Skip to main content
    • Aa
    • Aa

Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers

  • B. J. Luft (a1), C. Schechter (a2), R. Kotov (a3), J. Broihier (a1), D. Reissman (a4), K. Guerrera (a1), I. Udasin (a5), J. Moline (a6), D. Harrison (a7), G. Friedman-Jimenez (a7), R. H. Pietrzak (a8) (a9), S. M. Southwick (a8) (a9) and E. J. Bromet (a3)...

Thousands of rescue and recovery workers descended on the World Trade Center (WTC) in the wake of the terrorist attack of September 11, 2001 (9/11). Recent studies show that respiratory illness and post-traumatic stress disorder (PTSD) are the hallmark health problems, but relationships between them are poorly understood. The current study examined this link and evaluated contributions of WTC exposures.


Participants were 8508 police and 12 333 non-traditional responders examined at the WTC Medical Monitoring and Treatment Program (WTC-MMTP), a clinic network in the New York area established by the National Institute for Occupational Safety and Health (NIOSH). We used structural equation modeling (SEM) to explore patterns of association among exposures, other risk factors, probable WTC-related PTSD [based on the PTSD Checklist (PCL)], physician-assessed respiratory symptoms arising after 9/11 and present at examination, and abnormal pulmonary functioning defined by low forced vital capacity (FVC).


Fewer police than non-traditional responders had probable PTSD (5.9% v. 23.0%) and respiratory symptoms (22.5% v. 28.4%), whereas pulmonary function was similar. PTSD and respiratory symptoms were moderately correlated (r=0.28 for police and 0.27 for non-traditional responders). Exposure was more strongly associated with respiratory symptoms than with PTSD or lung function. The SEM model that best fit the data in both groups suggested that PTSD statistically mediated the association of exposure with respiratory symptoms.


Although longitudinal data are needed to confirm the mediation hypothesis, the link between PTSD and respiratory symptoms is noteworthy and calls for further investigation. The findings also support the value of integrated medical and psychiatric treatment for disaster responders.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about sending content to Dropbox.

      Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about sending content to Google Drive.

      Exposure, probable PTSD and lower respiratory illness among World Trade Center rescue, recovery and clean-up workers
      Available formats
The online version of this article is published within an Open Access environment subject to the conditions of the Creative Commons Attribution-NonCommercial-ShareAlike licence . The written permission of Cambridge University Press must be obtained for commercial re-use.
Corresponding author
*Address for correspondence: E. Bromet, Ph.D., Distinguished Professor, Departments of Psychiatry and Preventive Medicine, Stony Brook University, Stony Brook, NY 11794, USA. (Email:
Hide All
Akaike H (1974). A new look at the statistical model identification. IEEE Transactions on Automatic Control 19, 716723.
Aldrich TK, Gustave J, Hall CB, Cohen HW, Webber MP, Zeig-Owens R, Cosenza K, Christodoulou V, Glass L, Al-Othman F, Weiden MD, Kelly KJ, Prezant DJ (2010). Lung function in rescue workers at the World Trade Center after 7 years. New England Journal of Medicine 362, 12631272.
Berninger A, Webber MP, Cohen HW, Gustave J, Lee R, Niles JK, Chiu S, Zeig-Owens R, Soo J, Kelly K, Prezant DJ (2010). Trends of elevated PTSD risk in firefighters exposed to the World Trade Center disaster: 2001–2005. Public Health Reports 125, 556566.
Bills CB, Levy NA, Sharma V, Charney DS, Herbert R, Moline J, Katz CL (2008). Mental health of workers and volunteers responding to events of 9/11: review of the literature. Mount Sinai Journal of Medicine 75, 115127.
Blechert J, Michael T, Grossman P, Lajtman M, Wilhelm FH (2007). Autonomic and respiratory characteristics of posttraumatic stress disorder and panic disorder. Psychosomatic Medicine 69, 935943.
Boscarino JA, Chang J (1999). Electrocardiogram abnormalities among men with stress-related psychiatric disorders: implications for coronary heart disease and clinical research. Annals of Behavioral Medicine 21, 227234.
Brackbill RM, Hadler JL, DiGrande L, Ekenga CC, Farfel MR, Friedman S, Perlman SE, Stellman SD, Walker DJ, Wu D, Yu S, Thorpe LE (2009). Asthma and posttraumatic stress symptoms 5–6 years following exposure to the WTC terrorist attack. Journal of the American Medical Association 302, 502516.
Brackbill RM, Thorpe LE, DiGrande L, Perrin M, Sapp JH 2nd, Wu D, Campolucci S, Walker DJ, Cone J, Pulliam P, Thalji L, Farfel MR, Thomas P (2006). Surveillance for World Trade Center disaster health effects among survivors of collapsed and damaged buildings. Morbidity and Mortality Weekly Report: Surveillance Summaries 55, 118.
Burney PG, Laitinen LA, Perdrizet S, Huckauf H, Tattersfield AE, Chinn S, Poisson N, Heeren A, Britton JR, Jones T (1989). Validity and repeatability of the IUATLD (1984) Bronchial Symptoms Questionnaire: an international comparison. European Respiratory Journal 2, 940945.
Burnham KP, Anderson DR (2002). Model Selection and Multimodel Inference: A Practical Information-Theoretic Approach, 2nd edn. Springer-Verlag: New York, NY.
CDC (2004). Mental health status of World Trade Center rescue and recovery workers and volunteers – New York City, July 2002–August 2004. Morbidity and Mortality Weekly Report. Surveillance Summaries 53, 812815.
Chrousos GP (1995). The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. New England Journal of Medicine 332, 13511362.
Cohen J (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum: Hillsdale, NJ.
Dales RE, Spitzer WO, Schechter MT, Suissa S (1989). The influence of psychological status on respiratory symptom reporting. American Review of Respiratory Disease 139, 14591463.
Delahanty DL, Dougall AL, Craig KJ, Jenkins FJ, Baum A (1997). Chronic stress and natural killer cell activity after exposure to traumatic death. Psychosomatic Medicine 59, 467476.
DiGrande L, Neria Y, Brackbill RM, Pulliam P, Galea S (2011). Long-term posttraumatic stress symptoms among 3,271 civilian survivors of the September 11, 2001, terrorist attacks on the World Trade Center. American Journal of Epidemiology 173, 271281.
Eaton WW (ed.) (2005). Medical and Psychiatric Comorbidity over the Course of Life. American Psychiatric Publishing: Arlington, VA.
Engel CC (2004). Somatization and multiple idiopathic physical symptoms: relationship to traumatic events and posttraumatic stress disorder. In Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress (ed. Schnurr P. P. and Green B. L.), pp. 191215. American Psychological Association: Washington, DC.
Enright P, Skloot G, Herbert R (2008). Standardization of spirometry in assessment of responders following manmade disasters: World Trade Center worker and volunteer medical screening program. Mount Sinai Journal of Medicine 75, 109114.
Farfel M, DiGrande L, Brackbill R, Prann A, Cone J, Friedman S, Walker DJ, Pezeshki G, Thomas P, Galea S, Williamson D, Frieden TR, Thorpe L (2008). An overview of 9/11 experiences and respiratory and mental health conditions among World Trade Center Health Registry enrollees. Journal of Urban Health: Bulletin of the New York Academy of Medicine 85, 880909.
Gavett SH (2003). World Trade Center fine particulate matter – chemistry and toxic respiratory effects: an overview. Environmental Health Perspectives 111, 971.
Goodwin RD, Jacobi F, Thefeld W (2003). Mental disorders and asthma in the community. Archives of General Psychiatry 60, 11251130.
Hankinson JL, Odencrantz JR, Fedan KB (1999). Spirometric reference values from a sample of the general U.S. population. American Journal of Respiratory and Critical Care Medicine 159, 179187.
Herbert R, Moline J, Skloot G, Metzger K, Baron S, Luft B, Markowitz S, Udasin I, Harrison D, Stein D, Todd A, Enright P, Stellman JM, Landrigan PJ, Levin SM (2006). The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program. Environmental Health Perspectives 114, 18531858.
Herbstman JB, Frank R, Schwab M, Williams DL, Samet JM, Breysse PN, Geyh AS (2005). Respiratory effects of inhalation exposure among workers during the clean-up effort at the World Trade Center disaster site. Environmental Research 99, 8592.
Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry 164, 150153.
Ironson G, Wynings C, Schneiderman N, Baum A, Rodriguez M, Greenwood D, Benight C, Antoni M, LaPerriere A, Huang HS, Klimas N, Fletcher MA (1997). Posttraumatic stress symptoms, intrusive thoughts, loss and immune function after Hurricane Andrew. Psychosomatic Medicine 59, 128141.
Izbicki G, Chavko R, Banauch GI, Weiden MD, Berger KI, Aldrich TK, Hall C, Kelly KJ, Prezant DJ (2007). World Trade Center ‘sarcoid-like’ granulomatous pulmonary disease in New York City Fire Department rescue workers. Chest 131, 14141423.
Johnson SB, Langlieb AM, Teret SP, Gross R, Schwab M, Massa J, Ashwell L, Geyh AS (2005). Rethinking first response: effects of the clean-up and recovery effort on workers at the World Trade Center disaster site. Journal of Occupational and Environmental Medicine 47, 386391.
Kass RE, Raftery AE (1995). Bayes factors. Journal of the American Statistical Association 90, 773795.
Kline RB (2011). Principles and Practice of Structural Equation Modeling, 3rd edn. Guilford Press: New York, NY.
Landrigan PJ, Lioy PJ, Thurston G, Berkowitz G, Chen LC, Chillrud SN, Gavett SH, Georgopoulos PG, Geyh AS, Levin S, Perera F, Rappaport SM, Small C; NIEHS World Trade Center Working Group (2004). Health and environmental consequences of the world trade center disaster. Environmental Health Perspectives 112, 731739.
Levin S, Herbert R, Skloot G, Szeinuk J, Teirstein A, Fischler D, Milek D, Piligian G, Wilk-Rivard E, Moline J (2002). Health effects of World Trade Center site workers. American Journal of Industrial Medicine 42, 545547.
Lioy PJ, Georgopoulos P (2006). The anatomy of the exposures that occurred around the World Trade Center site: 9/11 and beyond. Annals of the New York Academy of Sciences 1076, 5479.
Marsh HW, Hau KT, Wen Z (2004). In search of golden rules: comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler's (1999) findings. Structural Equation Modeling 11, 320341.
McEwen BS, Stellar E (1993). Stress and the individual. Mechanisms leading to disease. Archives of Internal Medicine 153, 20932101.
McGee JK, Chen LC, Cohen MD, Chee GR, Prophete CM, Haykal-Coates N, Wasson SJ, Conner TL, Costa DL, Gavett SH (2003). Chemical analysis of World Trade Center fine particulate matter for use in toxicologic assessment. Environmental Health Perspectives 111, 972980.
Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Crapo R, Enright P, van der Grinten CP, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino R, Viegi G, Wanger J; ATS/ERS Task Force (2005). Standardisation of spirometry. European Respiratory Journal 26, 319338.
Muthén LK, Muthén BO (2010). Mplus. Statistical Analyses with Latent Variables. User's Guide, 6th edn. Muthén & Muthén: Los Angeles, CA.
National Center for Health Statistics (1996). NHANES III Reference Manuals and Reports [CD-ROM]. Centers for Disease Control and Prevention: Hyattsville, MD.
Niles JK, Webber MP, Gustave J, Cohen HW, Zeig-Owens R, Kelly KJ, Glass L, Prezant DJ (2011). Comorbid trends in World Trade Center cough syndrome and probable PTSD in firefighters. Chest. Published online: 5 May 2011. doi:10.1378/chest.10-2066.
NIOSH (2006). Health Hazard Evaluations. National Institute for Occupational Safety and Health ( Accessed 30 July 2011.
North CS, Pfefferbaum B, Vythilingam M, Martin GJ, Schorr JK, Boudreaux AS, Spitznagel EL, Hong BA (2009). Exposure to bioterrorism and mental health response among staff on Capitol Hill. Biosecurity and Bioterrorism 7, 379388.
Perrin MA, DiGrande L, Wheeler K, Thorpe L, Farfel M, Brackbill R (2007). Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. American Journal of Psychiatry 164, 13851394.
Prezant DJ (2008). World Trade Center cough syndrome and its treatment. Lung 186 (Suppl. 1), S94–S102.
Prezant DJ, Weiden M, Banauch GI, McGuinness G, Rom WN, Aldrich TK, Kelly KJ (2002). Cough and bronchial responsiveness in firefighters at the World Trade Center site. New England Journal of Medicine 347, 806815.
Reissman DB, Howard J (2008). Responder safety and health: preparing for future disasters. Mount Sinai Journal of Medicine 75, 135141.
Savitz DA, Oxman RT, Metzger KB, Wallenstein S, Stein D, Moline JM, Herbert R (2008). Epidemiologic research on man-made disasters: strategies and implications of cohort definition for World Trade Center worker and volunteer surveillance program. Mount Sinai Journal of Medicine 75, 7787.
Schnurr PP, Green BL (2004). Understanding relationships among trauma, post-traumatic stress disorder, and health outcomes. Advances in Mind-Body Medicine 20, 1829.
Schnurr PP, Jankowski MK (1999). Physical health and post-traumatic stress disorder: review and synthesis. Seminars in Clinical Neuropsychiatry 4, 295304.
Scott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyad J, de Girolamo G, Demyttenaere K, Gasquet I, Gureje O, Haro JM, He Y, Kessler RC, Levinson D, Medina Mora ME, Oakley Browne M, Ormel J, Posada-Villa J, Watanabe M, Williams D (2009). Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys. Psychological Medicine 39, 3343.
Skloot GS, Schechter CB, Herbert R, Moline JM, Levin SM, Crowley LE, Luft BJ, Udasin IG, Enright PL (2009). Longitudinal assessment of spirometry in the World Trade Center Medical Monitoring Program. Chest 135, 492498.
Spitzer C, Barnow S, Volzke H, John U, Freyberger H, Grabe HJ (2009). Trauma, posttraumatic stress disorder, and physical illness: findings from the general population. Psychosomatic Medicine 71, 10121017.
Stellman JM, Smith RO, Katz CL, Sharma V, Charney DS, Herbert R, Moline J, Luft BJ, Markowitz S, Udasin I, Harrison D, Baron S, Landrigan PJ, Levin SM, Southwick S (2008). Enduring mental health morbidity and social function impairment in World Trade Center rescue, recovery, and cleanup workers: the psychological dimension of an environmental health disaster. Environmental Health Perspectives 116, 12481253.
Tapp LC, Baron S, Bernard B, Driscoll R, Mueller C, Wallingford K (2005). Physical and mental health symptoms among NYC transit workers seven and one-half months after the WTC attacks. American Journal of Industrial Medicine 47, 475483.
Terhakopian A, Sinaii N, Engel CC, Schnurr PP, Hoge CW (2008). Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist. Journal of Traumatic Stress 21, 290300.
Thormar SB, Gersons BP, Juen B, Marschang A, Djakababa MN, Olff M (2010). The mental health impact of volunteering in a disaster setting: a review. Journal of Nervous and Mental Disease 198, 529538.
Ursano RJ, Fullerton CS, Benedek DM, Hamaoka DA (2007). Hurricane Katrina: disasters teach us and we must learn. Academic Psychiatry 31, 180182.
Üstün TB, Sartorius N (1995). Mental Illness in General Health Care: An International Study. John Wiley & Sons Ltd: Chichester, UK.
Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH (1997). Collaborative management of chronic illness: essential elements. Annals of Internal Medicine 127, 10971102.
Von Korff MR, Scott KM, Gureje O (eds) (2009). Global Perspectives on Mental-Physical Comorbidity in the WHO World Mental Health Surveys. Cambridge University Press: New York, NY.
Weathers F, Litz B, Herman D, Huska J, Keane T (1993). The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.
Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L, Keller MB (2002). Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Services 53, 848854.
Wheeler K, McKelvey W, Thorpe L, Perrin M, Cone J, Kass D, Farfel M, Thomas P, Brackbill R (2007). Asthma diagnosed after 11 September 2001 among rescue and recovery workers: findings from the World Trade Center Health Registry. Environmental Health Perspectives 115, 15841590.
Wisnivesky JP, Teitelbaum SL, Todd AC, Boffetta P, Crane M, Crowley L, de la Hoz RE, Dellenbaugh C, Harrison D, Herbert R, Kim H, Jeon Y, Kaplan J, Katz C, Levin S, Luft B, Markowitz S, Moline JM, Ozbay F, Pietrzak RH, Shapiro M, Sharma V, Skloot G, Southwick S, Stevenson LA, Udasin I, Wallenstein S, Landrigan PJ (2011). Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study. Lancet 378, 888897.
Yellowlees PM, Kalucy RS (1990). Psychobiological aspects of asthma and the consequent research implications. Chest 97, 628634.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary Table

Luft Supplementary Table
Supplementary Table S1. Fit indices for structural equation models

 Word (38 KB)
38 KB


Altmetric attention score

Full text views

Total number of HTML views: 20
Total number of PDF views: 123 *
Loading metrics...

Abstract views

Total abstract views: 284 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd October 2017. This data will be updated every 24 hours.