by DAVID WIKLANSKI
Among the early references TO what we now call post-traumatic stress disorder (PTSD) was that described by Herodotus in 440 B.C. He reported that Epizelus was stricken with blindness in the Battle of Marathon that continued throughout his life although there was no apparent physical reason to explain it. The primary factors in the loss of his vision were said to be the fright he experienced and witnessing his friend’s death. PTSD has been observed over the centuries among soldiers in battle and individuals who have experienced traumatic events-natural disasters, horrific accidents, or other tragedies. The term PTSD arose out of research on Vietnam War veterans, Holocaust survivors, and other trauma victims; it first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980).
The DSM-5 (2013) uses some of the following diagnostic criteria for PTSD. However, do not use this list to self-diagnose. If you feel that you may have PTSD, please contact a mental health clinician for appropriate screening.1
- Exposure. The person’s possible exposure to actual or threatened death, serious injury, or sexual violence through direct experience or witnessing or through learning about such an event occurring to a family member or a close friend. Another cause could be repetitive exposure because of one’s occupation-e.g., dealing with fire victims, technical rescue assignments, motor vehicle fatalities, pediatric cardiac arrest, violence (shootings, stabbings), and so forth.
- Intrusion symptoms. Memories, dreams, flashbacks, distress triggered by internal/external cues, and marked physiological reactions-e.g., heart racing or rapid breathing.
- Avoidance areas. Memories, thoughts, feelings, people, places, objects, and situations that cause distress.
- Negative moods or thoughts. Inability to remember an important detail of the event, negative beliefs about oneself or blaming oneself, a negative emotional state, a loss of interest in previously enjoyable activities, a feeling of detachment, or an inability to be positive.
- Sudden changes in arousal or reactivity. Angry outbursts without provocation, self-destructive behavior, increased vigilance, an increased startle response, an inability to concentrate, and sleep disturbances.
- The length of time that the symptoms are present. In this assessment, the amount of time elapsed since the symptoms were first noticed.
Additional considerations are the following:
- Clinically significant distress in functioning. Changes in the person’s activities of daily living (ADLs)-e.g., getting up to go to work, showering, and eating habits-to a problematic degree.
- Outside causes such as drugs/alcohol, or other medical conditions. PTSD is not specifically the cause of the symptoms. Alcohol, drugs, or another medical issue (e.g., organic brain syndrome) may be involved. All other possible causes must be ruled out before coming up with a diagnosis.
The prevalence of PTSD in any group is not always precisely known. Prevalence is the proportion or percentage of a population that has a condition such as PTSD. Period prevalence is the proportion/percentage of a population that has the condition at some time during a given period (e.g., a 12-month prevalence) and includes people who already have the condition at the start of the study period and those who acquire it during that period. Lifetime prevalence is the proportion of a population that at some point in their lives (up to the time of assessment) have experienced the condition.
Determining prevalence depends on the assessment test cutoff score, the minimum score needed to indicate that an individual in the population assessed has PTSD. The problem for clinicians is that there is no accepted cutoff score across the board. Several completed studies reflect a wide variation in the scores and the inclusion rates. As such, to score what percentage of a population has PTSD, we would need to agree on a common score. An article by A. Terhakopian shows several variations with their corresponding inclusion and exclusion rates.2 In academia, 70 percent is considered a passing grade of C or average. Lowering the passing grade to 60 percent allows more of your participants to pass; the same applies with cutoff scores. The lower the score, the higher the number of subjects who will test positive for a particular disorder. The higher the score, the lower the number of subjects who will test positive.
The estimated lifetime prevalence rate of PTSD in the U.S. population is 6.8 percent3 with a 12-month prevalence rate of 3.5 percent.4 This is a baseline for the prevalence in the general population of the United States. It would be reasonable to expect first responders to have a higher level than the general population because of the types of incidents that we encounter regularly and the number of our responses to critical incidents.
What prevalence do we see in first responders? That’s not a simple answer. Depending on the nature of your employment-police, fire, emergency medical services (EMS)-and the types of work you do, the numbers vary widely. Although there is a large amount of research on police officers and PTSD, only limited research is available for fire and EMS personnel. According to the National Fire Protection Association’s Special Report on Firefighter Behavioral Health, as many as 37 percent of firefighters suffer from PTSD.5 Let that sink in for a moment, and if you are reading this in the firehouse around the kitchen table, look to your left, now look to your right, and realize that a member of your company will likely experience PTSD in his lifetime. According to one study, PTSD rates among emergency medical technicians (EMTs) are greater than 20 percent.6
Calling the Mayday
The fire service prides itself on taking care of our own. Most of our profession is built around a team concept. No matter what seems to be going on, there is always a fellow firefighter available to help out. Need help moving furniture? Call one of our brethren. Got spare tickets to a sporting event? Call one of our brethren. Need a ride home because your vehicle broke down? Call one of our brethren.
But why is it that when firefighters have a mental health problem and can’t handle it alone, we still try to keep it to ourselves? The answer lies in the culture of the fire service. We are problem solvers. Don’t know whom to call to fix a problem? Send the fire department; let the firefighters figure it out. But this works only with external problems. Emergency response, community relations, EMS, and technical rescue aren’t problems for us.
But when one of our own has a personal issue, who can that member call for help? Can that person turn to his fellow firefighters as he would for any other need? He should be able to, but the stigma attached to mental illness doesn’t allow firefighters to ask for that help.
We all know about the firehouse culture and mentality. Most of the jokes and the laughter come from breaking someone’s chops. Although it’s a great way to develop esprit de corps, does it allow members to feel that they can share their personal issues? Or do they feel that such a disclosure would expose them to ridicule and make them the big joke around the firehouse for the next month or so? This mindset forces firefighters to keep their emotions bottled up and to feel as though they can’t turn to their brethren for the support they need to get through their current crisis.
In most firehouses, asking for help is perceived as a weakness. On the fireground, when you call a Mayday, you know we will move mountains to come to rescue you. But if you have a mental health issue, you won’t call for help. That’s why we need a “Psychological Mayday” for anyone in need to call for help. It should be just as acceptable as calling a Mayday on the fireground. If we can’t turn to our fellow firefighters for support, to whom can we turn?
I can’t speak for your municipality, but where I work, we have a contract with an employee assistance program (EAP) to allow our employees and their immediate families to receive short-term counseling for any of the many issues that may occur in life, not just job-related issues. A major benefit of this program is the confidentiality of the sessions. Regardless of the nature of the discussion, the contents of that session are confidential. The few exceptions that apply are explained before the session begins. For example, if you are a danger to yourself or others, the EAP is legally required to disclose the pertinent information to the appropriate authorities. In this case, the exceptions don’t apply to fitness for duty as they only attach to being a danger to yourself or others. Your emotional state or mental health issues are not discussed with your superiors and are not part of your “permanent record.” These sessions will not be used in an evaluation of your fitness for duty, promotion, or assignment-they are isolated from the department as a whole. This confidentiality allows the EAP participant to speak freely, address the underlying issues causing the problems, and receive the support he needs from clinicians trained to listen and who have compassion.
“But these mental health counselors aren’t firefighters, so what do they know about the job?” I understand that. If your department contracts with an EAP that is specifically trained in handling emergency workers, great! If not, there are things we can do to foster a better working relationship with these counselors. If it is not against your directives, formally invite your EAP counselors to participate in a ride-along and have them spend time in the firehouse to get to know the members and, perhaps more importantly, allow the members to get to know them.
Another option is to invite the counselors to break bread with you; there are very few problems in the world that can’t be solved by a group of firefighters sitting around the kitchen table. By including the counselor, he will be able to get a more complete understanding of the overall fire department operations. Opening up to a complete stranger is difficult for most people, especially when it’s about a mental health issue. Having the EAP counselors in your quarters can serve as an ice breaker and allow you to put a face to a name prior to requesting professional services.
A great example of this occurred after Hurricane Katrina. The Louisiana State University Health Sciences Center had developed a working relationship with first responders prior to Katrina. After the storm hit, first responders ended up living on two large cruise ships. Clinicians were placed aboard the ships with the responders to provide front-line mental health assessments. Although this was a nontraditional work environment for the clinicians, it allowed for informal conversations with responders who could open up to the clinicians about their feelings.
Additionally, departments have chaplains who provide interfaith counseling and support. The same confidentiality rules apply to the chaplains as to a mental health counselor. This offers another avenue for the support needed in a crisis.
If in-person support and counseling aren’t what you need and you would prefer to call a phone number and speak to someone or use online resources to locate your own provider, several services are available such as the Firefighter Behavioral Health Alliance (http://www.nvfc.org/hot-topics/share-the-load-support-program-for-fire-and-ems) is geared toward supporting firefighters and EMTs and operates the Fire/EMS Helpline (888-731-3473).
We follow a strict chain of command in the fire service, since we are a paramilitary organization. If a firefighter has a problem, he goes to his supervisor. If the supervisor can’t solve that problem, it goes to the next level. Can we handle mental health issues in the same way? Can we train senior officers to be “mental health officers” dedicated to taking care of our own? We know our co-workers and subordinates. We know when someone didn’t get much sleep last night or when someone had a spat with his significant other. We can see the change in behavior, but we are not trained to address it. Providing firefighters with behavioral health education will enable them to provide peer support. Training senior officers to recognize the warning signs of a behavioral health issue and providing them with the tools to manage them will allow us to better support our fellow firefighters.
PTSD Screening Tools
An initial PTSD screening involves answering the following four simple, self-reported, yes-or-no questions of the Primary Care for Post-Traumatic Stress Disorder (PC-PTSD) screen developed 2003.7 It will determine whether the screening process needs to go further. The inventory is available online and easy to find. Following the opening statement, respondents answer the following questions with a yes or no:
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you
- Have had nightmares about it or thought about it when you did not want to?
- Tried hard not to think about it or went out of your way to avoid situations that reminded you about it?
- Were constantly on guard, watchful, or easily startled?
- Felt numb or detached from others, activities, or your surroundings?
The nonspecific nature of this screen allows it to be used for a number of different stressors and to be applied across different fields.
Additionally, there is the PTSD Checklist (PCL-5), a more in-depth self-reporting inventory. The PCL-5 is normed against the DSM-5 and the current PTSD criteria. The 20-question inventory first looks at the specific traumatic experience and the individual’s role in it and then asks a series of questions. The higher number of questions allows for a different cutoff score in determining whether PTSD is present. The questions correlate to the diagnostic criteria, which allows clinicians to form a more comprehensive picture of their clients.
Perhaps the “gold standard” of PTSD screening devices is the Clinician-Administered PTSD Scale 5 (CAPS-5). This 30-question, structured interview format is designed for a mental health clinician to administer one-on-one with a client. As such, the self-reporting factors are eliminated, and additional questions can be employed to get to the root of the issue. The CAPS-5 enables clinicians to make a current diagnosis of PTSD (within the past month), a lifetime diagnosis, and a past-week diagnosis. A full interview will take between 45 and 60 minutes but will paint the most complete picture of the presence or absence of PTSD.
How can a large number of responders witness and participate in a single traumatic event and only some of them develop PTSD? What is it about a single incident that triggers sleep disturbances in a firefighter and other signs of PTSD? I wish there was a good answer and a single item we could point to and shout, “There it is-that will cause PTSD!” Unfortunately, isolating specifics is often difficult, if not impossible, because of the nature and frequency of the operations in which emergency responders are involved.
Resiliency-the ability to recover after something bad happens-plays a large part in our ability to handle the stress of the job. Resiliency and its associated coping mechanisms determine whether a responder develops PTSD. Responders with strong social, peer, and family relationships; high self-confidence and self-esteem; unit cohesion; and strong coping skills are less likely to exhibit PTSD symptoms.
Resiliency is not something you are born with; it is a teachable skill. According to the American Psychological Association (APA), becoming more resilient involves the ability to do the following: manage strong feelings and impulses, make realistic plans and goals and take steps toward carrying them out, have a positive view of yourself and confidence in your own skills and abilities, and have communication and problem-solving skills.
The APA Web site offers 10 ways to build resilience:
- Make connections.
- Don’t see crises as insurmountable problems.
- Accept that change is a part of living.
- Move toward your goals.
- Take decisive actions.
- Look for opportunities for self-discovery.
- Nurture a positive view of yourself.
- Keep things in perspective.
- Maintain a hopeful outlook.
- Take care of yourself.
First responders should know that they aren’t alone-numerous options are available for the asking. If bringing PTSD into the light allows one firefighter to ask for the help needed, then all of the time was worth it. Don’t be afraid to extend your hand to a fellow firefighter and offer help if it is needed. Get training in peer support; become an advocate for mental health issues, and be the change that you want to see.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C.: American Psychiatric Association.
- Terhakopian, A, N Sinaii, CC Engel, PP Schnurr, and CW Hoge. (2008). “Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist.” Journal of Traumatic Stress, 21(3), 290-300. http://www.ncbi.nlm.nih.gov/pubmed/18553416.
- Kessler, RC, P Berglund, O Demler, R Jin, KR Merikangas, and EE Walters. (2005). “Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.” Archives of General Psychiatry, 62(6), 593-602. http://www.ph.ucla.edu/epi/faculty/detels/PH150/Kessler_DSMIV_AGP2009.pdf.
- Kessler, RC, WT Chiu, O Demler, and EE Walters. (2005). “Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication.” Archives of General Psychiatry, 62(6), 617-627. http://www.ncbi.nlm.nih.gov/pubmed/15939839/.
- Wilmoth, J. (2014). NFPA Special Report on Firefighter Behavioral Health. Retrieved from http://www.nfpa.org/newsandpublications/nfpa-journal/2014/may-june-2014/features/special-report-firefighter-behavioral-health.
- Donnelly, E and D Siebert. (2009). “Occupational risk factors in the emergency medical services.” Prehospital and Disaster Medicine, 24(05), 422-429. http://www.ncbi.nlm.nih.gov/pubmed/20066645.
- Prins, A, P Ouimette, R Kimerling, RP Cameron, DS Hugelshofer, J Shaw-Hegwer, and JI Sheikh. (2003). “Primary Care PTSD Screen.” PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. http://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp.
DAVID WIKLANSKI is a firefighter/emergency medical technician (EMT) with the New Brunswick (NJ) Fire Department and a NJ certified fire instructor II and EMT instructor. Wiklanski has a master’s degree in behavioral sciences from Kean University, where he is an adjunct professor with the School of Psychology. He is also the owner of Alpha Omega Training Solutions.
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