The Strongest Correlates of PTSD for Firefighters: Number, Recency, Frequency, or Perceived Threat of Traumatic Events?

Assessment of the Psychological Effects on Firefighters in the Aftermath of the Pazarcik and Elbistan Earthquakes in 2023

In February 2023, two catastrophic earthquakes in Turkey resulted in over 50,000 fatalities and over 300,000 injuries. This study investigated the psychological effects on firefighters who engage in rescue operations following these earthquakes, focusing on trauma-related symptoms, depression, anxiety, stress, and resilience. The research employed validated psychometric instruments, including the Post-earthquake Trauma Level Determination Scale (PETLDS); Depression, Anxiety, Stress Scale-21 (DASS-21); PTSD Checklist for DSM-5 (PCL-5); and Brief Resilience Scale (BRS), to assess the psychological states of firefighters. The primary goal of this study was to evaluate the psychological impact of earthquakes on firefighters. Specific objectives include quantifying trauma levels; identifying the prevalence of post-traumatic stress disorder (PTSD), depression, anxiety, and stress among firefighters; and investigating the role of psychological resilience in mitigating the effects of disaster-related psychological trauma. This study is also aimed at providing empirical evidence to inform the development of psychological support and intervention strategies for firefighters in the aftermath of these earthquakes. In this study of 223 primarily male firefighters, significant psychological impacts from earthquake trauma were observed. The PETLDS scores indicated high trauma levels in 28 participants and modest levels in 195. Subscales revealed affective responses and cognitive structure were most affected. DASS-21 scores showed higher depression, anxiety, and stress in the high trauma group. PCL-5 and BRS analyses confirmed higher PTSD symptoms and lower resilience in high-trauma individuals. Correlation analysis highlighted strong associations between trauma, psychological distress, and decreased resilience. These findings highlight the necessity for targeted mental health interventions and support mechanisms for firefighters, contribute to the establishment of training programs to enhance psychological resilience among firefighters, and add valuable insights to the field of disaster psychology.

Mental health and post-traumatic stress disorder in firefighters: an integrated analysis from an action research study

Introduction

The presence of post-traumatic stress disorder (PTSD) symptomatology in firefighters is an ever-pressing issue that requires close attention for adequate interventions. The present study investigated PTSD and global psychopathology prevalence in a sample of highly risk-exposed Portuguese firefighters, collected after the widespread deadly wildfires in 2017 that ravaged the country. Following an action research approach, the aim of this study was to depict this sample and examine the impact of cumulative adverse experiences on their mental health, which is a phenomenon worth attention.

Method

From an initial sample of 283 firefighters who manifested interest in participating, a total of 139 firefighters from the Coimbra District, of whom 130 unequivocally experienced a potentially traumatic/adverse event as a firefighter, completed BSI (to obtain indicators on psychopathology), QEPAT (an inventory of adverse events possibly experienced as a firefighter), and PCL-5 (a measure of PTSD symptomatology) through an online survey during the year 2018 by the Regional Medical Organization, as proposed and supervised by the local Centre for Prevention and Treatment of Psychological Trauma (CPTTP).

Results

We found a global prevalence of 8.6% of possible PTSD and 14.4% of possible psychopathology (n = 139). When considering only firefighters who unequivocally reported a potentially traumatic/adverse event as a firefighter (n = 130), 9.2% present possible PTSD, and 13.8% present possible global psychopathology. This sample experienced a mean of 28 adverse events during firefighting work. Linear regressions (n = 118) demonstrated that the perceived severity of the most traumatic event reported and the experience of more adverse events were both related to an increase in PTSD symptomatology. Global psychopathology was associated with PCL-5 scores, with an emphasis on paranoid ideation, hostility, depression, anxiety, and phobic anxiety.

Discussion

The severe wildfires of 2017 did not impact PTSD scores in this sample (collected the year after), suggesting that cumulative adverse events are more important than particular episodes. However, the number of reported events was related to PTSD scores. These results can be used to develop interventions that target all firefighters by addressing risk and protective factors. This action research study motivated specialized aid for firefighters involved in this study.

Path Model Analysis of the Effects of Perceived Formalism, and Fear of COVID-19 on Police Officers' PTSD and Insomnia

This study examines whether law enforcement officers' fear of COVID-19, job burnout, and job stress have increased their PTSD and insomnia during the epidemic. This article introduces the perceived formalism of police agencies into the causal model to explore whether perceived formalism increases the job burnout and job stress of police officers. The formalism of administrative agencies is rarely included in epidemic research. This study collected 306 Taiwanese police officers as research subjects. We used confirmatory factor analysis and SEM for hypothesis testing. The study found that perceived formalism positively affects the job burnout and job stress of police officers. Job stress, fear of COVID-19, and job burnout positively affect PTSD and insomnia.

Duty-related trauma and PTSD symptoms in US urban firefighters

BACKGROUND

Little is known about the multi-dimensional nature of traumatic duty-related events encountered by firefighters in relation to their post-traumatic stress disorder (PTSD) risk.

AIMS

To describe the types of duty-related events encountered by career firefighters and explore if years in the fire service or total event load moderated the association of trauma exposure to PTSD symptoms.

METHODS

Participants included 755 career, male firefighters (19% of the department's firefighters and 76% of those who accessed the electronic anonymous survey). The Duty-Related Incident Stressors scale was used to assess exposure to 25 potentially traumatic events (event load) and self-appraisal of the stress associated with these events, grouped by type of event (indirect, direct and colleague-related). The Post-Traumatic Stress Disorder Checklist was used to assess PTSD symptoms.

RESULTS

Firefighters rated colleague-related events as the most stressful, followed by indirect and direct events. Event load (r = 0.25) and indirect, direct and colleague-related events stress (r = 0.32-0.35) were positively associated with PTSD symptoms. Results of moderation analyses indicated that event load served as a risk factor in the relation of indirect events stress to PTSD symptoms, and as a buffer in the relation of direct events stress to PTSD symptoms. Years in the fire service were not associated with PTSD symptoms nor moderated the relation of event stress to PTSD symptoms.

CONCLUSIONS

Findings underscored the importance of considering the differential effects that types of duty-related traumatic events and cumulative exposure to trauma may have on firefighters' PTSD symptoms.

A mild stressor induces short-term anxiety and long-term phenotypic changes in trauma-related behavior in female rats

Introduction

Anxiety and anxiety-influenced disorders are sexually dimorphic with women being disproportionately affected compared to men. Given the increased prevalence in women and the documented differences in anxiety and trauma behavior between male and female rats this paper sought to examine the link between stress, anxiety, and fear learning and extinction in female rats. We tested the hypothesis that a mild stressor will induce short-and long-term increases in anxiety and produce long term effects on subsequent fear learning and extinction behavior.

Methods

We induced anxiety in female Sprague- Dawley rats with a short (3 min) exposure to a ball of cat hair infused with 150 μl of cat urine (mild stressor) that elicits innate fear but does not cause fear conditioning. The control group was exposed to fake cat hair. Anxiety was assessed in the Light-Dark Open Field (LDOF) or Elevated Plus Maze (EPM) before, immediately after and 4 days after stimulus exposure. Two weeks later, all animals were subject to Contextual Fear Conditioning (CFC) in the Shock Arm of a Y-maze, blocked off from the rest of the maze. Memory and fear extinction (learning of safety) was assessed in the following four days by placing each rat in one of the Safe Arms and measuring avoidance extinction (time spent and number of entries in the Shock Arm).

Results

Cat hair exposure induced changes in anxiety-like behavior in the short-term that appeared resolved 4 days later. However, the cat-hair exposed rats had long-term (2 weeks) phenotypic changes expressed as altered exploratory behavior in an emotionally neutral novel place. Fear learning and extinction were not impaired. Yet, using avoidance extinction, we demonstrated that the phenotypic difference induced by the mild stressor could be documented and dissociated from learning and memory.

Discussion

These findings demonstrate that the history of stress, even mild stress, has subtle long-term effects on behavior even when short-term anxiety appears resolved.

The mental health impact of the COVID-19 pandemic and exposure to other potentially traumatic events up to old age

We investigated whether the impact of potentially traumatic events (PTEs) on trauma-related symptoms changes across the transitional adult lifespan (i.e., 16-100 years old) and if this association differs for self-reported COVID-19-related PTEs compared to other PTEs. A web-based cross-sectional study was conducted among 7,034 participants from 88 countries between late April and October 2020. Participants completed the Global Psychotrauma Screen (GPS), a self-report questionnaire assessing trauma-related symptoms. Data were analyzed using linear and logistic regression analyses and general linear models. We found that older age was associated with lower GPS total symptom scores, B = -0.02, p < .001; this association remained significant but was substantially weaker for self-reported COVID-19-related PTEs compared to other PTEs, B = 0.02, p = .009. The results suggest an association between older age and lower ratings of trauma-related symptoms on the GPS, indicating a blunted symptom presentation. This age-related trend was smaller for self-reported COVID-19-related PTEs compared to other PTEs, reflecting the relatively higher impact of the COVID-19 pandemic on older adults.

Appraisals of Social Trauma and Their Role in the Development of Post-Traumatic Stress Disorder and Social Anxiety Disorder

Cognitive theories of post-traumatic stress disorder (PTSD) feature appraisal of trauma as a critical factor in the development and maintenance of the disorder. Here we explored appraisals of social trauma (severe rejection or humiliation). Participants were outpatients with social anxiety disorder (SAD) and clinically significant PTSD symptoms (PTSS) after social trauma (n = 15); two clinical control groups of either SAD (n = 32) or obsessive-compulsive disorder (OCD; n = 13); and a control group with no diagnoses (n = 38). Measures included a clinical interview to assess social trauma and related open-ended appraisals and the Posttraumatic Cognitions Inventory (PTCI). Raters blind to group assignment performed content analyses of appraisals. Results showed that the PTSS group scored significantly higher than either clinical group on the PTCI SELF subscale. Only the SELF subscale predicted a diagnosis of both PTSS and SAD. All but one PTSS participant reported primarily negative beliefs about their social trauma, and the most common categories were flawed self and others are critical or cruel. Post-traumatic appraisals implicated in the course of PTSD are significant in how individuals respond to social trauma, with negative self-cognitions linked to both PTSS and SAD.

Trauma Exposure and Suicidal Ideation among Korean Male Firefighters: Examining the Moderating Roles of Organizational Climate

Background

This study investigated the relationship between trauma exposure and suicidal ideation. Moreover, this study examines the moderating roles of organizational climate on the association between trauma exposure and suicidal ideation in Korean male firefighters.

Methods

A total of 15,104 male firefighters who completed a questionnaire were analyzed. The data were obtained using an online self-administered questionnaire from the Firefighter Research on Enhancement of Safety and Health Study. Poisson regression analysis was performed to determine the effects of trauma exposure on suicidal ideation and the moderating effect of organizational climate.

Results

The results showed that 389 firefighters (2.6%) responded that they had experienced suicidal ideation. In the final model, trauma exposure was positively related to suicidal ideation (adjusted risk ratio [aRR], 1.076; 95% confidence interval [CI]: 1.051-1.103), and organizational climate was negatively associated with suicidal ideation (aRR, 0.772; 95% CI: 0.739-0.806). Additionally, the interaction term (trauma exposure × organizational climate) was related to suicidal ideation (aRR, 1.016; 95% CI: 1.009-1.023).

Conclusions

This study suggests that trauma exposure might play a significant role in developing suicidal ideation and that positive organizational climate moderates the negative effects of trauma exposure on suicidal ideation among firefighters. It is necessary to perform a follow-up study of various intervention strategies to maintain a healthy organizational climate or work environment. Such interventions should promote lasting trust within teams, provide social support and belonging, and nurture job value.

Investigation of Psychological Stress and Sleep Quality of Emergency Medical Technicians in Taiwan Fire Department during the COVID-19 Pandemic

When the coronavirus disease 2019 (COVID-19) began to ravage the world in 2019, the World Health Organization became concerned. The epidemic has a high mortality and contagion rate, with severe health and psychological impacts on frontline emergency medical service system practitioners. There are many hospital staff surveys, but few have covered the stress among emergency medical technicians. DASS-21, PSQI, and AUDIT questionnaires were used to evaluate the sources of psychological stress factors of firefighters in Taiwan. Multiple logistic regression was used to analyze the questionnaire content. We conducted questionnaire surveys from May 2022 to July 2022. Our sample comprised 688 participants. The odds ratios of increased depression, anxiety, and stress levels due to reduced family or peer understanding and support were 2.72 (95% CI: 1.50−4.92), p = 0.001; 2.03 (95% CI: 1.11−3.68), p = 0.021; and 3.27 (95% CI: 1.83−5.86), p < 0.001, respectively. The odds ratios of poor sleep quality due to depression, anxiety, and increased stress levels were 5.04 (3.18−7.99), p < 0.001; 2.44 (95% CI: 1.57−3.81), p < 0.001; and 4.34 (95% CI: 2.76−6.82), p-value < 0.001, respectively. During the COVID-19 pandemic, poor sleep quality and a lack of understanding and support from the Taiwan firefighting agency staff, family, or peers resulted in increased depression, anxiety, and stress levels.

Perceived health, adversity, and posttraumatic stress disorder in Syrian and Iraqi refugees

BACKGROUND

Exposure to armed conflict and fleeing country of origin for refugees has been associated with poorer psychological health.

METHODS

Within the first month following their arrival in the United States, 152 Syrian and Iraqi refugees were screened in a primary care setting for posttraumatic stress disorder (PTSD), anxiety, and depression and rated their perceived health, and perceived level of adversity of violence, armed conflict/flight. The moderating effects of psychiatric symptoms on the relation between perceived adversity and perceived health were assessed.

RESULTS

Three models based on diagnosis (PTSD, anxiety, and depression) were tested. While significant effects were found on perceived adversity negatively influencing perceived health across diagnoses, slightly different patterns emerged based on diagnosis.

DISCUSSION

Findings suggest that refugees' perception regarding adversity of violence, armed conflict, and flight may contribute to perceived health, with a moderating role of clinically significant symptoms of PTSD, anxiety, and depression.

Predictors of Mental Health among the General Population of U.S. Adults Eight Months into the COVID-19 Pandemic

Background:

The COVID-19 pandemic has had profound impacts on mental health. We examined whether mental health differed based on sociodemographic and background characteristics, political party affiliation, and concerns about COVID-19.

Methods:

A cross-sectional, national sample of 1095 U.S. adults were surveyed October 22–26, 2020. The survey collected information on demographics, risk and protective behaviors for COVID-19, and mental health using the Mental Health Inventory-5 (MHI-5) scale. Independent samples t-tests, one-way Analysis of Variance tests, and a multivariable linear regression model were conducted.

Results:

Regression results showed respondents with criminal justice (B = −6.56, 95% CI = −10.05, −3.06) or opioid misuse (B = −9.98, 95% CI = −14.74, −5.23) histories reported poorer mental health than those without. Those who took protective behaviors (e.g., wearing masks) reported poorer mental health compared to those who indicated protective behaviors were unnecessary (B = 7.00, 95% CI = 1.61, 12.38) while those who took at least one risk behavior (e.g., eating in a restaurant) reported better mental health than those who did not.

Conclusions:

Our study shows that certain groups have experienced poorer mental health during the COVID-19 pandemic, suggesting that mental health should continue to be monitored so that public health interventions and messaging help prevent the spread of COVID-19 without increasing poor mental health outcomes.

Psychological distress and alcohol use disorder during the COVID-19 era among middle- and low-income U.S. adults

PURPOSE

This study examined how exposure to events during the Coronavirus Disease-19 (COVID-19) era is linked to symptoms of major depressive disorder (MDD), generalized anxiety disorder (GAD), COVID-19 era-related stress (CS), alcohol use disorder (AUD), and suicidal ideation (SI) in low and middle-income U.S adults.

METHODS

A national sample of 6,607 adults (4.4% who reported testing positive for COVID-19, 25.3% testing negative, and 70.3% untested) were recruited an online platform andcompleted the Patient Health Questionnaire-2, Generalized Anxiety Disorder-2, PTSD-Checklist for DSM-5, the Alcohol Use Disorder Identification-Consumption scale, and an item assessing SI in May-June 2020. A series of multivariable analyses were conducted.

RESULTS

In the total sample, 35.3% screened positive for current AUD, 33.6% for MDD, 33.6% for GAD, 24.6% for SI, and 20.2% for CS. Past 2-week SI (adjusted odds ratios [AORs]= 1.49-12.06), number of close friends (AORs= 1.40-2.72), history of AUD (AORs= 1.15-1.92), history of anxiety disorder (AORs= 1.07-2.63), and younger age (AORs= 0.97-0.98) were significantly associated with screening positive for MDD, GAD, CS, and AUD. COVID-19 status was not independently associated with these conditions, but the combination of testing positive for COVID-19, meeting criteria for AUD, and screening positive for MDD, GAD, or CS predicted a 96% probability for SI.

CONCLUSION

Predisposing factors are stronger predictors of psychological distress than personal COVID-19 infection or exposure. The additive effects of COVID-19 infection, alcohol use, and psychiatric problems in predicting SI suggest screening, monitoring, and treating these conditions in population-based prevention and treatment efforts may be important.

Measuring Trauma Exposure: Count Versus Variety of Potentially Traumatic Events in a Binational Sample

Traumatic event checklists typically ask respondents to indicate whether they have experienced particular types of potentially traumatic events (PTEs) and then sum these endorsements to gauge cumulative trauma exposure. However, the sum of these endorsements indicates the variety of PTEs respondents have experienced rather than the count of exposure events. The main objective of the present study was to explore the association between PTE count and variety to examine assumptions regarding the use of traumatic event checklists to measure cumulative trauma exposure. The limited empirical research suggests that count and variety are strongly associated; however, there may be variation in magnitude concerning whether participants' environments confer an increased or decreased risk of exposure. We present Life Event Checklist data from a large sample of Mexican and U.S. participants (n = 1,820), which allowed us to compare reports of count and variety. Count and variety were strongly correlated, Kendall's tau-b = .74, such that count accounted for 54.6% of the variance in variety. A negative binomial regression analysis revealed that this association was moderated by county and municipio homicide rate, used as a proxy for violent crime, but not by natural disaster history. Variety was more strongly associated with scores on the Posttraumatic Stress Checklist for DSM-5, Kendall's tau-b = .26, than was PTE count, Kendall's tau-b = .22, Fisher's z = -8.04, p < .001. Although there are challenges in estimating PTE counts, the present findings suggest that PTE variety is not a good proxy for cumulative trauma exposure.

Buffering PTSD in Canine Search and Rescue Teams? Associations with Resilience, Sense of Coherence, and Societal Acknowledgment

Rescue workers present an elevated risk for posttraumatic stress disorder (PTSD) and recently, research has begun to focus on coping styles and social support as protective factors in this population. Associations in the particular group of search and rescue dog handlers still lack evidence. The aim of the study is to investigate if functional cognitions and social support also decrease the risk for PTSD. Active voluntary rescue dog handlers (n = 116) rated levels of resilience, sense of coherence, and social acknowledgment (SAQ; subscales general disapproval, familial disapproval, recognition), in addition to a trauma checklist and PTSD symptoms. Linear regression analyses and two different graph models were calculated to explore associations, as well as potential pathways. Controlling for trauma exposure, the SAQ general disapproval emerged as the only significant predictor in the regression model. In the graph models, SAQ familial disapproval was linked to SAQ recognition and SAQ general disapproval. The latter, together with a sense of coherence manageability, affected PTSD re-experiencing symptoms through resilience. The findings are in line with earlier work. The study underlines the importance of targeting resilience and manageability, as well as enhancing social support in prevention programs for PTSD in canine search and rescue teams. Future research is warranted to further investigate model stability and replicate findings.

Characterizing Objective and Self-Reported Levels of Physical Activity Among Florida Firefighters Across Weight Status Category: A Cross-Sectional Pilot Study

Background: Firefighters suffer from a disproportionally high burden of chronic diseases that could be prevented from regular bouts of physical activity (PA). The goal(s) of this pilot study were to (a) describe typical PA levels in professional paid firefighters, and (b) assess their ability to estimate their own levels of PA. Methods: A repeated measures study design was used to assess self-reported and objectively measured levels of PA from a non-probabilistic sample of firefighters (n = 18) over 1 week. Objective measures of PA, measured by accelerometry were defined as the number of minutes spent in sedentary, light, moderate, and vigorous PA. Firefighters completed a follow-up questionnaire recording their self-reported levels of PA. Results: Obese (body mass index [BMI] > 30 kg/m²) firefighters spent 8,033 ± 2,543 minutes/week in sedentary activity, overweight (BMI = 25-29 kg/m²) firefighters 6,533 ± 1,587 minutes/week, and healthy weight (BMI = 18.5-24.9 kg/m²) firefighters 5,846 ± 1,160 minutes/week. The difference in self-reported weekly minutes spent in light, moderate, and vigorous activity and objectively measured minutes in activity was calculated. Healthy weight firefighters reported the least difference (1,924 minutes/week), followed by the overweight (3,884 minutes/week) and obese (5,749 minutes/week). Conclusion/Application to Practice: Firefighters poorly estimated their true level of PA compared with their objectively measured PA and obese firefighters reported the greatest inconsistency. Occupational health nurses should aim to support firefighters in achieving PA levels that assist firefighters to achieve a healthy weight and educate them about what it means to be engaged in each level of PA.

Mental Disorders in Firefighters Following Large-Scale Disaster

Firefighting service is known to involve high rates of exposure to potentially traumatic situations, and research on mental health in firefighting populations is of critical importance in understanding the impact of occupational exposure. To date, the literature concerning prevalence of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) has not distinguished between symptomology associated routine duty-related exposure and exposure to large-scale disaster. The present systematic review synthesizes a heterogeneous cross-national literature on large-scale disaster exposure in firefighters and provides support for the hypothesis that the prevalence of PTSD, major depressive disorder, and anxiety disorders are elevated in firefighters compared with rates observed in the general population. In addition, we conducted narrative synthesis concerning several commonly assessed predictive factors for disorder and found that sociodemographic factors appear to bear a weak relationship to mental disorder, while incident-related factors, such as severity and duration of disaster exposure, bear a stronger and more consistent relationship to the development of PTSD and depression in cross-national samples. Future work should expand on these preliminary findings to better understand the impact of disaster exposure in firefighting personnel.

Heart Rate Variability and Accelerometry as Classification Tools for Monitoring Perceived Stress Levels-A Pilot Study on Firefighters

Chronic stress is the main cause of health problems in high-risk jobs. Wearable sensors can become an ecologically valid method of stress level assessment in real-life applications. We sought to determine a non-invasive technique for objective stress monitoring. Data were collected from firefighters during 24-h shifts using sensor belts equipped with a dry-lead electrocardiograph (ECG) and a three-axial accelerometer. Levels of stress experienced during fire incidents were evaluated via a brief self-assessment questionnaire. Types of physical activity were distinguished basing on accelerometer readings, and heart rate variability (HRV) time series were segmented accordingly into corresponding fragments. Those segments were classified as stress/no-stress conditions. Receiver Operating Characteristic (ROC) analysis showed true positive classification as stress condition for 15% of incidents (while maintaining almost zero False Positive Rate), which parallels the amount of truly stressful incidents reported in the questionnaires. These results show a firm correspondence between the perceived stress level and physiological data. Psychophysiological measurements are reliable indicators of stress even in ecological settings and appear promising for chronic stress monitoring in high-risk jobs, such as firefighting.

Social trauma and its association with posttraumatic stress disorder and social anxiety disorder

The key characteristic of a traumatic event as defined by the Diagnostic and Mental Manual of Mental Disorders (DSM) seems to be a threat to life. However, evidence suggests that other types of threats may play a role in the development of PTSD and other disorders such as social anxiety disorder (SAD). One such threat is social trauma, which involves humiliation and rejection in social situations. In this study, we explored whether there were differences in the frequency, type and severity of social trauma endured by individuals with a primary diagnosis of SAD (n = 60) compared to a clinical control group of individuals with a primary diagnosis of obsessive compulsive disorder (OCD, n = 19) and a control group of individuals with no psychiatric disorders (n = 60). The results showed that most participants in this study had experienced social trauma. There were no clear differences in the types of experiences between the groups. However, one third of participants in the SAD group (but none in the other groups) met criteria for PTSD or suffered from clinically significant PTSD symptoms in response to their most significant social trauma. This group of SAD patients described more severe social trauma than other participants. This line of research could have implications for theoretical models of both PTSD and SAD, and for the treatment of individuals with SAD suffering from PTSD after social trauma.

A Relational Model for Stress: A Systematic Review of the Risk and Protective Factors for Stress-Related Diseases in Firefighters

Firefighters are considered a high-risk group for the development of PTSD and other stress-related diseases. More than the exposure to potentially traumatic events, personal and occupational characteristics have been pointed out as interfering in the perception of stress, which may lead to the emergence of mental and physical symptoms. This study aimed to analyze the relationship between the main factors that contribute to stress-related diseases in firefighters. A systematic review was conducted in order to identify original articles focusing on risk and protective factors for stress in this population. Personality traits, training, experience in extreme situations and social and organizational support influence the perception of stress and, consequently, the choice of coping strategies, which may protect against or potentiate the stress reactions. The findings of this study allow us to draw a relational model that represents the dynamics among the factors related to stress in firefighters. The development of PTSD and other stress-related diseases depends on a host of pre-trauma and post-trauma factors and, although training is an important protective factor, being prepared to face extreme situations does not mean being immune to traumatic stress.

Modeling Patterns of Polyvictimiztion and Their Associations with Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the Israeli Population

Although evidence is accumulating for the conceptual validity of the ICD-11 proposal for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD), our understanding of the specificity of trauma-related predictors is still evolving. Specifically, studies utilizing advanced statistical methods to model the association between trauma exposure and ICD-11 proposals of traumatic stress and differences in profiles of trauma exposure are lacking. Additionally, time since trauma and a clear memory of the trauma are yet to be examined as predictors of PTSD and CPTSD. We analyzed trauma exposure as reported by a general population sample of Israeli adults (N = 834), using latent class analysis, and the resultant classes were used in regression models to predict PTSD and CPTSD operationalized both dimensionally and categorically. Four distinct groups were identified: child and adult interpersonal victimization, community victimization-male, community victimization-female, and adult victimization. These groups were differentially related to PTSD and CPTSD, with only child and adult interpersonal victimization consistently predicting CPTSD and disturbances in self-organization. When modeled dimensionally, PTSD was associated with the child and adult interpersonal victimization and adult victimization groups, whereas only the child and adult interpersonal victimization group was predictive of PTSD when operationalized categorically. The roles of time since trauma and a clear memory of the trauma differed across PTSD and CPTSD. These findings support the use of trauma typologies for predicting PTSD and CPTSD and provide important insight into the distribution of trauma exposure in the Israeli population.

Two-month point prevalence of exposure to critical incidents in firefighters in a single fire service

BACKGROUND

Firefighters have high rates of exposures to critical events that contribute to physical and mental stress, resulting in high rates of injury and work-injury compensation claims.

OBJECTIVE

To determine the prevalence of critical incidents in firefighters from a single fire service, and whether the number of critical events varied based on age, gender, years of service and/or rank.

METHODS

We recruited 300 full-time firefighters. Firefighters were asked to complete a self-report Critical Incident Inventory survey that included questions on exposure to critical events during firefighting duties, with a time reference point of the past two months.

RESULTS

Among the 293 firefighters, 252 (85%) indicated exposure to some type of critical incident. More specifically, 187 (64%) reported a respond to incident involving one or two deaths, 155 (53%) indicated a direct exposure to blood and body fluids, and 98 (33%) reported a response to an incident involving multiple serious injuries. Age, gender, years of service and rank accounted for only 1% of the variance in the number of critical incidents among firefighters.

CONCLUSIONS

In this study, 85% of firefighters had been exposed to some type of critical incident in the previous 2-months and this did not vary by age, gender, years of service and/or rank.

Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues

First responders are regularly confronted with exposure to traumatic events, including potentially life-threatening situations as well as the grave injuries and deaths of colleagues and civilians. Evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is substantially higher among first responders than the general population. This article provides information about the outpatient trauma services at McLean Hospital's LEADER (Law Enforcement, Active Duty, Emergency Responder) program to assist clinicians who encounter these first responders in their practices or who are specifically interested in working with this patient population. We begin by synthesizing the literature on the prevalence of PTSD in first responders following work-related exposure to traumatic stress, and by addressing the occupation-specific risk factors and the third-variable risk factors that may contribute to potentiated risk. We then discuss assessment strategies and treatment options used in our program, which is tailored for individuals who are dealing with mental health issues stemming from occupation-specific traumatic-stress exposure. We also address the unique challenges of treating traumatized first responders with more complex issues such as traumatic stress exposure across the lifespan and safety issues, including acute suicidality. We conclude by discussing notable gaps in the literature, including the need to investigate why and how women present with different PTSD symptoms than men and how these differences need to be taken into account in determining appropriate treatment for women.

PTSD Symptoms, Vicarious Traumatization, and Burnout in Front Line Workers in the Homeless Sector

Work with clients who have trauma-related problems is reported to lead to a constellation of reactions including vicarious traumatization, compassion fatigue, and burnout. Traumatic experiences are ubiquitous in the lives of homeless people, stemming from multiple life events prior to, and as a result of, experiencing homelessness. While most studies examine either burnout and vicarious traumatization or potential PTSD in people who work with those who are traumatized, they generally do not look at the possible co-existence of all three factors. They also do not explore if these factors indicate the extent to which burnout or vicarious traumatization may lead to PTSD symptoms or that the existence of PTSD symptoms may precipitate greater rates of burnout. In addition, there are no existing studies that provide a quantitative view of the characteristics of frontline workers in homeless services. In this study, we surveyed 472 individuals who work in frontline positions in homeless shelters in 23 different organizations. We found rates of burnout, vicarious traumatization and compassion satisfaction, comparable to workers in other social services organizations but found rates of PTSD symptoms to be at 33% of the total population. This higher incidence of PTSD symptoms suggests that workers under-report traumatic stress when it is described as vicarious traumatization, that they specifically attribute this to client contact, and that vicarious traumatization is traumatic stress specifically attributed to job-related events.

The impact of trauma exposure on the development of PTSD and psychological distress in a volunteer fire service

Emergency service workers (ESWs) are at increased risk of trauma-related mental disorders. However, volunteer ESWs, who comprise the majority of firefighters in Western countries, have limited access to the necessary support services for mental health problems. This study aimed to examine the impact of the level and types of trauma exposure on the development of mental disorders in a volunteer fire service. Members of an Australian volunteer fire service (N = 459) completed a cross-sectional survey. Information on the number and types of distressing critical incidents involved within the last year was collected. Validated, self-report measures were used to determine probable post-traumatic stress disorder (PTSD) and psychological distress caseness. The risk of probable PTSD was significantly higher for those with the most frequent involvement with distressing incidents and the highest levels of cumulative trauma exposure. Being trapped in a dangerous situation or being assaulted by other people, resulted in the greatest odds of developing a mental disorder. Volunteer fire service members with the highest levels of trauma exposure and involvement with particular types of critical incidents are at elevated risk of mental health problems. The implications for the provision of psychological support measures amongst volunteer emergency services are discussed.

Personality characteristics and individual factors associated with PTSD in firefighters one month after extended wildfires

BACKGROUND

Firefighters participate in activities with intense physical and psychological stress and are constantly at risk to develop various psychopathological reactions.

AIMS

To investigate psychological reactions in firefighters one month after devastating wildfires in Greece, during August 2007, which lead to the devastation of large areas and the death of 43 people among whom three were firefighters.

METHODS

One month after the wildfires, a joint task force of mental health clinicians was organized in order to provide psychological support and to investigate the psychological consequences of wildfires to firefighters. One hundred and two firefighters, living within the fire-devastated area, who were on duty for the whole period of wildfires were interviewed and assessed with the use of several questionnaires and inventories.

RESULTS

Post-traumatic stress disorder (PTSD) was detected in 18.6% of firefighters. Multiple logistic regression found that existence of fear of dying during firefighting, insomnia and increased scores in neuroticism, as well as in depression subscale of the SCL-90, were significantly associated with greater likelihood for having PTSD. Additionally those firefighters who worked permanently had 70% lower probability of having PTSD vs. those seasonally employed.

CONCLUSIONS

Insomnia, depressive symptoms, as well as personality characteristics as neuroticism and the perception of fear of imminent death during firefighting operations may precipitate the development of PTSD in firefighters. Within this context, mental health clinicians should be aware that the early detection of these predisposing factors may facilitate the prevention and mitigation of PTSD in firefighters particularly those who are seasonally employed.

The influences of cognitive appraisal, physical injury, coping strategy, and forgiveness of others on PTSD symptoms in traffic accidents using hierarchical linear modeling

The purpose of this study was to identify how physical injury, perceived threat, forgiveness of others, and problem-focused coping influence the change of posttraumatic stress disorder (PTSD) symptoms. One hundred twenty patients who had experienced a traumatic vehicle accident participated in 1 to 2 months after the accident; 70 of these people involved at 6 months after the accident. We used a hierarchical linear model analysis to verify the impacts of predictors on change of PTSD symptoms as time passed. The results showed that PTSD symptoms decreased over time, and greater perceived threat would worsen PTSD symptoms and more forgiveness would decrease PTSD symptoms. On the other hand problem-focused coping and physical injury severity were not significantly related to the PTSD symptoms. Specifically, greater perceived threat was found to be related with a deceleration of the decrease in PTSD symptoms, whereas greater forgiveness of others was associated with an acceleration of this decrease. However, problem-focused coping and physical injury severity had no influence on the change rate of PTSD symptoms. Cognitive variable could be more important than physical injury to understand PTSD. In addition, forgiveness of other in a traumatic situation needs to be considered as one of coping strategies.

Sense of Threat as a Mediator of Peritraumatic Stress Symptom Development During Wartime: An Experience Sampling Study

Exposure and sense of threat have been associated with stress symptoms, yet these relationships have not been clarified during the peritraumatic period. We investigated the mediating role of sense of threat in the link between exposure to rocket warning sirens and stress symptoms during wartime, and the effect of severe mental illness (SMI) status and gender on this mediation. A 30-day twice-daily smartphone-based intensive assessment of exposure to sirens, sense of threat, and peritraumatic stress symptoms was performed during the 2014 Israel-Gaza conflict. Participants included 182 highly exposed individuals with or without SMI. Multilevel structural equation modeling analysis was performed, with SMI status and gender as confounders. Exposure affected the level of peritraumatic stress symptoms both directly, b = 1.07, p < .001, 95% CI [0.32, 1.82], and indirectly, b = 0.78, p < .001, 95% CI [0.24, 1.33], through sense of threat. The effect of sense of threat on stress symptoms was larger in the SMI group, b = 0.86, p < .001, 95% CI [0.31, 1.40]. Gender did not have a significant effect. Sense of threat has a key role in symptom development during the peritraumatic timeframe. Intervention and prevention efforts should start early and focus on promoting a sense of safety, particularly with people with SMI.

Duty-Related Trauma Exposure and Posttraumatic Stress Symptoms in Professional Firefighters

Firefighters commonly encounter traumatic events during duty hours. The purpose of this study was to investigate the characteristics of duty-related trauma as risk factors for posttraumatic stress disorder in professional firefighters. A sample of 212 firefighters participated in the study and completed self-reported questionnaires. Potentially traumatic events (PTE) were assessed using a list of 17 traumatic event types. The posttraumatic stress symptoms (PTSS) were measured by the Impact of Event Scale-Revised (Lim et al., 2009; Weiss, 2007). A higher score for the composite index, which reflects both multiple PTE and peritraumatic suffering, increased the odds for significant PTSS after adjusting for age, sex, marital status, education, numbers of years worked, childhood trauma, and depressive symptoms (adjusted odds ratio [AOR] = 2.26, p = .001, Cohen's d = 0.20). Furthermore, indirect (AOR = 1.93, p = .009, Cohen's d = .16) and colleague-related PTE (AOR = 1.97, p = .037, Cohen's d = .16) showed significant associations with PTSS. It is noteworthy that the combination of multiple PTE and peritraumatic suffering was more predictive of PTSS than either factor alone. Our findings also suggest that daily work exposure to indirect PTE may contribute to the occurrence of PTSS among professional firefighters.

Correlates of suicidality in firefighter/EMS personnel

BACKGROUND

Firefighter and Emergency Medical Services (EMS) personnel experience higher rates of lifetime suicidal ideation and attempts than the general population and other protective service professions. Several correlates of suicidality (alcohol use, depression, posttraumatic stress) have been identified in the literature as applicable to firefighter/EMS populations; however, few studies to date have examined the specific correlates of suicidality (lifetime suicidal ideation and/or attempts) in a firefighter/EMS sample.

METHODS

Participants (N=3036) from a large, urban fire department completed demographic and self-report measures of alcohol dependence, depression, posttraumatic stress disorder (PTSD) symptom severity, and lifetime suicidal ideation and attempts. Participants in this sample performed both firefighter and EMS duties, were predominately male (97%), White (61.6%), and 25-34 years old (32.1%).

RESULTS

Through hierarchical linear regressions, depression (β=.22, p<.05) and PTSD symptom severity (β=.21, p<.05) were significantly associated with lifetime suicidal ideation (R² =17.5). Depression (β=.15, p<.001), and PTSD symptom severity (β=.07, p<.01) were significantly associated with lifetime suicide attempts (R²=5.1).

LIMITATIONS

Several limitations are addressed in the current study. The survey was a self-report pre-existing dataset and lifetime suicidal ideation and attempts were measured using sum scores. Additionally, the disproportionately large sample of males and large, urban setting, may not generalize to female firefighters and members of rural community fire departments.

CONCLUSIONS

The current study highlights the importance of targeting depression and PTSD symptom severity in efforts to reduce suicidality in firefighter/EMS personnel.

Exploring Reliability and Validity of the Deployment Risk and Resilience Inventory-2 Among a Nonclinical Sample of Discharged Soldiers Following Mandatory Military Service

The Deployment Risk and Resilience Inventory (DRRI) is a widely used questionnaire assessing deployment-related risk and resilience factors among war veterans. Its successor, the DRRI-2, has only been validated and used among veterans deployed for overseas military missions, but because many countries still enforce compulsory military service, validating it among nonclinical samples of healthy discharged soldiers following mandatory service is also a necessity. In the current study, a sample of 101 discharged Israeli soldiers (39 males, 62 females; mean time since discharge 13.92, SD = 9.09 years) completed the DRRI-2. There were 52 participants who completed the questionnaire at a second time point (mean time between assessments 19.02, SD = 6.21 days). Both physical and mental health status were examined, as well as symptomatology of depression, anxiety, and posttraumatic stress disorder. Cronbach's αs for all latent variables in the inventory ranged from .47 to .95. The DRRI-2 risk factors were negatively associated with psychological functioning, whereas resilience factors were positively associated with better self-reported mental health. Test-retest reliability coefficients were generally high (Pearson correlations were .61 to .94, all p values < .01). Our study provides evidence for the reliability and validity of the DRRI-2 in assessing salient deployment experiences among a nonclinical sample following mandatory military service.

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: results of a longitudinal study

BACKGROUND

A significant proportion of trauma survivors experience an additional critical life event in the aftermath. These renewed experiences of traumatic and stressful life events may lead to an increase in trauma-related mental health symptoms.

METHOD

In a longitudinal study, the effects of renewed experiences of a trauma or stressful life event were examined. For this purpose, refugees seeking asylum in Germany were assessed for posttraumatic stress symptoms (PTS), Posttraumatic Stress Diagnostic Scale (PDS), anxiety, and depression (Hopkins Symptom Checklist [HSCL-25]) before treatment start as well as after 6 and 12 months during treatment (N=46). Stressful life events and traumatic events were recorded monthly. If a new event happened, PDS and HSCL were additionally assessed directly afterwards. Mann-Whitney U-tests were performed to calculate the differences between the group that experienced an additional critical event (stressful vs. trauma) during treatment (n=23) and the group that did not (n=23), as well as differences within the critical event group between the stressful life event group (n=13) and the trauma group (n=10).

RESULTS

Refugees improved significantly during the 12-month period of our study, but remained severely distressed. In a comparison of refugees with a new stressful life event or trauma, significant increases in PTS, anxiety, and depressive symptoms were found directly after the experience, compared to the group without a renewed event during the 12 months of treatment. With regard to the different critical life events (stressful vs. trauma), no significant differences were found regarding overall PTS, anxiety, and depression symptoms. Only avoidance symptoms increased significantly in the group experiencing a stressful life event.

CONCLUSION

Although all clinicians should be aware of possible PTS symptom reactivation, especially those working with refugees and asylum seekers, who often experience new critical life events, should understand symptom fluctuation and address it in treatment.