PTSD Symptom Trajectories in World Trade

Center Responders

Adriana Feder, MD, Robert Pietrzak, PhD, MPH, Steven Southwick, MD

Icahn School of Medicine at Mount Sinai

Yale University School of Medicine

Funded by NIOSH/CDC Contract 200-2011-41919

Research Team / Collaborators

Janice Rodriguez

Leo Cancelmo

Leah Klein, LMSW

Cindy Aaronson, PhD

Ryan Salim

Natalie Mota, PhD

Clyde B. Schechter, MD

Evelyn J. Bromet, PhD

Fatih Ozbay, MD

Jeanne M. Stellman, PhD

Craig L. Katz, MD

Dori B. Reissman, MD

Vansh Sharma, MD

Robin Herbert, MD

Michael Crane, MD

Denise Harrison, MD

Stephen M. Levin, MD

Benjamin J. Luft, MD

Steven Markowitz, MD

Jacqueline M. Moline, MD

Iris G. Udasin, MD

Rachel Yehuda, PhD

Juan Wisnivesky, MD, DrPH

Philip J. Landrigan, MD

WTC Hazards

Physical hazards

Toxic exposures (e.g., asbestos,

pulverized cement, acid mists)

Fires

Collapsing buildings

Falling debris

Noise

Extremes of temperature

Blood-borne pathogens

Psychological trauma

Psychological risk factors

Fear of personal harm○ During building fires, collapse○ While on “pile” Poor visibility at night; many physical hazards Threat of additional building collapse Fire flare-ups

Limited ability to exert control

Initially chaotic conditions

Witnesses to aftermath Family/friends lost in collapse Few survivors rescued Contact with human remains Fatigue, sleep deprivation, injury

Introduction

Little research on potentially protective factors for

PTSD or correlates of symptom improvement

Protective factors in trauma-exposed adults

o Coping strategies

o Higher social support

o Purpose in life

In first responders specifically

o Work support

o Occupation

o Preparedness for type of work

PTSD Trajectories StudyAims

Characterize longitudinal trajectories of WTC-related PTSD symptoms in WTC responders

Identify risk predictors and correlates of longitudinal trajectories

Specific exposures, secondary stressors, other trauma exposures,

co-morbid medical conditions

Incorporate a range of potentially protective and modifiable personal and psychosocial characteristics into the prediction models

Web-based survey focused on potentially protective factors

Pietrzak et al 2014Feder et al under review

Trajectories Study Design

10,835 WTC responders

4,035 police

6,800 non-traditional responders (e.g., workers in construction, utility,

transportation, asbestos/cleaning)

(NYC firefighters participated in a separate program)

WTC Health Program: regional clinical consortium, 5 sites

Provides medical and mental health monitoring and treatment to WTC

rescue, recovery and clean-up workers

Coordinating site: Mount Sinai Dpt. of Community and Preventive Medicine

10,835 completed monitoring visits 1, 2, 3 at WTC Health Program

Average of 3, 6 and 8 years after 9/11/01

4,487 participated in Web-based survey at time 4 (2012-2014)

Measure – Dependent Variable

PTSD Checklist – Specific Stressor Version

(PCL-S)

17-item self-report instrument based on DSM-IV

Blanchard et al 1996Ruggiero et al 2003

Not at all A little bit Moderately Quite a bit Extremely

Repeated, disturbing memories, thoughts, or images of the

disaster?1 2 3 4 5

Repeated, disturbing dreams of the disaster? 1 2 3 4 5

Suddenly acting or feeling as if the disaster were happening

again (as if you were reliving it)?1 2 3 4 5

Feeling very upset when something reminded you of the

disaster?1 2 3 4 5

Having physical reactions (e.g., heart pounding, trouble

breathing, or sweating) when something reminded you of the

disaster?

1 2 3 4 5

Avoid thinking about or talking about the disaster or avoid

having feelings related to it?1 2 3 4 5

Avoid activities or situations because they remind you of the

disaster?1 2 3 4 5

Trouble remembering important parts of the disaster? 1 2 3 4 5

Loss of interest in things that you used to enjoy? 1 2 3 4 5

Feeling distant or cut off from other people? 1 2 3 4 5

Feeling emotionally numb or being unable to have loving

feelings for those close to you?1 2 3 4 5

Feeling as if your future will somehow be cut short? 1 2 3 4 5

Trouble falling or staying asleep? 1 2 3 4 5

Feeling irritable or having angry outbursts? 1 2 3 4 5

Having difficulty concentrating? 1 2 3 4 5

Being “super alert” or watchful on guard? 1 2 3 4 5

Feeling jumpy or easily startled? 1 2 3 4 5

PTSD Checklist-Specific Stressor Version Below is a list of problems you may have experienced IN RELATION TO 9/11/2001. Please read each problem carefully and circle

one of the numbers to the right to indicate how much you have been bothered by that problem IN THE PAST MONTH.

Method

Web-based survey of a subset of participants who had been

followed prospectively at the WTC Health Program

n=1,874 police officers; n=2,613 non-traditional

responders

Mean - 12 years after 9/11/01

Identified trajectories using LGMM in Mplus

Multinomial regression analyses to examine potential

correlates of emerging trajectories

Trajectories of WTC-related PTSD symptoms

in police WTC responders (n=1,874)

17

22

27

32

37

42

47

52

57

62

67

3 yrs 6 yrs 8 yrs 12 yrs

PC

L-S

Sco

re

Years since 9/11/2001

Chronic (4.4%)

Improving (7.5%)

Worsening (12.1%)

No/Low Symptom (76.1%)

Mean age (SD) at time 1 = 41.7 (6.9) years, 85.4% male

Trajectories of WTC-related PTSD symptoms

in non-traditional WTC responders (n=2,613)

17

27

37

47

57

67

77

3 yrs 6 yrs 8 yrs 12 yrs

PC

L-S

Sco

re

Years since 9/11/2001

Steeply Worsening (5.9%)

Improving (8.5%)

Chronic (10.8%)

Subtly Worsening (19.3%)

No/Low Symptom (55.5%)

Mean age (SD) at time 1 = 46.2 (9.6) years, 86.3% male

Chronic PTSD

Unmet Treatment Need

Many WTC responders continue to suffer from clinically

significant WTC-related PTSD symptoms

8-year prospective cohort study of 10,835 WTC workers

23.7% with chronic or worsening WTC-related PTSD symptoms

Web-based survey, first 2,000 completers:

33.6% with persistent clinically significant WTC-related PTSD

symptoms

13.3% met screening criteria for full PTSD

20.3% met screening criteria for partial PTSD

Majority (77.9%) not receiving any psychotherapy or

pharmacotherapy

WTC Police Responders

Sample of 8,466 WTC police responders participating in the

WTC-Health Program –on average 4 years post-9/11/01

Compared with trauma-exposed responders with no/lower

symptoms:

Full PTSD: 20 times more likely to report perceived need for

mental healthcare

Partial PTSD: 5 times more likely to report perceived need for

mental healthcare

Most common reported need was for psychotherapy and

counseling

Pietrzak et al 2012

Potentially Modifiable Factors

Psychiatric history prior to 9/11

Diagnosis of depression, anxiety, and/or PTSD

4.96 (2.87-8.58)*** .94 (.48-1.82) 4.72 (2.33-9.57)*** 1.05 (.50-2.20)

Number of traumatic events before 9/11 1.07 (.98-1.17) 1.14 (1.06-1.22)** 1.12 (1.01-1.26)* .96 (.84-1.08)

Number of life stressors in year before 9/11

1.03 (.92-1.15) .94 (.84-1.05) 1.07 (.94-1.23) .96 (.83-1.11)

WTC exposure severity 1.26 (1.13-1.40)*** 1.13 (1.03-1.23)** 1.42 (1.22- 1.65)*** .89 (.75-1.05)

Number of life stressors in year after 9/11

1.13 (1.02-1.24)* 1.07 (.97-1.17) 1.11 (.98-1.26) 1.01 (.88-1.16)

Other life stressors after 9/11 1.38 (1.00-1.90) 1.42 (1.09-1.86)* 1.28 (.85-1.92) 1.08 (.69-1.69)

Number of traumatic events after 9/11 1.15 (1.05-1.28)** 1.20 (1.11-1.30)*** 1.15 (1.02-1.30)* 1.00 (.87-1.15)

Number of medical conditions After 9/11 1.09 (1.01-1.17)* 1.15 (1.09-1.23)*** 1.16 (1.05-1.27)** .94 (.84-1.05)

Avoidance Coping 2.96 (1.98-4.44)*** 3.11 (2.21-4.37)*** 4.24 (2.38-7.54)*** .70 (.37-1.33)

Substance Use 3.36 (1.47-7.68)** 5.12 (2.62-9.97)*** 4.50 (1.80-11.26)** .75 (.28-1.98)

Self-Blame and Venting 2.10 (1.22-3.60)** 2.48 (1.62-3.81)*** 2.27 (1.15-4.48)* .92 (.43-2.00)

Religious Coping 2.06 (1.33-3.19)** 1.68 (1.15-2.46)** 1.48 (.76-2.85) 1.40 (.68-2.87)

Police Responders (n=1,874) Trajectory

Improving (Ref: No/low symptom)

Worsening (Ref: No/low symptom)

Chronic (Ref:No/low symptom)

Improving

(Ref: Chronic)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Note. Reference group=resistant trajectory. Bolded OR (95%CI)=significant association with trajectory group, *p<.05; **p<.01; ***p<.001.

Avoidance coping: denial, behavioral disengagement (giving up), self-distraction

Active coping 1.83 (1.20-2.78)** 1.29 (.90-1.85) .78 (.39-1.57) 2.35 (1.09-5.05)*

Positive emotion-focused coping 1.47 (.91-2.35) .98 (.67-1.43) .72 (.39-1.31) 2.05 (1.03-4.10)*

Social coping 1.15 (.72-1.85) 1.38 (.93-2.06) 1.42 (.74-2.73) .82 (.39-1.71)

Number of important sources of family support while working at WTC site

.97 (.85-1.10) 1.00 (.89-1.12) 1.02 (.84-1.24) .95 (.76-1.19)

Number of important sources of work support while working at WTC site

.92 (.70-1.21) .95 (.75-1.21) 1.00 (.67-1.49) .92 (.59-1.44)

Social support .98 (.95-1.02) .97 (.94-.99)* .95 (.90-1.00) 1.03 (.97-1.10)

Purpose in life .94 (.89-.98)** .90 (.87-.94)*** .82 (.78-.87)*** 1.14 (1.07-1.22)***

Number of rescue/recovery occasions .99 (.89-1.10) 1.00 (.92-1.10) .96 (.82-1.11) 1.04 (.88-1.23)

Preparedness 1.02 (.81-1.28) 1.04 (.85-1.26) 1.11 (.80-1.54) .91 (.63-1.32)

Perceived preparedness .93 (.80-1.09) .79 (.69-.91)** .77 (.60-.98)* 1.22 (.93-1.60)

Police Responders (n=1,874) Trajectory

Improving (Ref: No/low symptom)

Worsening (Ref: No/low symptom)

Chronic(Ref: No/low symptom)

Improving

(Ref: Chronic)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Note. Reference group=resistant trajectory. Bolded OR (95%CI)=significant association with trajectory group, *p<.05; **p<.01; ***p<.001.

Positive emotion-focused coping: positive reframing, acceptance, humor

Psychiatric history prior to 9/11

2.82

(1.90-4.19)***

1.52

(1.08-2.14)*

1.78

(1.05-3.01)*

4.53

(3.02-6.79)***

1.17

(.70-1.96)

.62

(.40-.98)*

Number of traumatic events before 9/11

1.03 (.96-1.10) 1.01 (.96-1.07) 1.08

(1.00-1.17)

1.05

(.98-1.12)

1.07

(.99-1.15)

.98 (.91-1.06)

Number of life stressors in year before 9/11

.99 (.92-1.06) .96 (.91-1.02) .95 (.88-1.04) 1.03

(.97-1.10)

.99

(.91-1.08)

.95 (.88-1.03)

WTC exposure severity 1.19

(1.09-1.30)***

1.14

(1.07-1.22)***

1.04 (.93-1.16) 1.35

(1.23-1.48)***

.91

(.82-1.02)

.88 (.79-.98)

Number of life stressors in year after 9/11

1.18

(1.11-1.25)***

1.06

(1.01-1.12)*

1.11

(1.02-1.20)*

1.18

(1.11-1.26)***

1.05

(.97-1.13)

1.00

(.93-1.07)

Other life stressors after 9/11

1.29

(1.04-1.60)*

1.23

(1.03-1.45)*

1.83

(1.44-2.33)***

1.67

(1.35-2.07)***

1.50

(1.18-1.89)**

.77 (.60-.99)*

Traumatic events after 9/11

1.03 (.95-1.12) 1.15

(1.08-1.22)***

1.15

(1.06-1.26)**

1.14

(1.06-1.24)**

1.01

(.92-1.10)

.90 (.82-.99)*

Number of medical conditions after 9/11

1.13

(1.07-1.19)***

1.11

(1.06-1.15)***

1.22

(1.14-1.30)***

1.25

(1.18-1.32)***

1.10

(1.03-1.18)**

.90 (.85-.96)**

Avoidance coping 2.09

(1.54-2.84)***

2.49

(1.97-3.14)***

3.10

(2.06-4.68)***

2.83

(2.01-3.97)***

1.25

(.83-1.88)

.74 (.50-1.10)

Substance use 1.55 (.84-2.86) 2.34

(1.51-3.64)***

2.86

(1.53-5.36)**

3.38

(1.98-5.78)***

1.22

(.68-2.19)

.46 (.24-.88)*

Self-blame and venting 1.21 (.80-1.84) 1.61

(1.19-2.17)**

1.93

(1.21-3.07)**

1.46

(.96-2.21)

1.20

(.76-1.89)

.83 (.50-1.37)

Religious coping .95 (.66-1.36) 1.41

(1.08-1.84)*

1.95

(1.26-3.02)**

2.39

(1.66-3.45***

1.39

(.90-2.14)

.40

(.25-.62)***

Non-Traditional Responders (n=2,613)

Trajectory

Improving(Ref: No/LowSymptom)

SubtlyWorsening(Ref: No/lowsymptom)

Steeply Worsening(Ref: No/lowsymptom)

Chronic (Ref: No/lowsymptom)

Steeply Worsening (Ref: Subtly

Worsening)

Improving(Ref: Chronic)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Active coping 1.27 (.92-1.75) 1.49 (1.16-

1.91)**

1.19 (.74-1.91) 1.21

(.82-1.79)

.80

(.49-1.28)

1.05

(.67-1.63)

Positive emotion-focused coping

0.88 (0.64-1.22) 0.94 (0.74-1.21) 0.49 (0.32-

0.74)**

0.64 (0.45-

0.90)*

0.52 (0.34-

0.79)**

1.39 (0.93-

2.08)

Social coping 0.92 (0.64-1.32) 1.39 (1.06-1.82)* 1.30 (0.82-2.05) 1.91 (1.32-

2.77)**

0.94 (0.59-

1.48)

0.48 (0.31-

0.75)**

Number of important sources of family

support while working at WTC site

0.96 (0.87-1.07) 0.94 (0.88-1.03) 1.07 (0.93-1.23) 0.95 (0.85-

1.07)

1.13 (0.98-

1.29)

1.01 (0.88-

1.16)

Number of important sources of work

support while working at WTC site

1.24 (0.99-1.55) 1.07 (0.90-1.27) 0.82 (0.60-1.12) 0.83 (0.64-

1.08)

0.77 (0.56-

1.05)

1.49 (1.10-

2.01)**

Social support 1.00 (0.98-1.03) 0.97 (0.95-

0.99)**

1.00 (0.96-1.04) 1.00 (0.97-

1.03)

1.04 (1.00-

1.08)

1.01 (0.97-

1.04)

Purpose in life 0.97 (0.93-

0.99)*

0.90 (0.88-

0.93)***

0.82 (0.79-

0.86)***

0.83 (0.81-

0.86)***

0.91 (0.88-

0.95)***

1.16 (1.11-

1.21)***

Number of rescue/recovery occasions

0.91 (0.82-1.01) 0.96 (0.89-1.04) 1.03 (0.91-1.17) 0.93 (0.83-

1.04)

1.07 (0.94-

1.22)

0.98 (0.86-

1.13)

Preparedness 0.99 (0.81-1.22) 1.07 (0.91-1.25) 1.18 (0.90-1.55) 1.06 (0.84-

1.32)

1.11 (0.85-

1.45)

0.94 (0.72-

1.23)

Perceived preparedness 0.88 (0.79-

0.99)*

0.88 (0.81-

0.95)**

0.72 (0.62-

0.84)***

0.82 (0.72-

0.93)**

0.82 (0.70-

0.96)*

1.08 (0.93-

1.25)

Non-Traditional Responders (n=2,613)

Trajectory

Improving(Ref: No/low symptom)

Subtly Worsening (Ref: No/low symptom)

Steeply Worsening(Ref: No/low symptom)

Chronic (Ref:No/lowsymptom)

Steeply Worsening (Ref: Subtly Worsening)

Improving (Ref: Chronic)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

Potentially Modifiable Factors

Decrease avoidance coping (denial, giving up) and self-

blame

Increase positive emotion-focused coping (positive

reframing, acceptance)

Increase purpose in life

○ Meaning-making

Pilot intervention study

Thank you