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Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study

  • R. H. Pietrzak (a1) (a2) (a3), A. Feder (a3), R. Singh (a3), C. B. Schechter (a4), E. J. Bromet (a5), C. L. Katz (a3), D. B. Reissman (a6), F. Ozbay (a3), V. Sharma (a3), M. Crane (a7), D. Harrison (a8), R. Herbert (a7), S. M. Levin (a7), B. J. Luft (a9), J. M. Moline (a10), J. M. Stellman (a11), I. G. Udasin (a12), P. J. Landrigan (a7) and S. M. Southwick (a1) (a2) (a3)
  • DOI:
  • Published online: 03 April 2013

Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders.


A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks.


Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories.


Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Corresponding author
*Address for correspondence: R. H. Pietrzak, Ph.D., M.P.H., National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue 151E, West Haven, CT 06516, USA. (Email:
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