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Partial PTSD in disaster responders may be overlooked
Current mental health screening protocols may not fully gauge the problems associated with subsyndromal posttraumatic stress disorder symptoms in disaster responders after events such as the terrorist attacks on the World Trade Center, according to researchers.
“The reason that subsyndromal PTSD is overlooked in clinical settings is likely a consequence of it not being a diagnostic classification in DSM-IV,” Robert Pietrzak, PhD, MPH, a researcher from the National Center for PTSD and Yale School of Medicine, told Healio.com. “Further, there are several operational definitions for subsyndromal PTSD, and there are no standard procedures for identifying subsyndromal PTSD on commonly used PTSD screening instruments.”
The rate of subsyndromal PTSD was nearly three times greater than full PTSD in police who were involved in rescue and recovery work at ground zero after the Sept. 11, 2001, attacks, according Pietrzak and colleagues, who analyzed data on 8,466 police officers who completed an initial evaluation for the World Trade Center Medical Monitoring and Treatment Program in New York City. Most of the program’s participants were New York City police officers (85%).
World Trade Center (WTC) exposures were assessed by a clinician-administered interview, which included the following:
- Early arrival (ie, beginning work at ground zero between Sept. 11, 2001, and Sept. 13, 2001).
- Being caught in the dust cloud from the collapsed buildings.
- Working at the collapse site, known as the “pit” or the “pile,” during September 2001.
- Working more than the median number of hours at ground zero.
- Exposure to human remains.
- Involvement in search and rescue efforts during September and October 2001.
- Death of a colleague, family member or friend on Sept. 11, 2001.
- Knowing someone who was injured on Sept. 11, 2001.
Stressful events were assessed using the Disaster Supplement of the Diagnostic Interview Schedule, and PTSD symptoms were assessed using the Posttraumatic Stress Disorder Checklist-Specific Version, which is based on DSM-IV criteria for PTSD. The researchers also analyzed data for depression, panic disorder, alcohol use problems, functional disability, somatic symptoms, social support and perceived mental health care needs. Multinomial logistic regression analyses were used to determine the link between risk factors and perceived mental health care needs associated with full and subsyndromal PTSD, and the link between PTSD status and psychiatric comorbidities and functional impairment.
A total of 15.4% of police were identified as having subsyndromal PTSD symptoms, compared with 5.4% with full PTSD. Loss of someone or knowing someone injured on Sept. 11, 2001 (OR=1.56-1.86), stressors originating before recovery and rescue (OR=1.3-1.5), family support (OR=0.83-0.94) and union membership (OR=0.5-0.52) were associated with both full and subsyndromal PTSD. Results also showed that exposure to the dust cloud (OR=1.36), performing search and rescue work (OR=1.29) and work support (OR=0.98) were also associated with subsyndromal PTSD.
Rates of comorbid depression, panic disorder and alcohol use problems (OR=3.82-41.74), and somatic symptoms and functional difficulties (OR=1.3-1.95) were highest among police with full PTSD, compared with rates among police with subsyndromal PTSD (OR=2.93-7.02 and OR=1.18-1.6, respectively).
According to the researchers, police with full PTSD (41.1%) and subsyndromal PTSD symptoms (19.8%) were significantly more likely than trauma-exposed controls (6.8%) to report a need for a range of mental health services (OR=1.99-38.58).
Pietrzak and colleagues wrote that there are several clinical and public health implications of the study results:
- Subsyndromal PTSD is not a diagnostic classification and may not be routinely identified through screenings in police and other emergency medical services workers, and clinicians may underestimate the burden of traumatic stress and related morbidities in this population.
- Subsyndromal PTSD is associated with a number of comorbid psychiatric conditions, functional difficulties and somatic symptoms, suggesting that clinicians, disaster response organizations and public health officials should focus on more than PTSD alone.
- With nearly 20% of police with subsyndromal PTSD reporting a need for mental health services, this population may also require resources in the aftermath of responding to mass disasters.
- Stressors originating before Sept. 11, 2001, were associated with WTC-related full and subsyndromal PTSD, suggesting that confidential and routine mental health screenings may be helpful in monitoring stressful life events and the psychological well-being of police.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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The substantial paper adds to the literature on PTSD and its variants, focusing on the psychological effects of working following the 9/11 disaster in Manhattan.
There are three take-home points for me: 1) there was a toll on a least 20% of the police workers who were exposed; 2) it is essential to use a more comprehensive and inclusive assessment than just a PTSD checklist, to find both subsyndromal PTSD and related comorbidities; and 3) confidential screenings and referrals are necessary since many police officers are concerned that seeking treatment may affect their job.
The findings parallel to what we see in soldiers and other service members from the wars in Iraq and Afghanistan. First of all, both soldiers and police are a well-trained and, overall, resilient group. Secondly, all of the points in the paragraph above would equally apply to service members.
There is currently a lot of discussion about revising DSM-IV criteria for PTSD, to eliminate so-called criteria A-2, the requirement that individuals experience fear, hopelessness and horror. Both police and service members are well trained and do the job they are trained to do, usually without fear or helplessness.
Another theme this paper illustrates is exposure to environmental hazards; in this case, the dust cloud leading to detrimental mental effects. After every disaster, exposure to environmental hazards leads to concerns about physical health. Remember the first Gulf War and Gulf War illness? Or the anthrax attacks, and the concerns of the postal workers at Brentwood? Then there is the exposure to the body parts and having colleagues killed or injured. I have often called these “psychological toxins.” This paper highlights the importance of inquiring about those exposures.
Another aspect highlighted by this paper is the importance of social support following a disaster.
In summary, this is an excellent contribution to the literature, both about the psychological consequences of working after a disaster and the importance of proactive measures to mitigate those consequences.