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ICU patients exhibit a high incidence of post-traumatic stress disorder (PTSD). During treatment, procedural pain (e.g., suctioning, ventilator asynchrony) and communication barriers can trigger significant stress responses, exacerbating feelings of fear and helplessness, ultimately contributing to PTSD post-extubation. Current research predominantly relies on cross-sectional studies, failing to capture the dynamic progression of PTSD. As recovery evolves, patients' psychological and physical states continuously change, necessitating adaptive intervention strategies. There is an urgent need for longitudinal studies to elucidate PTSD development trajectories, clinical characteristics, and risk factors. However, research on the psychological recovery pathways of post-ICU patients remains scarce. This study aimed to identify the heterogeneous developmental trajectories of PTSD in ICU patients receiving mechanical ventilation within 6 months post-extubation and to analyze relevant factors across trajectory subgroups. From July 2023 to June 2024, a consecutive sampling method was employed to select mechanically ventilated patients admitted to the ICU of a tertiary hospital in Zunyi, China. At 7 days post-extubation (T0), baseline assessments were conducted using the following instruments: a general information questionnaire, the Impact of Event Scale-Revised (IES-R), the Hospital Anxiety and Depression Scale (HADS), the Simplified Coping Style Questionnaire (SCSQ), the short-form Chinese version of the Eysenck Personality Questionnaire-Revised (EPQ-RSC), and the Perceived Social Support Scale (PSSS). Follow-up assessments were performed at 1 month (T1), 3 months (T2), and 6 months (T3) post-extubation using the IES-R. Data were analyzed using Mplus 8.3 and SPSS 29.0. Prospective longitudinal study. Among 204 completed cases (89.1% retention), four trajectories emerged: high-risk deterioration (6.9%), high-risk improvement (27.2%), medium-risk maintenance (14.3%), and low-risk improvement (51.6%). Lower education, prolonged hospitalization, delayed ICU discharge post-extubation, and baseline anxiety independently predicted adverse trajectories (P < 0.05). PTSD trajectories in mechanically ventilated ICU patients exhibit significant heterogeneity. Clinicians should prioritize screening high-risk subgroups (e.g., less-educated patients, extended hospitalization) for early PTSD intervention to enhance recovery outcomes. Targeted PTSD monitoring and psychological support are recommended for at-risk populations to mitigate long-term mental health burdens.