Evaluating firefighters for risk of developing PTSD

Linda Willing

We know that firefighters are at increased risk for developing Post-Traumatic Stress Disorder (PTSD). Rates in the data can be as high as 25 percent of firefighters showing symptoms based on who is surveyed, when they are asked and how the questions are phrased. Rates in the general population tend to be around 3-5 percent.

The high risk of post-traumatic stress injuries or symptoms among firefighters isn’t particularly surprising given that firefighters are so consistently exposed to trauma. The first criteria for a clinical diagnosis of PTSD is being exposed to actual or threatened death, injury or violence. Most firefighters meet that criteria by the time they have been on the job a month.

Who is pre-disposed to developing PTSD?

So, why do some firefighters develop PTSD and others don’t? And can you screen candidates to determine who is at high risk when making hiring decisions?

While the literature is mixed on exactly what puts some people at higher risk for PTSD after trauma exposure, a number of factors have been studied as risk factors.

For instance, existing mental health challenges, exposure to trauma in childhood, being introverted or neurotic and having weak coping strategies have all been found to be related to the development of PTSD. According to the National Institute of Mental Health, several environmental factors, such as lack of social support after trauma exposure, may also influence who will develop PTSD.

One of the challenges with most studies that examine these relationships is that they aren’t done until after someone develops PTSD, so it is difficult to know if the characteristics developed because of the PTSD or if they were there before the trauma ever occurred.

Physiological responses could show tendency to developing PTSD

Even with the limitations of the data, research has been done on whether pre-employment screening is possible. Studies have been conducted on military and first responders prior to traumatic exposures on the job to determine who develops symptoms and who doesn’t.

In a review of the literature in “Psychiatry Research,” Dr. Marshall and colleagues reviewed 21 studies on the topic. They concluded that only a few measures were predictive of developing PTSD among first responders.

Physiologic measures of response to simulated trauma seem to be somewhat predictive. For instance, when measures of skin conductance, eye blinks or corrugator electromyograms (EMG) were measured while participants were exposed to threats, shocks or startles in the lab, those with high arousal were more likely to develop PTSD. However, the differences only explained 30 percent of the variance. The authors suggest that these measures might be predictive because they are don’t have the response bias that self-report measures might have.

Poor coping techniques, such as catastrophic thinking or rumination, also have some value in predicting PTSD development as do personality traits such as anger. Unfortunately, no measures were consistently and strongly related to PTSD development. With any existing assessments, it is highly likely that strong candidates would be screened out unnecessarily.

Legality of pre-screening for PTSD

There may be legal ramifications for the idea of pre-hire screening for previous psychological issues. For instance, the Uniformed Services Employment and Reemployment Rights Act (USERRA) and Title I of the Americans with Disabilities Act (ADA) make it illegal to discriminate again veterans due to service-related disabilities, including PTSD.

So the answer to the question is no; there has not been a reliable measure for screening out people at high risk for PTSD as a pre-employment measure. While the data isn’t conclusive about the relationship between pre-existing conditions or risk factors for PTSD, what research is available highlights the importance of bolstering behavioral health efforts in the fire service.

What is consistent in the literature is that having a supportive environment with strong social bonds is protective against developing clinically significant symptoms. Limiting the impact of the job and risk for PTSD is important for individuals, but is also a job for the whole crew.

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