World Trade Center disaster and sensitization to subsequent life stress: A longitudinal study of disaster responders

A longitudinal follow-up study of rescue and recovery narratives of Oklahoma City bombing responders nearly a quarter century later

BACKGROUND

Most research examining first responders of terrorist incidents has been conducted in early post-disaster periods, utilized quantitative research methods, and focused on psychopathology such as post-traumatic stress.

METHODS

Longitudinal follow-up assessments of 124 workers from 181 baseline volunteer rescue and recovery workers originally studied were completed nearly a quarter century after the terrorist bombing of the Murrah Federal Building in Oklahoma City. Open-ended qualitative interviews were used in the follow-up study.

RESULTS

The rescue and recovery work, vividly described decades later, was gruesome. These workers' descriptions captured their mental toughness and their professional missions, as well as the emotional and mental health (MH) toll on their lives.

CONCLUSIONS

The extreme nature of rescue and recovery work in the aftermath of terrorism suggests potential utility for MH interventions to address the psychological toll that can be expected of human beings under the most extraordinary circumstances.

Public Works Employees and Posttruamatic Stress Disorder: an At-Risk Population

Although not widely known, public works employees in the United States were designated as emergency providers during critical incidents in 2003 and have provided these public works services, when activated. These public works employees may be either employees of a specific government entity or, more recently, privately contracted employees who provide similar services for a government entity. First responders working critical incidents are at risk for psychological trauma and posttraumatic stress disorder (PTSD). It is less clear, however, whether government/contracted public works employees working the same critical incidents are subject to the same risk of onset. This paper reviewed 24 empirical studies assessing this possible association from 1980 to 2020. These studies included 94,302 government/contracted employees. Psychological trauma/PTSD was reported in all 24 manuscripts assessing PTSD. Three of these studies additionally reporting serious somatic health problems. Public works employees are at risk for onset and this is a worldwide issue. Study findings and treatment implications are presented.

Religiosity and Social Support Predict Resilience in Older Adults After a Flood

In this study, we examined religiosity and social support as predictors of resilience after a devastating flood. Three flood exposure groups of primarily middle-aged and older adults were compared: (1) non-flooded adults as controls, (2) once-flooded adults with structural damage to homes and property in the 2016 flood, and (3) twice-flooded adults who had relocated inland because of prior catastrophic losses in the 2005 Hurricanes Katrina and Rita and then flooded again in 2016. Resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC). Correlation analyses confirmed that older age was correlated with higher religiosity, charitable work done for others, and resilience. Regression analyses indicated that religious beliefs and coping, social support, and charitable work done for others were associated with higher levels of resilience, whereas flood damage was unrelated to resilience. Implications for current views on post-disaster adversity and resilience in later life are discussed.

Investigating the impact of terrorist attacks on the mental health of emergency responders: systematic review

BACKGROUND

Terrorist attacks have strong psychological effects on rescue workers, and there is a demand for effective and targeted interventions.

AIMS

The present systematic review aims to examine the mental health outcomes of exposed emergency service personnel over time, and to identify risk and resilience factors.

METHOD

A literature search was carried out on PubMed and PubPsych until 27 August 2021. Only studies with a real reported incident were included. The evaluation of the study quality was based on the Quality Assessment Tool for Quantitative Studies, and the synthesis used the 'Guidance on the Conduct of Narrative Synthesis in Systematic Reviews'.

RESULTS

Thirty-three articles including 159 621 individuals were identified, relating to five different incidents with a post-event time frame ranging from 2 weeks to 13 years. The post-traumatic stress disorder prevalence rates were between 1.3 and 16.5%, major depression rates were between 1.3 and 25.8%, and rates for specific anxiety disorders were between 0.7 and 14%. The highest prevalence rates were found after the World Trade Center attacks. Reported risk factors were gender, no emergency service training, peritraumatic dissociation, spatial proximity to the event and social isolation.

CONCLUSIONS

The inconsistency of the prevalence rates may be attributable to the different severities of the incidents. Identified risk factors could be used to optimise training for emergency personnel before and after catastrophic events. Voluntary repetitive screening of rescue workers for mental health symptoms is recommended.

Terrorism’s Impact on Mental Health Outcomes among Directly and Indirectly Exposed Victims and the Development of Psychopathology

After the events of 9/11, many police-responders developed post-traumatic stress disorder (PTSD) and were potentially vulnerable to developing depression and/or anxiety; in addition, nearly half of police with probable PTSD had comorbid depression and anxiety. Having in mind that victims who experience the effects of terrorism are exposed to high levels of psychological damage, we thus aimed to determine how sequelae of a terrorist act directly and indirectly affect victims. Quantitative synthesis findings were concluded on the basis of 200 records that met the inclusion criteria out of a total of 650. We grouped the patients according to their level of exposure to the WTC terrorist attack on 11 September 2001. The Level I group included individuals who had experienced the traumatic event and/or those who had observed the attack. The Level II group consisted of rescuers and/or persons who cleaned up debris in the area after the attack. The Level III group comprised the victims’ families. Our research enabled us to create a profile for those who were most vulnerable to mental disorders after the WTC terrorist attack. Patients who had survived the terrorist attack and/or those who had observed the incident exhibited fewer traumatic symptoms and a lower percentage of suicidal thoughts in comparison to individuals who had worked as rescuers or cleaning staff in the area after the attack. The number of symptoms rose along with increased contact time with the stressor. The dominant symptom was the triad of intrusion, avoidance, and hyperarousal. The findings may confirm the positive effect of protracted court cases in legal proceedings for compensation on the maintenance and development of psychopathology. Our research may contribute to a better understanding of the consequences of terrorism outcomes on the human psyche and be used in the development of standards for dealing with victims of terrorism’s impact.

Cortical complexity in world trade center responders with chronic posttraumatic stress disorder

Approximately 23% of World Trade Center (WTC) responders are experiencing chronic posttraumatic stress disorder (PTSD) associated with their exposures at the WTC following the terrorist attacks of 9/11/2001, which has been demonstrated to be a risk factor for cognitive impairment raising concerns regarding their brain health. Cortical complexity, as measured by analyzing Fractal Dimension (FD) from T1 MRI brain images, has been reported to be reduced in a variety of psychiatric and neurological conditions. In this report, we hypothesized that FD would be also reduced in a case-control sample of 99 WTC responders as a result of WTC-related PTSD. The results of our surface-based morphometry cluster analysis found alterations in vertex clusters of complexity in WTC responders with PTSD, with marked reductions in regions within the frontal, parietal, and temporal cortices, in addition to whole-brain absolute bilateral and unilateral complexity. Furthermore, region of interest analysis identified that the magnitude of changes in regional FD severity was associated with increased PTSD symptoms (reexperiencing, avoidance, hyperarousal, negative affect) severity. This study confirms prior findings on FD and psychiatric disorders and extends our understanding of FD associations with posttraumatic symptom severity. The complex and traumatic experiences that led to WTC-related PTSD were associated with reductions in cortical complexity. Future work is needed to determine whether reduced cortical complexity arose prior to, or concurrently with, onset of PTSD.

Artificial intelligence language predictors of two-year trauma-related outcomes

BACKGROUND

Recent research on artificial intelligence has demonstrated that natural language can be used to provide valid indicators of psychopathology. The present study examined artificial intelligence-based language predictors (ALPs) of seven trauma-related mental and physical health outcomes in responders to the World Trade Center disaster.

METHODS

The responders (N = 174, Mage = 55.4 years) provided daily voicemail updates over 14 days. Algorithms developed using machine learning in large social media discovery samples were applied to the voicemail transcriptions to derive ALP scores for several risk factors (depressivity, anxiousness, anger proneness, stress, and personality). Responders also completed self-report assessments of these risk factors at baseline and trauma-related mental and physical health outcomes at two-year follow-up (including symptoms of depression, posttraumatic stress disorder, sleep disturbance, respiratory problems, and GERD).

RESULTS

Voicemail ALPs were significantly associated with a majority of the trauma-related outcomes at two-year follow-up, over and above corresponding baseline self-reports. ALPs showed significant convergence with corresponding self-report scales, but also considerable uniqueness from each other and from self-report scales.

LIMITATIONS

The study has a relatively short follow-up period relative to trauma occurrence and a limited sample size.

CONCLUSIONS

This study shows evidence that ALPs may provide a novel, objective, and clinically useful approach to forecasting, and may in the future help to identify individuals at risk for negative health outcomes.

Longitudinal Mental Health Effects of the 2016 Terrorist Attack in Berlin on Various Occupational Groups of Emergency Service Personnel

Emergency service personnel who respond to terrorist attacks may experience persistent stress following the event. This occupational stress must be examined in order to develop occupation-specific response preparation and follow-up measures. An explorative pilot study examined the occupational stress-related effects of the 2016 terrorist attack on Breitscheidplatz in Berlin on emergency service personnel. The present study examines whether the results of the pilot study can be replicated and whether the effects changed after 2 years. The participants were 60 emergency personnel (including 11 police officers and 24 firefighters) who were deployed to the attack, and a control group of 60 personnel (including 37 police officers and 21 firefighters) who were not deployed. Data on stress, quality of life, and current mental state were gathered 3 to 4 months after the attack and 18 to 21 months after the first survey. The data showed that police officers who responded to the attack had significantly higher levels of aggression and hostility at both time points, and firefighters had significantly lower levels of environmental quality of life at both time points. Quality of life in terms of physical health for firefighters could not be replicated. Due to the different types of stress experienced by emergency service personnel, a differentiated approach is necessary. More specific preparation and follow-up measures are necessary to counteract persistent stress. Further research in this area could lead to specific predeployment and postdeployment training measures.

Increases in distress during stay-at-home mandates During the COVID-19 pandemic: A longitudinal study

The Coronavirus disease 2019 (COVID-19) pandemic has contributed to over 500,000 deaths, and hospitalization of thousands of individuals worldwide. Cross-sectional data indicate that anxiety and depression levels are greater during the pandemic, yet no known prospective studies have tested this assertion. Further, individuals with elevated trait anxiety prior to a global pandemic may theoretically be more apt to experience greater pandemic-related anxiety and/or impairment. The current study tested whether anxiety and depression increased from the month before the state's Stay-At-Home order to the period of the Stay-At-Home order among 120 young adults in Louisiana, a state with especially high rates of COVID-19 related infections and deaths. We also tested whether pre-pandemic social anxiety was related to greater pandemic related anxiety, depression, and COVID-related worry and impairment. Depression but not anxiety increased during the Stay-At-Home order. Further, pre-pandemic trait anxiety, social anxiety, and depression were statistically significant predictors of anxiety and depression during the Stay-At-Home order, although only social anxiety was robustly related to COVID-related worry and impairment. Emotional distress increased during the COVID-19 pandemic Stay-At-Home order and this is especially the case among individuals with pre-pandemic elevations in trait anxiety (especially social anxiety) and depression.

The impact of psychopathology, social adversity and stress-relevant DNA methylation on prospective risk for post-traumatic stress: A machine learning approach

BACKGROUND

A range of factors have been identified that contribute to greater incidence, severity, and prolonged course of post-traumatic stress disorder (PTSD), including: comorbid and/or prior psychopathology; social adversity such as low socioeconomic position, perceived discrimination, and isolation; and biological factors such as genomic variation at glucocorticoid receptor regulatory network (GRRN) genes. This complex etiology and clinical course make identification of people at higher risk of PTSD challenging. Here we leverage machine learning (ML) approaches to identify a core set of factors that may together predispose persons to PTSD.

METHODS

We used multiple ML approaches to assess the relationship among DNA methylation (DNAm) at GRRN genes, prior psychopathology, social adversity, and prospective risk for PTS severity (PTSS).

RESULTS

ML models predicted prospective risk of PTSS with high accuracy. The Gradient Boost approach was the top-performing model with mean absolute error of 0.135, mean square error of 0.047, root mean square error of 0.217, and R2 of 95.29%. Prior PTSS ranked highest in predicting the prospective risk of PTSS, accounting for >88% of the prediction. The top ranked GRRN CpG site was cg05616442, in AKT1, and the top ranked social adversity feature was loneliness.

CONCLUSION

Multiple factors including prior PTSS, social adversity, and DNAm play a role in predicting prospective risk of PTSS. ML models identified factors accounting for increased PTSS risk with high accuracy, which may help to target risk factors that reduce the likelihood or course of PTSD, potentially pointing to approaches that can lead to early intervention.

LIMITATION

One of the limitations of this study is small sample size.

Prospective risk and protective factors for psychopathology and wellbeing in civilian emergency services personnel: a systematic review

Emergency services personnel have an elevated risk of developing mental health conditions. Most research in this area is cross-sectional, which precludes inferences about temporal and potentially causal relationships between risk and protective factors and mental health outcomes. The current study systematically reviewed prospective studies of risk and protective factors for mental health outcomes in civilian emergency services personnel (firefighters, paramedics, police) assessed at pre-operational and operational stages. Out of 66 eligible prospective studies identified, several core groups of risk and protective factors emerged: (1) cognitive abilities; (2) coping tendencies; (3) personality factors; (4) peritraumatic reactions and post-trauma symptoms; (5) workplace factors; (6) interpersonal factors; (7) events away from work. Although there was insufficient evidence for many associations, social support was consistently found to protect against the development of mental health conditions, and peritraumatic dissociation, prior mental health issues, and prior trauma exposure were risk factors for future mental health conditions. Among operational studies, neuroticism was significantly associated with future PTSD symptoms, burnout, and general poor mental health, and avoidance and intrusion symptoms of PTSD were associated with future PTSD and depression symptoms. The current review results provide important targets for future research and interventions designed to improve the mental health of emergency services personnel.

The Mindfulness-Based Phase-Oriented Trauma Therapy (MB-POTT): Hypnosis-informed mindfulness approach to trauma

Hypnosis has long been successfully used in the treatment of trauma and related disorders. In this paper, I describe a hypnosis-informed approach to PTSD using mindfulness. The Mindfulness-Based Phase-Oriented Traumatic Therapy (MB-POTT) follows the phase-oriented tradition that was originally proposed by Pierre Janet, later expanded by Daniel Brown and Erika Fromm using clinical hypnosis. MB-POTT comprises four distinct, yet recursive, stages: (1) therapeutic alliance building and symptom stabilization, (2) formation of a narrative about the trauma, (3) re-creation of meaning of life after trauma, and (4) future symptom management. In explaining these categories, I delineate the nature of mindfulness, both similarities and dissimilarities to hypnosis, with an emphasis on techniques that resemble hypnotic approaches (e.g., ego state therapy, ego-strengthening). Finally, I provide a case study in which MB-POTT was implemented with a client who suffered from PTSD after a near-fatal industrial accident.

Long-term effects of the terror attack in Berlin in 2016 on paranoid ideation in female emergency personnel

In a pilot study, female emergency personnel showed increased paranoid ideation following a terror attack. This newly designed confirmatory study aims to replicate these previously found gender-specific results and investigate the progression of effects after 2 years. Participants were exposed and unexposed emergency personnel (n = 120). Exposed female versus exposed male personnel showed higher paranoid ideation at both time points. There was a group × time interaction effect in paranoid ideation: paranoid ideation increased over time in the exposed versus the unexposed female group. The same effect was observed with exposed female emergency personnel showing a significant 2-year post-deployment increase compared with the total group including unexposed female as well as exposed and unexposed male emergency personnel. There is, as yet, no conclusive explanation for this difference. Sexual harassment in a male-dominated profession may be a vulnerability factor. Differentiated preparation and follow-up for emergency responders is recommended moving towards health-related equality.

The Impact of Job Loss on Posttraumatic Stress Disorder Among Asian Americans: 11-12 Years After the World Trade Center Attack

Adversities following disasters are associated with the delayed onset and persistence of post-traumatic stress disorder (PTSD). In the wake of the World Trade Center attack, a sizeable group of Asian Americans being directly exposed to the disaster had endured job loss during the decade afterwards. Yet, no studies to date have examined the relationship between job loss and long-term PTSD in this group. This study examined the 10-11-year prevalence of probable PTSD (≥ PCL score of 44) among Asian (n=1,712) and Caucasian American (n=25,011) participants of the World Trade Center Health Registry who had completed three waves of survey studies (2003-04, 2006-08, 2011-12). Logistic regression was used to model the relationship between job loss since the disaster and probable PTSD for the two racial groups separately while controlling for sociodemographics, disaster exposure, post-disaster traumatic/stressful events exposure, lower respiratory symptoms, PTSD history since 911, and mental health service use. The long-term prevalence of probable PTSD was 15.1% for Asian Americans and 14.4% for Caucasian Americans, with no significant difference. For both groups, having job loss since 911 was a significant risk factor for probable PTSD (Asian Americans: AOR=1.80; 95% CI=1.19, 2.71; Caucasian Americans: AOR=1.73; 95% CI=1.56, 1.93). While job loss was an important risk factor, employment opportunities were more restricted for Asian Americans given the cultural and language limitations. Current findings highlight the importance of improving employment as part of post-disaster assistance.

Safety and Security in International Humanitarian Missions - Assessing the Stress Level of Responders in Critical Situations during a Realistic Full-Scale Training

INTRODUCTION

Crises, wars, and disasters are remarkably increasing across the world. Responders are frequently tackled with an ever-greater number of challenges, and undoubtedly, they are physically and mentally affected during and after their missions, during which posttraumatic stress disorder (PTSD) is considered high-risk. To the authors' knowledge, no studies have addressed which type of incident has the greatest influence to trigger stress, and consequently, to cause PTSD for the responders after their missions.

METHODS

A prospective longitudinal study was conducted with 69 participants of the "Safety and Security" course at the Federal Office for Civil Protection and Disaster Aid of the Federal Ministry of Interior Affairs (Berlin, Germany). The course is certified by the Hostile Environment Awareness Training (HEAT) guidelines of Europe's New Training Initiative for Civilian Crisis Management (ENTRi; Center for International Peace Operations; Berlin, Germany). Four incidents were evaluated: hostage-taking, carjacking, evacuation, and border-crossing. The participants completed the Positive and Negative Affect Schedule (PANAS) before and after each incident. For each incident, the delta of the PANAS scores was calculated. The differences between the described incidents, as well as the differences between novice and experienced responders, were evaluated.

RESULTS

The hostage-taking incident had the greatest influence on the participants' temper, followed by carjacking and evacuation. Ultimately, the border-crossing event had the least effect on the responders. Novices were more affected by hostage-taking than experienced responders; however, no significant difference had been demonstrated between novices and experienced responders for the other evaluated incidents.

CONCLUSION

Different incidents have big psychological impacts on humanitarian responders, in which consequences vary from short-term effects to PTSD. Therefore, humanitarian responders should be selected very carefully. They should also have more specific preparation for their missions. Mental after-care should be obligatory. Further studies are needed to understand and avoid reasons for the development of PTSD or other potential problems of responders.

The role of modifiable health-related behaviors in the association between PTSD and respiratory illness

BACKGROUND

Posttraumatic stress disorder (PTSD) increases risk of future respiratory illness. However, mechanisms that underpin the association between these common and debilitating conditions remain unknown. The aim of this study was to identify modifiable, health-related behaviors they may explain the link between PTSD and respiratory problems.

METHODS

World Trade Center responders (N = 452, 89% male, mean age = 55 years) completed baseline PTSD and sleep questionnaires, followed by 2-weeks of daily diaries, actigraphy and ambulatory spirometry to monitor lower respiratory symptoms, pulmonary function, activity levels, stressors, and sleep. Lipid levels were obtained from electronic medical records.

RESULTS

Cross-sectional mediation analyses revealed that the association between PTSD and self-reported respiratory symptoms was explained by poor sleep, low activity, and daily stressors. The association between PTSD symptoms and pulmonary function was explained by insomnia and low activity.

CONCLUSIONS

A range of health-related daily behaviors and experiences, especially sleep disturbances and inactivity, may explain excess respiratory illness morbidity in PTSD. The findings were generally consistent across daily self-report and spirometry measures of respiratory problems. Targeting these behaviors might enhance prevention of and intervention in respiratory problems in traumatized populations.

Exposure to multiple disasters: The long-term effect of Hurricane Sandy (October 29, 2012) on NYC survivors of the September 11, 2001 World Trade Center attack

This study evaluated the impact of pre-Hurricane Sandy (Sandy) post-traumatic stress disorder (PTSD) trajectories on the relationship between Sandy exposures and post-Sandy 9/11-related PTSD among World Trade Center Health Registry (Registry) enrollees. The study population included 3,199 adult Registry enrollees who completed three surveys prior to Sandy in 2003-4, 2006-7, and 2011-12; a post-Hurricane Sandy survey (2013); and a follow-up survey in 2015-16. PTSD was assessed using the PTSD Checklist (PCL). Latent class growth analysis was used to identify groups of enrollees who shared a similar trajectory of change in PCL score in the time period prior to Sandy. We compared enrollees in each trajectory group to assess the impact of Sandy-related PTSD, Sandy exposures, and optimism on 9/11-related PTSD status post-Sandy (2015-16) using bivariate analyses and multivariable log-binomial regression. Sandy-related PTSD was the strongest predictor of subsequent 9/11-related PTSD. Lower optimism and higher Sandy exposure significantly predicted 9/11-related PTSD only in some trajectory groups. Hurricane Sandy may have exacerbated previously resolved symptoms of 9/11-related PTSD. This indicates a need after a disaster to assess and address mental health sequelae from previous traumatic exposures.

Past Experiences of Getting Bullied and Assaulted and Posttraumatic Stress Disorder (PTSD) After a Severe Traumatic Event in Adulthood: A Study of World Trade Center (WTC) Responders

Although experiencing bullying and other forms of assault is associated with adverse physical, emotional, and psychological consequences, the long-term consequences, especially in the aftermath of a severe trauma in adulthood, is not known. This study examined the relationship between history of being bullied and/or assaulted and posttraumatic stress disorder (PTSD) symptoms among responders to the World Trade Center (WTC) disaster. During 2015-16, a modified life events checklist was administered to responders at Stony Brook WTC Health Program. WTC-related PTSD symptoms were assessed by PTSD checklist (PCL). Longitudinal mixed models examined associations between bullying, other forms of assault, and severity and chronicity of PTSD symptoms. Approximately 13% of 920 responders had probable WTC-PTSD (PCL≥44). Being bullied in childhood was associated with increased odds of WTC-PTSD (adjusted odds ratio [aOR] =7.34; 95% confidence interval [CI] = 2.12-25.34), adjusted for demographics, other stressors, and WTC exposures. PTSD odds decreased over time among those not bullied (aOR 0.82; 95% CI: 0.73-0.92), but not among victims. Experiencing physical, sexual, or verbal assaults during adulthood, also had a significant association with WTC-PTSD (aOR 4.64; 95% CI: 1.98-10.92). Findings suggest being bullied in childhood and/or assaulted in adulthood can increase PTSD risk and progression after mass trauma.

Posttraumatic Stress Trajectories in World Trade Center Tower Survivors: Hyperarousal and Emotional Numbing Predict Symptom Change

There is a paucity of knowledge concerning the underlying symptomatology of heterogeneous posttraumatic stress symptom (PTSS) trajectories following mass trauma, such as a terrorist attack. This study examined longitudinal PTSS trajectories using latent growth mixture modeling in 2,355 World Trade Center (WTC) tower survivors surveyed by the WTC Health Registry an average of 2.5, 5.5, and 10.5 years after the September 11, 2001 terrorist attacks. Covariates included sociodemographic characteristics, WTC-related exposure, and other traumas/stressors. Four curvilinear PTSS trajectories were identified: low symptom (74.9%), recovering (8.0%), worsening (6.7%), and chronic (10.4%). The majority of WTC survivors (85.3%) maintained stable symptom trajectories over time, with PTSS changes occurring less often. Although WTC-related exposure was associated with initial PTSS severity, exposure was not associated with chronicity or change of PTSS over time. Male gender and a higher number of post-WTC disaster life-stressors were associated with worsening symptom severity over time. Individuals with more severe hyperarousal symptoms at Wave 1, particularly of anxious arousal, were more likely to have PTSS that worsened over time, adjusted odds ratio (aOR) = 1.55. Less severe emotional numbing symptoms, particularly of dysphoria, at Wave 1, were marginally significantly associated with subsequent PTSS recovery, aOR = 0.75. Interventions that target hyperarousal and emotional numbing symptoms may mitigate a worsening of symptoms and facilitate posttraumatic recovery following future mass traumas, such as terrorist attacks. Further clinical implications are discussed.

Loss of loved ones or home due to a disaster: Effects over time on distress in immigrant ethnic minorities

Exposure to mass trauma may bring about increased sensitivity to new or ongoing stressors. It is unclear whether sensitivity to stress associated with ethnic minority/immigrant status may be affected by severe exposure to mass trauma. We examined whether the loss of loved ones or home due to a disaster is associated with more persistent disaster-related distress in ethnic minorities compared with Dutch natives in the Netherlands. In residents affected by a fireworks disaster ( N = 1029), we assessed disaster-related distress after 3 weeks, 18 months, and 4 years. The effects of loss of loved ones or home and ethnic minority/immigrant status on distress were analyzed using latent growth modeling. After controlling for age, gender, education, employment, and post-disaster stressful life events, the loss of loved ones was associated with more persistent disaster-related distress in ethnic minorities compared with natives at 18 months, and the loss of home was associated with more persistent disaster-related distress in ethnic minorities compared with natives between 18 months and 4 years. Our results suggest that the loss of loved ones may increase sensitivity to stress associated with ethnic minority/immigrant status during the early phase of adaptation to a disaster. Loss of home may lead to further resource loss and thereby increase sensitivity to stress associated with ethnic minority/immigrant status in the long term. Efforts to prevent stress-related psychopathology following mass trauma should specifically target ethnic minority groups, notably refugees and asylum seekers, who often experienced multiple losses of loved ones as well as their homes.

Neurological disease in the aftermath of terrorism: a review

The purpose of our review is to discuss current knowledge on long-term sequelae and neurological disorders in the aftermath of a terrorist attack. The specific aspects of both psychological and physical effects are mentioned in more detail in this review. Also, the outcomes such as stress-related disorders, cardiovascular disease, and neurodegenerative disease are explained. Moreover, PTSD and posttraumatic structural brain changes are a topic for further investigations of the patients suffering from these attacks. Not only the direct victims are prone to the after effects of the terroristic attacks, but the rescue workers, physicians, witnesses and worldwide citizens may also be affected by PTSD and other neurological diseases as well. The determination of a whole series of risk factors for developing neurological disorders can be a means to set up early detection, preventative measures, to refine treatment and thus to gain better outcome in the future.

Rumination and PTSD symptoms among trauma-exposed Latinos in primary care: Is mindful attention helpful?

The present investigation examined the moderating role of mindful attention in the relation between rumination and posttraumatic stress (PTS) symptoms (i.e., re-experiencing, avoidance, arousal, and total PTSD symptoms) among trauma-exposed Latinos in a primary care medical setting. It was hypothesized that mindful attention would moderate, or lessen, the relation between rumination and all facets of PTS, even after controlling for clinically relevant covariates. Participants included 182 trauma-exposed adult Latinos (89.0% female; M_age = 37.8, SD = 10.6% and 95.1% reported Spanish as their first language) attending a community-based integrated healthcare clinic in the Southwestern United States. Mindful attention was a significant moderator of relations between rumination and all PTS facets. Specifically, rumination and PTSD symptoms were significantly related yet only in the context of low (vs. high) levels of mindful attention. Mindfulness-based skills may offer incremental value to established treatment protocols for traumatic stress, especially when high levels of rumination are present. Rumination may also serve to identify those who are at greatest risk for developing PTSD after trauma exposure and, therefore, most likely to benefit from mindfulness-based strategies.

Hurricane Sandy Exposure and the Mental Health of World Trade Center Responders

The psychological consequences of a second disaster on populations exposed to an earlier disaster have rarely been studied prospectively. Using a pre- and postdesign, we examined the effects of Hurricane Sandy on possible World Trade Center (WTC) related posttraumatic stress disorder (PTSD Checklist score of ≥ 50) and overall depression (major depressive disorder [MDD]; Patient Health Questionnaire depression score of ≥ 10) among 870 WTC responders with a follow-up monitoring visit at the Long Island WTC Health Program during the 6 months post-Hurricane Sandy. The Hurricane Sandy exposures evaluated were damage to home (8.3%) and to possessions (7.8%), gasoline shortage (24.1%), prolonged power outage (42.7%), and filing a Federal Emergency Management Agency claim (11.3%). A composite exposure score also was constructed. In unadjusted analyses, Hurricane Sandy exposures were associated with 1.77 to 5.38 increased likelihood of PTSD and 1.58 to 4.13 likelihood of MDD; odds ratios for ≥ 3 exposures were 6.47 for PTSD and 6.45 for MDD. After adjusting for demographic characteristics, WTC exposure, pre-Hurricane Sandy mental health status, and time between assessments, reporting ≥ 3 Hurricane Sandy exposures was associated with a 3.29 and 3.71 increased likelihood of PTSD and MDD, respectively. These findings underscore the importance of assessing the impact of a subsequent disaster in ongoing responder health surveillance programs.

Emotional nonacceptance within the context of traumatic event exposure: The explanatory role of anxiety sensitivity for traumatic stress symptoms and disability among Latinos in a primary care setting

OBJECTIVE

Research has found that Latinos (versus non-Latino Whites) evince higher rates of posttraumatic stress symptoms (PTS) and posttraumatic stress disorder (PTSD), yet little attention has been given to intra-individual, emotion-related processes to explicate the higher incidence of these symptoms among Latinos.

METHOD

Participants included 183 trauma-exposed adult Latinos (88.5% female; Mage=37.7, SD=10.7 and 93.4% reported Spanish as their first language) who attended a community-based primary healthcare clinic in Houston. It was hypothesized that anxiety sensitivity would explain the relation between emotional nonacceptance and traumatic stress symptoms, namely re-experiencing, avoidance, and arousal difficulties as well as overall disability. Additionally, it was expected that the observed effects would be evident above and beyond the variance accounted for by number of traumas reported, gender, age, marital status, educational status, years living in the U.S., and negative affectivity.

RESULTS

Consistent with our hypotheses, difficulties accepting negative emotions were associated with increased trauma-related re-experiencing, avoidance, and arousal difficulties. Additionally, anxiety sensitivity was an underlying mechanism in the association between emotional nonacceptance and all but one facet of traumatic stress symptoms (i.e., re-experiencing symptoms) and disability. Alternative models yielded no significant effects, providing greater confidence in the direction of the hypothesized effects.

CONCLUSION

Findings are discussed in the context of their significance for informing the development of specialized intervention strategies that target anxiety sensitivity for Latinos in primary care with elevated risk for PTS and PTSD by their heightened levels of emotional nonacceptance.

Latent typologies of posttraumatic stress disorder in World Trade Center responders

Posttraumatic stress disorder (PTSD) is a debilitating and often chronic psychiatric disorder. Following the 9/11/2001 World Trade Center (WTC) attacks, thousands of individuals were involved in rescue, recovery and clean-up efforts. While a growing body of literature has documented the prevalence and correlates of PTSD in WTC responders, no study has evaluated predominant typologies of PTSD in this population. Participants were 4352 WTC responders with probable WTC-related DSM-IV PTSD. Latent class analyses were conducted to identify predominant typologies of PTSD symptoms and associated correlates. A 3-class solution provided the optimal representation of latent PTSD symptom typologies. The first class, labeled "High-Symptom (n = 1,973, 45.3%)," was characterized by high probabilities of all PTSD symptoms. The second class, "Dysphoric (n = 1,371, 31.5%)," exhibited relatively high probabilities of emotional numbing and dysphoric arousal (e.g., sleep disturbance). The third class, "Threat (n = 1,008, 23.2%)," was characterized by high probabilities of re-experiencing, avoidance and anxious arousal (e.g., hypervigilance). Compared to the Threat class, the Dysphoric class reported a greater number of life stressors after 9/11/2001 (OR = 1.06). The High-Symptom class was more likely than the Threat class to have a positive psychiatric history before 9/11/2001 (OR = 1.7) and reported a greater number of life stressors after 9/11/2001 (OR = 1.1). The High-Symptom class was more likely than the Dysphoric class, which was more likely than the Threat class, to screen positive for depression (83% > 74% > 53%, respectively), and to report greater functional impairment (High-Symptom > Dysphoric [Cohen d = 0.19], Dysphoric > Threat [Cohen d = 0.24]). These results may help inform assessment, risk stratification, and treatment approaches for PTSD in WTC and disaster responders.

Risk, coping and PTSD symptom trajectories in World Trade Center responders

Trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms are often heterogeneous, and associated with common and unique risk factors, yet little is known about potentially modifiable psychosocial characteristics associated with low-symptom and recovering trajectories in disaster responders. A total of 4487 rescue and recovery workers (1874 police and 2613 non-traditional responders) involved during and in the aftermath of the unprecedented World Trade Center (WTC) attacks, were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Among police responders, WTC-related PTSD symptoms were characterized by four trajectories, including no/low-symptom (76.1%), worsening (12.1%), improving (7.5%), and chronic (4.4%) trajectories. In non-traditional responders, a five-trajectory solution was optimal, with fewer responders in a no/low-symptom trajectory (55.5%), and the remainder in subtly worsening (19.3%), chronic (10.8%), improving (8.5%), and steeply worsening (5.9%) trajectories. Consistent factors associated with symptomatic PTSD trajectories across responder groups included Hispanic ethnicity, pre-9/11 psychiatric history, greater WTC exposure, greater medical illness burden, life stressors and post-9/11 traumas, and maladaptive coping (e.g., substance use, avoidance coping). Higher perceived preparedness, greater sense of purpose in life, and positive emotion-focused coping (e.g., positive reframing, acceptance) were negatively associated with symptomatic trajectories. Findings in this unique cohort indicate considerable heterogeneity in WTC-related PTSD symptom trajectories over 12 years post-9/11/2001, with lower rates of elevated PTSD symptoms in police than in non-traditional responders. They further provide a comprehensive risk prediction model of PTSD symptom trajectories, which can inform prevention, monitoring, and treatment efforts in WTC and other disaster responders.

DSM-IV post-traumatic stress disorder among World Trade Center responders 11-13 years after the disaster of 11 September 2001 (9/11)

BACKGROUND

Post-traumatic symptomatology is one of the signature effects of the pernicious exposures endured by responders to the World Trade Center (WTC) disaster of 11 September 2001 (9/11), but the long-term extent of diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) post-traumatic stress disorder (PTSD) and its impact on quality of life are unknown. This study examines the extent of DSM-IV PTSD 11-13 years after the disaster in WTC responders, its symptom profiles and trajectories, and associations of active, remitted and partial PTSD with exposures, physical health and psychosocial well-being.

METHOD

Master's-level psychologists administered sections of the Structured Clinical Interview for DSM-IV and the Range of Impaired Functioning Tool to 3231 responders monitored at the Stony Brook University World Trade Center Health Program. The PTSD Checklist (PCL) and current medical symptoms were obtained at each visit.

RESULTS

In all, 9.7% had current, 7.9% remitted, and 5.9% partial WTC-PTSD. Among those with active PTSD, avoidance and hyperarousal symptoms were most commonly, and flashbacks least commonly, reported. Trajectories of symptom severity across monitoring visits showed a modestly increasing slope for active and decelerating slope for remitted PTSD. WTC exposures, especially death and human remains, were strongly associated with PTSD. After adjusting for exposure and critical risk factors, including hazardous drinking and co-morbid depression, PTSD was strongly associated with health and well-being, especially dissatisfaction with life.

CONCLUSIONS

This is the first study to demonstrate the extent and correlates of long-term DSM-IV PTSD among responders. Although most proved resilient, there remains a sizable subgroup in need of continued treatment in the second decade after 9/11.

Posttraumatic stress symptoms and smoking among World Trade Center disaster responders: A longitudinal investigation

PURPOSE

The current longitudinal study examined posttraumatic stress disorder (PTSD) symptom severity in relation to smoking abstinence and reduction over time among responders to the World Trade Center (WTC) disaster.

METHOD

Participants were 763 police and 1881 non-traditional (e.g., construction workers) WTC responders who reported being smokers at an initial examination obtained between July 2002 and July 2011 at the WTC Health Program (WTC-HP). WTC responders were reassessed, on average, 2.5 years later.

RESULTS

For police WTC responders, higher levels of WTC-related PTSD symptoms at the initial visit were associated with a decreased likelihood of smoking abstinence (OR=0.98, p=.002) and with decreased smoking reduction (β=-.06, p=.012) at the follow-up visit. WTC-related PTSD symptom severity was not related to likelihood of smoking abstinence or change in number of cigarettes smoked among non-traditional responders. Post hoc analyses suggested that for police, hyperarousal PTSD symptoms were predictive of decreased abstinence likelihood at the follow-up visit (OR=0.56, p=.006).

DISCUSSION

The present findings suggest that PTSD symptoms may be differentially related to smoking behavior among police and non-traditional WTC responders in a naturalistic, longitudinal investigation. Future work may benefit from exploring further which aspects of PTSD (as compared to each other and to common variance) explain smoking maintenance.