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Objective: A positive association between mental health conditions and poor asthma control has been documented in the World Trade Center-exposed population. Whether factors such as medication adherence mediate this association is unknown. Methods: The study population was drawn from adult participants of the World Trade Center Health Registry Cohort who self-reported as asthmatic after the disaster and who were currently prescribed a long-term control medication (LTCM). Multivariable linear regression was used to estimate the associations between mental health condition (PTSD, depression, or anxiety) and continuous adherence and Asthma Control Test (ACT) scores. Results: In the study sample of 1,293, 49% were not adherent to their LTCM and two thirds reported poorly or very poorly controlled asthma. Presence of any mental health condition was associated with a 2-point decline in ACT and half a point decrease in adherence scores. However, in the multivariable model, better adherence was statistically significantly associated with slightly worse control. Conclusions: The total effect of mental health on asthma control was opposite in sign from the product of the paths between mental health and adherence and adherence and asthma control; we therefore found no evidence to support the hypothesis that adherence mediated the negative association between poor mental health and adequate asthma control. More research is needed to understand the complex causal mechanisms that underlie the association between mental and respiratory health.

We observed that World Trade Center (WTC) exposure, post-traumatic stress disorder (PTSD) symptoms and depressive symptoms were associated with subjective cognitive concerns in Fire Department of the City of New York (FDNY) rescue/recovery workers. This follow-up study examined whether PTSD symptoms and/or depressive symptoms mediate the observed association between WTC exposure and subjective cognitive concerns. We included WTC-exposed FDNY workers who completed the Cognitive Function Instrument (CFI), measuring self-perceived cognitive decline ( N = 9516). PTSD symptoms and depressive symptoms were assessed using the PCL-S and CES-D, respectively. Multivariable linear regression estimated the association between WTC exposure and CFI score, adjusting for confounders. Mediation analyses followed the methods of Vanderweele (2014). Participants' average age at CFI assessment was 56.6 ± 7.6 years. Higher-intensity WTC exposure was associated with worse CFI score, an effect that was entirely mediated by PTSD symptoms (%mediated: 110.9%; 95%CI: 83.1-138.9). When substituting depressive symptoms for PTSD symptoms, the WTC exposure-CFI association was largely mediated (%mediated: 82.1%; 95%CI: 60.6-103.7). Our findings that PTSD symptoms and depressive symptoms mediate the association between WTC exposure and subjective cognitive concerns indicate that in the absence of these symptoms, WTC exposure in rescue/recovery workers would not be associated with subjective cognition. Interventions targeting PTSD and depression may have additional value in mitigating cognitive decline in WTC-exposed populations.

The COVID-19 pandemic will likely lead to high rates of PTSD, depression, and substance misuse among survivors, victims' families, medical workers, and other essential personnel. The mental health response to the 9/11/01 terrorist attacks, culminating in a federally-funded health program, provides a template for how providers may serve affected individuals. Drawing on the 9/11 experience, we highlight effective prevention measures, likely short and long-term treatment needs, vulnerable subgroups, and important points of divergence between 9/11 and the COVID-19 pandemic. Mental health monitoring, early identification of at-risk individuals, and treatment irrespective of financial barriers are essential for minimizing chronic distress., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Craig Katz is a paid consultant to the International Association of Firefighters Center of Excellence for Behavioral Health Treatment and Recovery. Jonathan DePierro and Sandra Lowe have no competing financial or personal relationships that could have appeared influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To examine unique relations of three distinct dimensions of desirability of control with psychological and physical well-being and coping. Design: Study 1 ( n  = 122) surveyed undergraduates' response to everyday stressors, and Study 2 ( n = 105) examined undergraduates' adjustment to the 11 September 2001 terrorist attacks at 1 and 3 months post-attack. Main outcome measures included psychological distress, perceived stress, rumination, health behaviors, alcohol use and active vs. avoidant coping. Study 1 Results: Self- and other-control were associated with active coping, whereas relinquishing control was linked with avoidant coping. Only relinquishing control was uniquely linked with outcomes, including worse psychological and physical well-being and alcohol use; avoidant coping mediated relations to psychological well-being. Study 2 Results: Again, self-control was associated with active coping whereas relinquishing control was linked with avoidant coping. Self-control was associated with enhanced psychological well-being at T1 and increases in well-being over time; by contrast, relinquishing control was associated with worse T1 psychological well-being, which was mediated by avoidant coping. Conclusion: This is the first study to examine the unique contribution of each DOC dimension with outcomes. Self-control and relinquishing control showed divergent relations to psychological well-being, mediated by different coping pathways.

Fifteen years after the disaster, the World Trade Center Health Registry (Registry) conducted The Health and Quality of Life Survey (HQoL) assessing physical and mental health status among those who reported sustaining an injury on 11 September 2001 compared with non-injured persons. Summary scores derived from the Short Form-12 served as study outcomes. United States (US) population estimates on the Physical Component Score (PCS-12) and Mental Component Score (MCS-12) were compared with scores from the HQoL and were stratified by Post-traumatic Stress Disorder (PTSD) and injury status. Linear regression models were used to estimate the association between both injury severity and PTSD and PCS-12 and MCS-12 scores. Level of injury severity and PTSD history significantly predicted poorer physical health (mean PCS-12). There was no significant difference between injury severity level and mental health (mean MCS-12). Controlling for other factors, having PTSD symptoms after 9/11 predicted a nearly 10-point difference in mean MCS-12 compared with never having PTSD. Injury severity and PTSD showed additive effects on physical and mental health status. Injury on 9/11 and a PTSD history were each associated with long-term decrements in physical health status. Injury did not predict long-term decrements in one's mental health status. Although it is unknown whether physical wounds of the injury healed, our results suggest that traumatic injuries appear to have a lasting negative effect on perceived physical functioning.

Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.

Background: Studies of individuals directly exposed to the World Trade Center (WTC) terrorist attacks of September 11, 2001 have found increased risk for post-traumatic stress disorder (PTSD) and binge drinking (BD). No long-term studies have been conducted on one highly exposed group, WTC tower evacuees., Methods: The study sample included 7,695 adult civilians in the WTC Health Registry. Logistic regression was used to examine the odds of PTSD and BD in 1,946 towers evacuees compared to 5,749 others in nearby buildings or on the street., Results: WTC tower survivors were at increased risk for PTSD and BD compared to the others. Infrastructure and behavioral barriers experienced during evacuation were significantly associated with PTSD., Conclusions: WTC tower evacuees are at increased risk for PTSD and BD. Understanding the effects of disaster-related evacuation barriers on the long-term mental health status of survivors can help in the planning of continuing post-disaster treatment. Am. J. Ind. Med. 59:742-751, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

This mixed method systematic review appraises the individual, familial and systemic effect of 9/11 and the war on terror for majority and minority children and youth in North America. The results highlight the broad social consequences of the socio-political transformations associated with the terror context, which cannot be understood only through a trauma focus analysis. The social stereotypes transformed youth experiences of belonging and exclusion. The difference between the consequences for majority and minority youth suggests the need for a broader appraisal of this societal context to support the development of prevention and intervention intersectorial programs., (© The Author(s) 2013.)

Purpose: Much of the mental health research that has emerged from the September 11 (9/11) attacks has been focused on posttraumatic stress disorder and its symptoms. To better understand the broader experience of individuals following a disaster, focus groups were conducted with individuals from affected companies both at Ground Zero and elsewhere in New York City., Methods: Twenty-one focus groups with a total of 140 participants were conducted in the second post-9/11 year. Areas of identified concern were coded into the following themes: Disaster Experience, Emotional Responses, Workplace Issues, Coping, and Issues of Public Concern., Results: Discussions of focus groups included material represented in all five themes in companies both at Ground Zero and elsewhere. The emphasis and the content within these themes varied between the Ground Zero and other companies. Content suggesting symptoms of PTSD represented only a minority of the material, especially in the company groups not at Ground Zero., Conclusions: This study's findings revealed an array of psychosocial concerns following the 9/11 attacks among employees of companies in New York City that extended far beyond PTSD. This study's results provide further evidence that trauma exposure is central to individuals' post-disaster experience and focus, and to individuals' adjustment and experience after disaster.

Background: There is little current information about the unmet mental health care need (UMHCN) and reasons for it among those exposed to the World Trade Center (WTC) terrorist attacks. The purpose of this study was to assess the level of UMHCN among symptomatic individuals enrolled in the WTC Health Registry (WTCHR) in 2011-2012, and to analyze the relationship between UMHCN due to attitudinal, cost, and access factors and mental health symptom severity, mental health care utilization, health insurance availability, and social support., Methods: The WTCHR is a prospective cohort study of individuals with reported exposure to the 2001 WTC attacks. This study used data from 9,803 adults who completed the 2003-2004 (Wave 1) and 2011-2012 (Wave 3) surveys and had posttraumatic stress disorder (PTSD) or depression in 2011-2012. We estimated logistic regression models relating perceived attitudinal, cost and access barriers to symptom severity, health care utilization, a lack of health insurance, and social support after adjusting for sociodemographic characteristics., Results: Slightly more than one-third (34.2%) of study participants reported an UMHCN. Symptom severity was a strong predictor of UMHCN due to attitudinal and perceived cost and access reasons. Attitudinal UMHCN was common among those not using mental health services, particularly those with relatively severe mental health symptoms. Cost-related UMHCN was significantly associated with a lack of health insurance but not service usage. Access-related barriers were significantly more common among those who did not use any mental health services. A higher level of social support served as an important buffer against cost and access UMHCN., Conclusions: A significant proportion of individuals exposed to the WTC attacks with depression or PTSD 10 years later reported an UMHCN, and individuals with more severe and disabling conditions, those who lacked health insurance, and those with low levels of social support were particularly vulnerable.

Background: The triple disaster that struck the Tohoku region on March 11, 2011, has had massive psychiatric, social, and physical effects on the people of Japan. A staggering loss of life and property, as well as an ongoing nuclear disaster, has dramatically affected the ability of the country to recover., Objective: In an effort to better understand the current social, health, and mental health needs of the region affected by the disaster and to share lessons from 9/11, a group of 9/11 survivors and doctors from the Icahn School of Medicine at Mount Sinai traveled to sites throughout the Fukushima, Miyagi, and Iwate prefectures., Methods: A qualitative analysis was performed on transcripts of the cultural and medical exchanges, which occurred on this trip to identify relevant themes about the problems confronting the recovery effort almost 3 years after the disaster., Findings: Significant themes that emerged included a crippling radiation anxiety, a considerable stigma toward addressing mental health care, and a shortage of mental health care throughout the region, as well as ongoing psychiatric symptoms such as insomnia, anxiety, and alcohol misuse., Conclusions: These issues continue to complicate the recovery effort but suggest avenues for future interventions., (Copyright © 2014 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.)

A number of studies have assessed the association between acculturation and psychological outcomes following a traumatic event. Some suggest that low acculturation is associated with poorer health outcomes, while others show no differences or that low acculturation is associated with better outcomes. One year after the terrorist attacks on the World Trade Center, we surveyed a multi-ethnic population of New York City adults (N= 2,368). We assessed posttraumatic stress disorder (PTSD), major depression, panic attack, anxiety symptoms, and general physical and mental health status. We classified study respondents into "low," "moderate," or "high" acculturation, based on survey responses. Bivariate results indicated that low acculturation individuals were more likely to experience negative life events, have low social support, and less likely to have pre-disaster mental health disorders. Those in the low acculturation group were also more likely to experience post-disaster perievent panic attacks, have higher anxiety, and have poorer mental health status. However, using logistic regression to control for confounding, and adjusting for multiple comparisons, we found that none of these outcomes were associated with acculturation status. Thus, our study suggests that acculturation was not associated with mental health outcomes following a major traumatic event.

Researchers have identified health implications of religiosity and spirituality but have rarely addressed differences between these dimensions. The associations of religiosity and spirituality with physical and mental health were examined in a national sample (N = 890) after the September 11, 2001 terrorist attacks (9/11). Health information was collected before 9/11 and health, religiosity, and spirituality were assessed longitudinally during six waves of data collection over the next 3 years. Religiosity (i.e., participation in religious social structures) predicted higher positive affect (β = .12), fewer cognitive intrusions (β = -.07), and lower odds of new onset mental (incidence rate ratio [IRR] = .88) and musculoskeletal (IRR = .94) ailments. Spirituality (i.e., subjective commitment to spiritual or religious beliefs) predicted higher positive affect (β = .09), lower odds of new onset infectious ailments (IRR = 0.83), more intrusions (β = .10) and a more rapid decline in intrusions over time (β = -.10). Religiosity and spirituality independently predict health after a collective trauma, controlling for pre-event health status; they are not interchangeable indices of religion.

A wealth of research and experience after 9/11 has led to the development of evidence-based and evidence-informed guidelines and strategies to support the design and implementation of public mental health programs after terrorism and disaster. This article reviews advances that have been made in a variety of areas, including development of improved metrics and methodologies for conducting needs assessment, screening, surveillance, and program evaluation; clarification of risk and resilience factors as these relate to varying outcome trajectories for survivors and inform interventions; development and implementation of evidence-based and evidence-informed early, midterm, and late interventions for children, adults, and families; adaptation of interventions for cultural, ethnic, and minority groups; improvement in strategies to expand access to postdisaster mental health services; and enhancement of training methods and platforms for workforce development among psychologists, paraprofessionals, and other disaster responders. Continuing improvement of psychologists' national capacity to respond to catastrophic events will require more systematic research to strengthen the evidence base for postdisaster screening and interventions and effective methods and platforms for training. Policy decisions are clearly needed that enhance federal funding to increase availability and access to services, especially for longer term care. Traumatic bereavement represents a critical area for future research, as much needs to be done to clarify issues related to reactions and adaptation to a traumatic death., (© 2011 American Psychological Association)

The enduring impact of exposure to the 9/11 terrorist attacks on mental health and sociopolitical attitudes was examined in a sample of 427 adolescents (M = 16.20 years) and their mothers residing in New York City. Direct exposure to the terrorist attack was associated with youth depression symptoms and with mothers' posttraumatic stress disorder symptoms. There was no evidence of reciprocal effects of mother exposure on youth or of youth exposure on mothers. Although mothers reported engaging in more emotional processing coping assistance with their children, coping assistance was not associated with youth's symptomatology. Media exposure was found to be a strong predictor of youth's and mothers' sociopolitical attitudes about issues such as prejudice toward immigrants, social mistrust, and current events.

The need for mental health resources to provide care to the community following large-scale disasters is well documented. In the aftermath of the World Trade Center (WTC) disaster on September 11, 2001, many local agencies and organizations responded by providing informal mental health services, including disaster mental health training for practitioners. The quality of these programmes has not been assessed, however. The National Center for Disaster Preparedness at Columbia University's School of Public Health reviewed disaster mental health training programmes administered by community-based organizations, professional associations, hospitals, and government agencies after September 11. Results indicate that the quality and the effectiveness of programmes are difficult to assess. A wide range of curricula and a widespread lack of recordkeeping and credentialing of trainers were noted. Most of the training programmes provided are no longer available. Recommendations for improving the quality of disaster mental health training programmes are provided.

Objective: Understanding postdisaster workplace adjustment may help guide interventions for postdisaster emotional functioning and recovery., Methods: One to two years after the September 11, 2001, terrorist attacks, 12 focus groups were conducted with 85 employees of companies directly affected by the 9/11 attacks on New York City, to discuss mental health issues surrounding return to the workplace after the disaster., Results: Risk communication, tension between workplace productivity and employees' emotional needs, and postdisaster work space were topics discussed in the focus groups. Employees identified many effective responses by their companies after 9/11 relating to these areas of concern as well as gaps in response., Conclusions: Recommended risk communication procedures were applied but not systematically. Little direction was available for balancing workplace productivity and employees' emotional needs or for strategic management of postdisaster workspace, suggesting areas for future disaster workplace research.

In the aftermath of disasters, understanding relationships between disaster-related life disruption and children's functioning is key to informing future postdisaster intervention efforts. The present study examined attack-related life disruptions and psychopathology in a representative sample (N = 8,236) of New York City public schoolchildren (Grades 4-12) surveyed 6 months after September 11, 2001. One in 5 youth reported a family member lost their job because of the attacks, and 1 in 3 reported their parents restricted their postattack travel. These forms of disruption were, in turn, associated with elevated rates of probable posttraumatic stress disorder and other anxiety disorders (and major depressive disorder in the case of restricted travel). Results indicate that adverse disaster-related experiences extend beyond traumatic exposure and include the prolonged ripple of postdisaster life disruption and economic hardship. Future postdisaster efforts must, in addition to ensuring the availability of mental health services for proximally exposed youth, maintain a focus on youth burdened by disaster-related life disruption.

Making meaning out of negative experiences is one of the primary psychological challenges in the wake of adversity. Much of the empirical attention that psychologists have paid to meaning making has focused on personal hardships, but national tragedies similarly pose a challenge to meaning making. In the present study, which is grounded in the theoretical tradition of the narrative study of lives, a nationally representative sample of 395 adults wrote accounts about the 9/11 terrorist attacks approximately 2 months after 9/11. Accounts were coded for 3 narrative themes: closure, redemption, and contamination. Psychological well-being was significantly related to accounts that were high in closure and national redemption and, among those more directly exposed to the attacks, accounts high in redemptive imagery. Psychological distress was significantly related to accounts that were low in closure and high in themes of personal contamination. Understanding the narrative styles that characterize personal accounts of political events has important ramifications for the study of the socially embedded individual.

Objectives: We examined the extent to which the stress paradigm linking psychosocial stressors to mental health status has focused disproportionate attention on microlevel social stressors to the detriment of macrolevel stressors. Also, we assessed the effects of the terrorist attacks of September 11, 2001, on subsequent mental health among participants in a Midwestern cohort study., Methods: Respondents in a 6-wave longitudinal mail survey completed questionnaires before September 11, 2001, and again in 2003 and 2005. Regression analyses focused on measures of negative terrorism-related beliefs and fears, as well as psychological distress and deleterious alcohol use outcomes measured both before and after September 11., Results: Negative terrorism-related beliefs and fears assessed in 2003 predicted distress and drinking outcomes in 2005 after control for sociodemographic characteristics and pre-September 11 distress and drinking., Conclusions: The events of September 11 continue to negatively affect the mental health of the American population. Our results support the utility of according greater attention to the effects of such macrolevel social stressors in population studies embracing the stress paradigm.

Purpose: To determine the rate of post-traumatic stress disorder (PTSD) after 9/11 in a sample of New York City high school students and associations among personal exposure, loss of psychosocial resources, prior mental health treatment, and PTSD., Methods: A total of 1214 students (grades 9 through 12) attending a large community high school in Bronx County, 20 miles north of "Ground Zero," completed a 45-item questionnaire during gym class on one day eight months after 9/11. Students were primarily Hispanic (62%) and African American (29%) and lived in the surrounding neighborhood. The questionnaire included the PCL-T, a 17-item PTSD checklist supplied by the Office of Behavioral and Social Science Research of the National Institutes of Health (NIH). The PCL-T was scored following the DSM-IV criteria for PTSD requiring endorsement of at least one repeating symptom, two hyperarousal symptoms, and three avoidance symptoms. Bivariate analysis comparing PTSD with personal exposure, loss of psychosocial resources, and mental health variables was done and multiple logistic regression was used to identify significant associations., Results: There were 7.4 % of students with the PTSD symptom cluster. Bivariate analysis showed a trend for females to have higher rates of PTSD (males [6%] vs. females [9%], p = .06] with no overall ethnic differences. Five of the six personal exposure variables, and both of the loss of psychosocial resources and mental health variables were significantly associated with PTSD symptom cluster. Multiple logistic regression analysis found one personal exposure variable (having financial difficulties after 9/11, odds ratio [OR] = 5.27; 95% confidence interval [CI] 2.9-9.7); both the loss of psychosocial resources variables (currently feeling less safe, OR = 3.58; 95% CI 1.9-6.8) and currently feeling less protected by the government, (OR = 4.04; 95% CI 2.1-7.7); and one mental health variable (use of psychotropic medication before 9/11, OR = 3.95; 95% CI 1.2-13.0) were significantly associated with PTSD symptom cluster., Conclusions: We found a rate of PTSD in Bronx students after 9/11 that was much higher than other large studies of PTSD in adolescents done before 9/11. Adolescents living in inner cities with high poverty and violence rates may be at high risk for PTSD after a terrorist attack. Students who still felt vulnerable and less safe eight months later and those with prior mental health treatment were four times more likely to have PTSD than those without such characteristics, highlighting the influence of personality and mental health on development of PTSD after a traumatic event.

Background: To obtain prevalence estimates and identify factors associated with psychological problems and receipt of help by a geographically proximate population in which some persons had direct exposure but the overall prevalence of direct exposure was low, 5-15 months after the September 11th, 2001 terrorist incidents., Method: Telephone survey data from the Behavioral Risk Factor Surveillance System (BRFSS) (Connecticut Module) with a randomly selected cohort of 2741 women and 1899 men aged 18 and older were examined using bivariate Chi Square and multivariate logistic regression analyses of weighted data., Results: One in three respondents reported 9/11-related psychological problems, 26% of whom reported receiving formal services or peer support. Risk factors for reporting psychological problems included being surveyed earlier, female gender, age 64 or younger, Hispanic ethnicity, disability, recent depression, and reporting one day or more in the past 30 of poor mental health, sleep problems or worry. Poor mental health was associated with receipt of formal services, and increased alcohol use was associated with receipt of peer support., Conclusion: In the post-impact recovery period following mass trauma, psychological problems by persons with ongoing mental health conditions or increased alcohol use warrant continuing public and professional attention. Women, Hispanics, and disabled adults also may be under-served.

Over the past 30 years, studies have shown that survivors of community-wide disasters suffer from a variety of physical and mental health problems. Researchers also have documented increased substance use in the aftermath of these disasters. In the present study, we examined the relationship between alcohol use and mental health status within the context of the terrorist attacks on the World Trade Center in New York City (NYC). The data for the present report come from a 2-wave panel study of adults living in NYC on the day of the attacks. Wave 1 (W1) and Wave 2 (W2) interviews occurred one year and two years after the attacks, respectively. Overall, 2,368 individuals completed the W1 survey (cooperation rate, 63%) and 1,681 completed the W2 survey (re-interview rate, 71%). The alcohol use variables examined were binge drinking, alcohol dependence, increased days drinking, and increased drinks per day. The outcomes examined included measures of posttraumatic stress disorder (PTSD), major depression, BSI-18-Global Severity and measures of SF12-mental and physical health status. After controlling for demographic, stress, and resource factors, multivariate logistic regressions indicated that all alcohol measures were related to one or more of these outcomes. In particular, binge drinking was related to partial PTSD, while alcohol dependence was associated subsyndromal PTSD, severity of PTSD, depression, BSI-18 global severity, and SF-12 poor mental health status. Increased post-disaster drinking was positively associated with subsyndromal PTSD and negatively associated with SF-12 physical health. We discuss reasons for these results and the negative consequences that heavy alcohol use may have on the postdisaster recovery process.

Positive psychologists found the increase of seven character strengths that encompass the so-called theological virtues, including hope and spirituality, in Americans after the September 11, 2001, attacks. Little is known about how they may affect post-September 11, 2001, mental health. Using multivariate analysis, this study investigated the relationship of hope and spiritual meaning with depression and anxiety in a sample of 457 students 3 months after September 11, 2001. Both characters contributed to lower levels of symptoms. In qualitative analysis, of 313 answers to an open-ended question regarding personal change, four categories emerged. The first three were consonant with other studies on posttraumatic growth (PTG), including changes in the self or behavior, relationships, and worldviews. The fourth category unique to September 11, 2001, was changes in political views. These findings offer further credence to the study of positive aspects resulting from violence-related trauma and highlight the needs for addressing the nature of traumatic events and PTG.