Burden of full and subsyndromal PTSD in police who responded to the World Trade Center disaster
Studies have found that police demonstrated considerable resilience to posttraumatic stress disorder (PTSD) compared to other disaster workers after the September 11, 2001 terrorist attack on the World Trade Center (WTC). This has been attributed to effective screening and extensive training in the police force. New research suggests that, despite this greater resilience to PTSD, 15.4% of police endorse symptoms of subsyndromal PTSD that do not reach the level for a formal diagnosis of PTSD, but which are nonetheless associated with elevated rates of other psychiatric disorders and functional difficulties. The study is published online in advance of publication in the July issue of the Journal of Psychiatric Research.
"The prevalence of full PTSD observed in this study (5.4%) was comparable to previous studies of police responders to the WTC disaster. However, the rate of subsyndromal PTSD was nearly 3 times greater (15.4%), suggesting that one in five police exposed to WTC rescue and recovery work may have clinically significant WTC-related PTSD symptoms," says lead investigator Robert H. Pietrzak, PhD, MPH, of the National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, and Department of Psychiatry, Yale University School of Medicine. "Further, subsyndromal PTSD, which is not commonly assessed as part of screening efforts, was associated with elevated rates of comorbid psychiatric disorders, functional difficulties, somatic symptoms, and perceived need for mental health care."
Researchers assessed 8,466 police who worked or volunteered as part of rescue, recovery, restoration, or cleanup in Manhattan south of Canal Street, at the barge-loading piers in Manhattan, or the Staten Island landfill between September 11 and December 31, 2001. Participants completed an initial evaluation as part of the World Trade Center Medical Monitoring and Treatment Program. An interview assessed level of WTC exposure, such as early arrival, being caught in the dust cloud, or exposure to human remains. A range of self-report psychiatric assessments were completed, including measures of depression, panic disorder, and alcohol use; impairment in work, social or family life; and somatic symptoms, such as feeling run down or having headaches. Respondents identified important sources of social support while working at the WTC site, including spouse/partner, supervisor, and co-workers. They also indicated whether they thought they would need any mental health services in the next year. The level of posttraumatic stress was measured using the PTSD Checklist.
WTC-related work exposures that were most strongly associated with full and subsyndromal PTSD were losing someone on 9/11 and knowing someone who was injured in the disaster. A greater number of stressors prior to 9/11 was also associated with both full and subsyndromal PTSD. Union membership and greater family support played a protective role. Depression, panic disorder, alcohol use problems, and somatic symptoms and functional difficulties were highest among police with full PTSD, and occurred in intermediate levels among those with subsyndromal PTSD.
Police with subsyndromal PTSD were nearly five times as likely as controls to report that they might need at least one of the mental health services assessed, such as one-on-one counseling, stress management or psychotropic medication. "This finding underscores the importance of assessing for subsyndromal PTSD in disaster-exposed police responders, as these individuals may be overlooked despite some of these responders having an increased perception of need for mental healthcare," explains Dr. Pietrzak.
Dr. Pietrzak and colleagues note that subsyndromal PTSD is not a diagnostic classification and may not be routinely identified as part of screenings in police and other disaster response personnel. "Current screening and diagnostic criteria for disaster-related PTSD may be too restrictive in identifying the full complement of police who have clinically significant psychiatric and functional difficulties after responding to a mass disaster. These findings underscore the importance of screening, monitoring, and possibly treating disaster responders with subsyndromal PTSD," he concludes, adding that additional research is needed to confirm these findings using structured diagnostic interviews, to understand the longitudinal course of subsyndromal PTSD, and to evaluate the generalizability of these results to the broader population of police WTC responders.