Anger and Posttraumatic Stress Disorder in Disaster Relief
Workers Exposed to the September 11, 2001 World Trade
One-Year Follow-Up Study
Nimali Jayasinghe, PhD, Cezar Giosan, PhD, Susan Evans, PhD, Lisa Spielman, PhD,
and JoAnn Difede, PhD
Abstract: Although anger is an important feature of posttraumatic
stress disorder (PTSD) it is unclear whether it is simply concomitant
or plays a role in maintaining symptoms. A previous study of
disaster workers responding to the terrorist attacks of September 11,
2001 (Evans et al., 2006) indicated that those with PTSD evidenced
more severe anger than those without. The purpose of this study was
to conduct a 1-year follow-up to assess the role of anger in main-
taining PTSD. Workers with PTSD continued to report more severe
anger than those without; there were statistically significant associ-
ations between changes in anger, PTSD severity, depression, and
psychiatric distress. Multiple regression analysis indicated initial
anger severity to be a significant predictor of PTSD severity at
follow-up, which is consistent with the notion that anger maintains
PTSD. One implication is that disaster workers with high anger may
benefit from early intervention to prevent chronic PTSD.
Key Words: Anger, PTSD, disaster workers, longitudinal.
(J Nerv Ment Dis 2008;196: 844–846)
matic events, including combat (Kulka et al., 1990; Rosen et
al., 2001), physical or sexual assault (Riggs et al., 1992),
terrorism attacks (Evans et al., 2006), and motor vehicle
accidents (Mayou et al., 2002).
There is, however, a dearth of empirical evidence to
address whether anger is simply concomitant to posttraumatic
stress disorder (PTSD) or whether it plays a role in maintain-
ing the disorder. Anger has been implicated in the develop-
ment of PTSD in sexual assault victims (Riggs et al., 1992),
but studies do not clarify if its presence perpetuates the
esearch studies indicate anger to be a central feature of the
posttraumatic response in survivors of a variety of trau-
disorder. Other studies showed that, whereas anger predicted
the onset of PTSD in crime victims 1 month posttrauma, it
did not play a role in maintaining it at 6 months posttrauma
(Andrews et al., 2000). In contrast, another set of studies
demonstrated that anger in response to intrusive memories
predicted PTSD at 1- and 3-year follow-up in motor vehicle
accident victims (Mayou et al., 2002). We are not aware of
any studies in the literature that have examined these issues in
The mechanisms by which anger could perpetuate
PTSD are by contributing to perceptions of external threat
(Ehlers and Clark, 2000), diminishing treatment response or
preventing help seeking (Stevenson and Chemtob, 2000).
Research to clarify the role of anger in maintaining PTSD is
warranted as this may aid in treatment and in identification of
persons at risk for chronic PTSD.
The purpose of this study was to explore the relation-
ship over time between anger and PTSD in disaster workers
involved in the recovery processes at the World Trade Center
disaster. It was hypothesized that (a) PTSD diagnosis would
continue to be associated with higher levels of anger; (b) the
course of anger symptoms over time would be related to the
course of PTSD symptoms; and (c) anger severity at initial
evaluation would be a significant predictor of PTSD severity
The participants, procedure, and measures for this study
are more fully described in a cross-sectional study of anger in
this population (Evans et al., 2006) and a study of the
psychiatric consequences of disaster work in this population
(Difede et al., 2006).
Participants in this study were 1040 disaster rescue and
recovery workers deployed to the World Trade Center (WTC)
site during or in the aftermath of September 11, 2001.
The psychological screenings consisted of structured
clinical interview and self-report measures administered by
Department of Psychiatry, Weill Medical College of Cornell University,
New York, New York.
Send reprint requests to Nimali Jayasinghe, PhD, Department of Psychiatry,
Weill Medical College of Cornell University, 425 East 61st Street, Office
1358B, New York, NY 10065. E-mail: email@example.com.
Copyright © 2008 by Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 196, Number 11, November 2008
The State-Trait Anger Expression Inventory-2, a 57-
item, revised version of the State-Trait Anger Expression
Inventory (Speilberger, 1999). This study used the 15-item
state anger subscale that assesses 3 domains: “feeling anger,”
“feel like expressing anger verbally,” and “feel like express-
ing anger physically.”
The clinician-administered PTSD scale is a structured
interview that assesses the frequency and intensity of 17
PTSD symptoms and has well-established psychometric
properties (Blake et al., 1995). The items were keyed to the
WTC attacks. The PTSD checklist, a self-report measure of
PTSD (Weathers et al., 1993) was also administered.
Additional Measures of Distress
The Structured Clinical Interview for Diagnostic Sta-
tistical Manual (SCID) is a semi-structured clinical interview
with well-established reliability and validity that is used to
determine diagnoses according to the Diagnostic and Statis-
tical Manual-IV criteria (Skre et al., 1991). Major depressive
disorder, generalized anxiety disorder, and panic disorder
modules were administered during the screening. The Beck
Depression Inventory is a widely used self-report measure of
depressive with well-established psychometric properties (Beck
et al., 1961). The Brief Symptom Inventory is a 53-item version
of the Symptom Checklist-90-Revised (Derogatis and Mel-
isaratatos, 1983) that measures psychiatric distress. For the
purposes of this study, the Global Severity Index has been used.
Trauma Events Interview is a 13-item measure that
documents lifetime trauma history on a broad array of events
(e.g., natural disasters, injury, unwanted sexual contact, etc.)
(Foa and Rothbaum, 1985). The WTC Attack Exposure
Questionnaire is an instrument developed for the screening
program to assess a broad range of types of trauma exposure
both on the day of the attack, and during any subsequent
disaster work. This study used the exposure variable most
predictive of PTSD in the larger sample, namely, the percep-
tion of being in immediate danger during the course of
Independent t tests compared workers who met criteria
for PTSD with workers who did not meet criteria for PTSD
on anger severity, depression, and psychiatric distress. Next,
bivariate correlations were performed using change from time
1 to time 2 in anger severity, PTSD severity, depression, and
psychiatric distress, to explore whether changes in anger were
related to change in other symptoms. Finally, multiple regres-
sion analyses were performed to assess whether anger sever-
ity at time 1 was an independent predictor of PTSD at time 2.
The sample consisted primarily of middle-aged, white,
married men with high school education (Table 1). The mean
number of months between time 1 and time 2 was 11.22 (SD ?
1.89). The following psychiatric diagnoses were determined:
PTSD (6.8% full current, 6.1% subsyndromal current), major
depressive disorder (4.6% current, 11% past), generalized
anxiety disorder (2.2% current, 2.1% past), and panic disor-
der (2.4% current, 4.2% past). A third (31%) reported trauma
unrelated to WTC.
Independent t tests indicated that workers with PTSD
had significantly more severe symptoms of anger, depression,
and psychiatric distress than those without at both time points
(Table 2). The findings suggest that anger is a central feature
of PTSD over time.
Results showed that change in anger was significantly
related to changes in all other symptoms, with reductions in
anger associated with reductions in PTSD (Table 3). The
findings demonstrate that the course of anger symptoms over
time is related to the PTSD course.
Sociodemographic Characteristics (n ? 1040)
Age (M, SD)
Some or no high school
High school graduate
More than college
PTSD Diagnosis: Means and Standard Deviations
Anger, Depression, and Distress According to
PTSD No PTSD
tM SDM SD
*p ? 0.001.
The Journal of Nervous and Mental Disease • Volume 196, Number 11, November 2008Role of Anger in PTSD
© 2008 Lippincott Williams & Wilkins
Table 4 displays the results of multiple regressions to Download full-text
predict PTSD severity at time 2. Anger severity at time 1
accounted for a statistically significant, though small (2%), of
variance in PTSD severity at time 2. The finding is consistent
with the hypothesis that anger plays a role in maintaining
This study suggests that anger may make a unique
contribution to the maintenance of PTSD symptoms in disas-
ter workers. The findings bolster the limited amount of
longitudinal data about this issue and extend findings on
victims of motor vehicle accident, physical assault, or sexual
assault to a new population. Although the variance explained
(2%) was small, this is consistent with other studies and the
potential importance of anger should not be minimized (May-
ouet al., 2002). Implications of these findings are that careful
assessment of anger should be included in screening of
disaster-exposed workers and that disaster workers with high
levels of anger may benefit from early intervention as they
may be at risk for chronic symptoms.
One limitation of this study is that data are not available
on anger symptoms in the acute aftermath of disaster expo-
sure. In addition, as the population under study is predomi-
nantly male, there may be limits to generalizability. Because
this study examined state anger rather than trait anger, future
study of global and stable patterns of anger may prove
informative in clarifying the relationship between different
forms of anger and PTSD. Finally, the findings do not shed
light on the specific mechanisms accounting for the role of
anger in maintaining PTSD. Future research is warranted that
explores issues such as continued threat perception, interper-
sonal functioning difficulties, and barriers to treatment utili-
zation, among others.
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Relation of Change in Anger to Change in Other
*p ? 0.01.
STAXI-2 indicates State-Trait Anger Expression Inventory-2; BDI, Beck depres-
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Predicting PTSD Severity at Time 2
Summary of Multiple Regression Analyses
No. past diagnoses
Felt serious danger
CAPS severity time 1
STAXI-2 severity time 1
*p ? 0.5; **p ? 0.01; ***p ? 0.001.
Jayasinghe et al.
The Journal of Nervous and Mental Disease • Volume 196, Number 11, November 2008
© 2008 Lippincott Williams & Wilkins