John is a 40-year-old police officer who recently sought medical attention for repeated nightmares, difficulty sleeping, and vivid flashbacks of a traumatic encounter he experienced over six months ago while on duty.

He was the first to respond to a neighbour’s call to police about domestic abuse at a local apartment building where a husband and wife had been fighting. When John arrived, the man pulled a gun and held him hostage for over three hours before police backups arrived and took the man into custody. Immediately following the event, John was extremely shaken up, and experienced overwhelming feelings of fear as he thought his own death was imminent. Since the event, John has become socially withdrawn. He is not married, nor does he have any children to rely on for support. John always suffered from anxiety, but had previously found that a couple of beers seemed to take the edge off for him. Lately, he needs to drink more and more to try and relieve the high levels of anxiety he feels on a daily basis since that traumatic episode. He states that sometimes it feels as though he is actually reliving the experience. The feeling is so overwhelming that he frequently breaks out in sweat and feels like his heart is going to beat out of his chest. John is demonstrating many of the symptoms of Post-Traumatic Stress Disorder (PTSD).

PREVALANCE AND SCOPE OF PTSD
Data collected as recently as 2004 suggests that 6.8% of all adults will be diagnosed with PTSD in their lifetime. Among some groups, such as military veterans and emergency responders, the prevalence rates tend to be higher – approximately 13% --and even as high as 30% according to one study.. Self-reported symptoms of PTSD in a group of both American and Canadian firefighters were found to be similar to those reported by wounded Vietnam War veterans. A first-responder is six times more likely to experience PTSD symptoms than are crime victims. First-responders’ are put in situations that are more likely to lead to traumatic experiences and high levels of occupational stress than are the typical worker. Frequent exposure to victims of serious injuries and death, and extreme danger such as fires, high-speed chases and gunfire are all occupational hazards for individuals employed as first responders.  Therefore, this population is more likely to suffer from PTSD, and from a resulting number of psychological and physical consequences. Firefighters who develop PTSD, for example, have been found to experience cardiovascular problems, tension, substance abuse issues, and depressive episodes more often than their non-PTSD counterparts. The degrees of symptoms experienced by first-responders are related to both the severity as well as their proximity to the traumatic event.  Long-term exposure, as determined in part by length of time on the job and the number of distressing situations first-responders experience, is also a relevant predictor for developing PTSD. Studies have shown that, once traumatized, individuals are more vulnerable to the debilitating effects of PTSD for future episodes. It is much like a football player who suffers a concussion--the brain becomes more susceptible to future concussions. PTSD sufferers are ill equipped to handle future traumatic experiences.

STRESS AND STRESSORS
Law enforcement, EMS and firefighters are all subject to particularly stressful occupations. Stress can arise from an acute event or prolonged exposure. Stressors and stress are often confused, but are not the same thing. Stressors are the environmental events that tax our ability to cope, and stress is our physiological and psychological response to these stressors. Over fifty years ago an endocrinologist, named Hans Selye, noted that the body begins to show the effects of prolonged exposure to extreme stressors in fairly predictable ways. He termed this the General Adaptation Syndrome and it consists of three stages: alarm, resistance, and exhaustion. Exhaustion signals the breaking down of the body’s immune response and we then become prone to sickness.

Only a licensed mental health professional can diagnose someone. To be diagnosed with PTSD, an individual must experience exposure to some traumatic event, such as a natural disaster, assault, combat, or stressors that elicit a strong internal stress response. These can be experienced directly, by witnessing a traumatic event, or indirectly, as in learning from someone else of the event. The trauma also has to be viewed as threatening the life, serious physical injury or the personal integrity of the individual. The individual may experience an intense emotional response involving feelings such as hopelessness and fear, and these thoughts persist over at least a month past the trauma, often in the form of flashbacks. It is important to remember, however, that not everyone who experiences trauma will develop PTSD. Many of the factors that play a role in developing the disorder have to do with the individual coping styles of people.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association and used to classify mental disorders, contains the current criteria necessary for individuals to be diagnosed with one of the most debilitating stress disorders -- Posttraumatic Stress Disorder (PTSD). There are three clusters of typical symptoms: (1) An individual’s intense reliving of the trauma, (2) Avoidance and numbing of emotional responses that elicit feelings associated with the trauma, and (3) Hyperarousal, or anxiety-like symptoms experienced by the individual. Frequently, PTSD is accompanied by additional disorders such as depression and substance abuse disorder which can make an accurate diagnosis of PTSD difficult to make by a clinician.

TREATING PTSD IN 1ST RESPONDERS
Currently, the most effective forms of treatment for PTSD involve outpatient psychological and behavioral methods, pharmacological interventions, or a combination of the two, in instances such as treating patients with both PTSD and severe depression. Inpatient treatment may be necessary for some individuals who display suicidal tendencies. Treatment usually involves meeting with a therapist once a week for four to six months. Patients suffering from PTSD may be reluctant to seek treatment for a multitude of reasons. For one, they may view discussing their trauma in a therapeutic setting as a reminder of their ordeal that they wish to avoid. In addition, some view mental healthcare as stigmatizing. For these reasons, a crucial first step in treatment is educating patients about PTSD and its high rates of occurrence among survivors of trauma. The reality is that if an individual has PTSD for a year or more, the chances of recovering without any form of therapy or medication are remote.

As a consequence of the stigma surrounding treatment, many PTSD sufferers may fail to seek treatment, often ignoring their symptoms or self-medicating with alcohol and drugs. This approach only leads to drug and alcohol dependency. The National Center for Posttraumatic Stress Disorder reports that up to 75% of individuals who have experienced a violent trauma report some level of drinking problems. PTSD patients often report using alcohol or other substances as a way to cope with the stress induced by the trauma they experienced. However, alcohol can often exacerbate some typical PTSD symptoms such as anger, irritability, depression, and numbing of feelings. By trying to ignore the symptoms associated with PTSD, sufferers make them worse and prolong the suffering when self-medicating with alcohol and drugs. Additional research has shown that when PTSD and substance abuse disorder occur together, treatment outcomes are worse than for either disorder alone. In 2008, 20% of VA patients receiving treatment for PTSD also suffered from substance abuse disorder. Even though this figure can be disheartening, mental health professionals believe that these dual-diagnoses patients can effectively recover and this recovery is more likely to be successful the sooner these patients seek treatment.

Several treatments have proved effective for PTSD. The most common and one of the most effective treatments for patients suffering from PTSD is Cognitive Behavioral Therapy (CBT). CBT focuses on the reduction of the PTSD symptoms, whereby the ultimate goal for PTSD patients is to understand how to identify trauma-induced stress and the feelings it evokes, and learn how to replace these responses with more adaptive ways of thinking. This approach is commonly referred to as cognitive restructuring. CBT seeks to minimize avoidance-coping techniques many PTSD sufferers employed before seeking treatment, like social isolation and substance abuse. Additionally, antidepressant medications like Selective Serotonin Reuptake Inhibitors (SSRI’s) can be utilized with CBT to improve effectiveness of treatment.

Exposure Therapy is another type of treatment implemented for PTSD. Research has shown that exposing individuals to simulated trauma, like entering a burning building or being involved in a police standoff, presented in a controlled environment can decrease future emotional reactions when individuals face similar situations in real-life scenarios. Using this type of an intervention with emergency responders, who face traumatic events as a part of their career, can help lessen the degree to which these traumas have a lasting negative effect. Repeatedly exposing individuals to scenarios similar to what they will face in the line of duty until their distress decreases has been shown to improve performance, decrease feelings of fear and anxiety, and increase coping effectiveness.

Most importantly, seeking treatment means that individuals are much less likely to engage in a pattern of behavior (e.g. social isolation and substance abuse) that is typical of sufferers and ultimately lead to greater physical and psychological damage. By maintaining healthy lifestyle choices, surrounding oneself with a supportive network of friends and family, and by seeking help if stress becomes overwhelming, first-responders can learn to manage the difficult portion of their jobs and enjoy the rewards they receive from helping their community on a daily basis.

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Richard Ogle, Ph.D. is Professor and Chair of the Psychology Department at University of North Carolina Wilmington. His research interests are in the areas of substance abuse, trauma, and psychopathology.

Sarah Henry received her BA in Psychology at the University of North Carolina Wilmington in 2011, and she is currently a first-year student in the Master’s Program in Psychology at UNCW. Her research interests are in the areas of forensic and clinical psychology. 
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