Elsevier

Journal of Anxiety Disorders

Volume 34, August 2015, Pages 86-93
Journal of Anxiety Disorders

Characteristics of the traumatic stressors experienced by rural first responders

https://doi.org/10.1016/j.janxdis.2015.06.006Get rights and content

Highlights

  • 181 rural first responders were surveyed about traumatic workplace events.

  • Chaos and resource limitations characterized events associated with PTSD symptoms.

  • Event characteristics predicted peritraumatic dissociation and posttrauma cognitions.

  • Cognitive processes partially mediated event characteristics and PTSD symptoms.

Abstract

First responders routinely experience work-related events that meet the definition of a traumatic stressor. Despite the high exposure to traumatic events, prevalence rates of posttraumatic stress disorder (PTSD) are relatively low. This discrepancy points to the potential value of identifying factors that distinguish those traumatic stressors that produce ongoing traumatic stress symptoms from those that do not. The present study surveyed 181 first responders from rural settings. A repeated-measures design was used to compare characteristics of traumatic stressors that were or were not associated with ongoing PTSD symptoms. A factor analysis revealed that distressing events were characterized by chaos and resource limitations. Consistent with contemporary models, two mediational analyses revealed that each event characteristic predicted peritraumatic dissociation and posttraumatic cognitions, which in turn predicted PTSD symptoms. Moreover, the effect of each event characteristic on PTSD symptoms was partially mediated by these cognitive processes.

Introduction

Police, firefighters, and ambulance personnel (i.e., first responders) frequently encounter potentially traumatic events in the line of duty. Approximately 60%–90% of first responders have attended situations involving multiple casualties, 61%%–84% have witnessed the death of a child, 46%–84% have experienced the death of a person in care, and 55% have witnessed violence against others (Regehr et al., 2003a, Regehr et al., 2003b). Additionally, first responders routinely experience threats of violence against themselves (Regehr, Hill, & Glancy, 2000) and other safety hazards (Bryant & Harvey, 1996). Despite the frequency of such events, the prevalence of work-related PTSD is relatively low: approximately 7–8% for police (Carlier et al., 1997, Martin et al., 2009), and 12% for firefighters and paramedics (Bryant and Guthrie, 2007, Van der Ploeg and Kleber, 2003). The discrepancy indicates a low etiological connection between traumatic event exposure and the experience of PTSD symptoms.

This discrepancy underscores a general criticism of the Diagnostic and Statistical Manual (DSM) traumatic stressor criterion (i.e., Criterion A). According to Rosen and Lilienfeld (2008), Criterion A was intended to serve as a “gatekeeper”, meaning that individuals could not qualify for a diagnosis of PTSD unless they experienced a specific type of a traumatic event. Underlying this gatekeeping function is the assumption that the resulting PTSD symptoms are causally related to a Criterion A event. However, accumulating evidence shows that even very severe events do not evoke marked distress in most people. For example, Kessler, Sonnega, Bromet, Hughes, and Nelson (1995) found that the conditional prevalence rate (i.e., proportion of people who develop PTSD after experiencing a specific type of traumatic stressor) for events with a direct threat to life or personal safety were generally low, for example, combat (males: 38%; women: unavailable), physical abuse (males: 22.3%; females: 48.5%), and accidents (males: 6.3%; females: 8.8%). The highest conditional probability rate was for rape (males: 65%; females: 45.9%). Breslau and Kessler (2001) reported that the overall conditional probability of PTSD for people who reported experiencing DSM-IV (4th ed.; American Psychiatric Association [APA], 1994) Criterion A1 events was 9.2%. Clearly, the DSM stressor criterion is not fully capturing the characteristics of a traumatic stressor. What differentiates two events that meet the current Criterion A definition, one which results in PTSD, and the other which does not?

Following from the above, the goal of this study was to determine the event characteristics associated with PTSD symptoms within the specific occupational context of first responders. First responders differ from many trauma populations (e.g., victims of vehicle accidents, assaults) not only in the frequency with which they encounter events, but also in the nature of the traumas they encounter. For example, they repeatedly witness the horrific aftermath of traumas directly experienced by others (e.g., victims of accidents, fires, violent death) and are pressured by time demands and social responsibility for others’ well-being. Such event features may influence trauma symptoms (e.g., Alden, Regambal, & Laposa, 2008). Identifying the features associated with ongoing PTSD symptoms has practical implications for first responders given their routine exposure to potentially traumatic events.

First responders provide services in a complex occupational context. They often arrive on scene to a dynamic situation that includes events that are rapidly unfolding in front of them (e.g., a patient in cardiac arrest, an agitated person with a weapon) and where unexpected happenings can render established protocols ineffective causing uncertainty and confusion (e.g., Laposa & Alden, 2003). Foa and colleagues argued that events that are either uncontrollable or unpredictable are more likely to result in PTSD (Foa, Zinbarg, & Rothbaum, 1992). Uncontrollable and unpredictable events may be especially salient for first responders given that such events could become life threatening. For example, approximately 35% of volunteer firefighters indicated that their safety was threatened by unpredictable fires in which they had become trapped (Bryant & Harvey, 1996). Furthermore, 55% of police officers indicated having no or very little control during their most distressing event (Colwell, Lyons, Bruce, Garner, & Miller, 2011).

Other promising characteristics pertain to first responders’ need for resources to perform their duties in the midst of potentially traumatic events. Bacharach, Bamberger, and Doveh (2008) examined the association between firefighter's current distress and both “material resources” (e.g., having equipment to perform duties in the field, firehouse, and to maintain safety) and “conditional resources” (e.g., training and preparedness for routine and mass casualty events). Firefighters who were members of units with less adequate resources were more likely to experience distress than those with more adequate resources.

In a study predicting symptomatic distress in first responders responding to the Nimitz Freeway collapse, Weiss, Marmar, Metzler, and Ronfeldt (1995) developed a global Incident Exposure Scale (IES) to measure the extent of trauma exposure. The IES not only predicted symptoms immediately after the event, it also predicted PTSD symptoms measured 3.5 years later (Marmar et al., 1999). Because the IES included items that reflected a variety of event characteristics, however, it is not clear whether some event features were more crucial than others. A pilot study of characteristics of traumatic events in hospital emergency personnel revealed two potentially important dimensions, chaos (e.g., confusion, unexpected happenings) and resource strain (Alden, 2005), which echo other findings that link uncontrollability and resource limitations to PTSD (e.g., Bacharach et al., 2008, Foa et al., 1992). Taken as a whole, the extant data suggest it may be valuable to evaluate these particular features of traumatic events.

One way to validate salient characteristics of traumatic events is to determine whether they are related to processes shown to predict PTSD (e.g., Weiss et al., 1995). Contemporary PTSD models highlight cognitive processes during (i.e., peritraumatic processing) and after the traumatic event (i.e., posttrauma cognitions) as key factors in the development of PTSD (e.g., Brewin et al., 1996, Ehlers and Clark, 2000). A large body of literature has linked peritraumatic dissociation, often considered a marker of disrupted cognitive processing, to the development and maintenance of PTSD (e.g., Birmes et al., 2003, Ehlers et al., 1998). Additionally, several studies have shown dissociation to be one of the strongest predictors of PTSD/PTSD symptoms in first responders (e.g., Hodgins et al., 2001, Martin et al., 2009, McCaslin et al., 2008). Cognitive theorists argue that the nature of peritraumatic processing makes it susceptible to disruption by trauma characteristics (e.g., Ehlers & Clark, 2000). Indeed, dissociation has been related to objective trauma severity (Shalev et al., 1996, Van der Velden et al., 2006). Additionally, Marmar, Weiss, Metzler, and Delucchi (1996) found that their IES was a significant predictor in classifying first responders who experienced no/minimal peritraumatic dissociation and those who experienced moderate/high dissociation during the freeway collapse. Similarly, Alden (2005) found significant correlations between dimensions of chaos and resource strain and dissociation in hospital emergency workers.

PTSD theorists also underscore the importance of an individual's cognitions in the aftermath of a traumatic event. The Posttraumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) assesses negative cognitions about the self, the world, and self-blame. Consistent with these theories, individuals who experienced a Criterion A event demonstrated a significant medium to large correlation between the PTCI total score and PTSD symptoms (Belsher et al., 2012, Bennet et al., 2009). Features of the trauma can influence post-event cognitions. For example, Alden et al. (2008) found that emergency room nurses whose primary traumatic event was witnessed (e.g., patient death) evidenced more negative appraisals of their symptoms than those nurses whose primary event was directly experienced (e.g., assault).

This study had three goals. The first was to identify trauma characteristics that first responders perceived to be relevant for distressing Criterion A events (i.e., events causing lasting symptoms of PTSD). Consistent with the literature, we anticipated that themes reflecting uncontrollability/unpredictability (chaos) and resource availability would emerge. The second was to determine if the identified characteristics were more closely associated with events that produced lasting distress compared to similar events that did not. Therefore, participants selected and rated the trauma characteristics of two types of events, their most distressing work-related event and a control event similar in nature that did not cause ongoing distress. The third was to test the hypothesized relationships between the characteristics of traumatic stressors and the cognitive processes related to PTSD, specifically dissociation and posttrauma cognitions. Fig. 1 presents the hypothesized relationships. In congruence with the literature, we predicted that dissociation and posttrauma cognitions would mediate the relationship between trauma characteristics and PTSD symptoms.

A specific focus of the current study was to address these objectives in the context of rural first responders, a population that has largely been understudied, and who are often subjected to the salient trauma characteristics outlined above. Rural and smaller urban areas present unique challenges in providing emergency services. In particular, rural first responders are more likely to experience professional isolation and may be less likely to have access to professional backup. Studying this population provided an opportunity to assess the event characteristics identified in the literature.

Section snippets

Participants

Participants were active members of the Royal Canadian Mounted Police (RCMP; N = 98), British Columbia Ambulance Service (BCAS; N  = 38), and volunteer firefighters (N = 43) who responded to requests to participate in the research. Two participants (1.1%) did not indicate their profession. Only participants who chose a single work-related Criterion A type event for both their distressing and control event were included (N = 181 of 249 returned). The majority of the sample was male (73.5%), Caucasian

Data preparation

All questionnaires had very limited missing data with less than 1% missing data points on each measure. One participant was removed from all analyses using the PDS-S due to a large amount of missing data. Given the limited missing data, the missing value for each question was replaced with the individual participant's mean for the respective questionnaire. The PDS-S and PDEQ both had distributions that were significantly (p < .001) skewed (1.64 and 1.35, respectively) and kurtotic (2.59 and 1.61,

Discussion

In this sample of first responders, two factors were found to characterize emotionally distressing events associated with ongoing PTSD symptoms, Chaos and Resource Limitations. These factors distinguished groups of first responders who reported PTSD symptom scores in the clinical range on the PDS from those who did not, and also differentiated events described as producing ongoing PTSD symptoms from thematically similar events that did not. Consistent with contemporary PTSD models (e.g., Ehlers

Acknowledgements

This research was supported by grants from the Michael Smith Foundation, BCEHORN, and University of Northern British Columbia awarded to S.L. Wagner and University of British Columbia Hampton Research Grant 12R43560 awarded to L.E. Alden. Marci J. Regambal was also supported by a fellowship from WorkSafeBC. This manuscript is based in part on data used in Marci J. Regambal's doctoral dissertation.

We would like to thank the following people for their assistance in conducting this research:

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