binge drinking compared to those who did not report ISMA, irrespective of the number of PTSD symptom clusters endorsed. This finding supports those of previous studies on binge drinking within similarly exposed populations [8,[49][50][51][52]. Given their highly robust association in our sample population, it may be that binge drinking intensity could approximate ISMA intensity. However, this inference is based on an assumption that ISMA is necessarily akin to binge drinking behavior and given that ISMA data was derived from a two-item construct, it is possible that other constructs are driving this association. Future research should aim to expand the ISMA literature to include not only measures of prevalence, but also measures of intensity to further elucidate this association.
This study is subject to several limitations. Firstly, only those enrollees who were aware that at least some of their drinking was in response to distressing mental symptoms resulting from 9/11 reported ISMA. It is likely that there are people in our study sample who self-medicated but did not recognize their drinking behavior as such. Our measure of ISMA does not capture this group. Secondly, due to our cross-sectional study design, we are not able to comment on the longitudinal nature of the association between PTSD and ISMA. The survey used in this study did not include questions regarding drinking behaviors prior to 9/11, therefore we were also not able to distinguish those who engaged in ISMA and/or binge drinking before the exposure to 9/11 from those whose onset of this behavior was post-exposure. All the individuals in the WTCHR database were exposed to 9/11 and we can therefore not make comparisons with an unexposed control group. Furthermore, the ISMA question only appeared on the WTCHR survey as of W4, 15 years after 9/11, so we were not able to gauge the prevalence of ISMA soon after the event nor were we able to consider the individuals who engaged in this behavior at some point after the disaster, but who were no longer engaged with it at W4. Thus, given this study's design, we are unable to comment with any certainty on the temporal interplay between binge drinking, ISMA, and PTSD. Future research should consider the longitudinal effects of PTSD symptomology on ISMA. Finally, our criterion to include only those with complete PCLs at W4 in the study sample lead to the disproportionate exclusion of women compared to men, which may affect the generalizability of our findings. However, despite these limitations, the sizes of the effects we found were large and statistically significant and indicate that the long-term trajectory of this comorbidity may be an important area for further research.

Conclusions
Fifteen years post 9/11, a significant number of persons who were exposed to the disaster and continued to experience symptoms of 9/11-related PTSD used alcohol to intentionally self-medicate their symptoms. This dual burden of PTSD and alcohol use related to PTSD demonstrates that, more than a decade later, this population is still in great need of services that address PTSD and alcohol use concurrently, specifically those that intervene on maladaptive coping strategies. Moreover, our findings demonstrate that populations with higher PTSD burdens may be a greater risk for the ISMA of their resulting symptoms. Our findings highlight the importance of repeated screening for self-medicative alcohol use and binge drinking and the inclusion of psychoeducation about substance use in the treatment protocols for the survivors of mass traumas. Findings from this study will inform post-disaster interventions for populations at risk of using alcohol as means to medicate the psychological symptoms of resultant trauma. Funding: This study was supported by Cooperative Agreement U50/OH009739 from the National Institute for Occupational Safety and Health; Cooperative Agreement U50/ATU272750 from the Agency for Toxic Substances and Disease Registry of the Centers for Disease Control and Prevention, which included support from the National Center for Environmental Health (NCEH); and the New York City Department of Health and Mental Hygiene. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Centers for Disease Control.

Conflicts of Interest:
The authors declare no conflict of interest. Repeated, disturbing dreams of the events of 9/11 c.

Appendix A
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving c. Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy e. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 g. Avoiding activities or situations because they remind you of the events of 9/11 Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e. Having physical reactions (e.g., heart pounding, trouble Repeated, disturbing dreams of the events of 9/11 c. Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a. Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a.
Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a. Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a. Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f.
Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f.
Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a. Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled

A Little Bit
Moderately Qu A a.
Repeated, disturbing memories, thoughts, or images of the events of 9/11 b.
Repeated, disturbing dreams of the events of 9/11 c.
Suddenly acting or feeling as if the events of 9/11 were happening again (as if you were reliving it) d.
Feeling very upset when something reminded you of the events of 9/11 e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of the events of 9/11 f. Avoiding thinking about or talking about the events of 9/11 or avoiding having feelings related to it g.
Avoiding activities or situations because they remind you of the events of 9/11 h.
Trouble remembering the important parts of the events of 9/11 i.
Loss if interest in activities that you used to enjoy j.
Feeling distant or cut off from other people k.
Feeling emotionally numb or being unable to have loving feelings for those close to you l.
Feeling as if your future will somehow be cut short m.
Trouble falling or staying asleep n.
Feeling irritable or having angry outbursts o.
Having difficulty concentrating p.
Being "super alert" or watchful or on guard q.
Feeling jumpy or easily startled