The Journal of Emergency Medical Services suggests the mental health of first responders is highly overlooked. Even with the constant exposure to the job’s trauma and physical demands, front-line workers’ mental health needs are still not a priority. This oversight leads to re-occurring stress, suicide-ideation, and posttraumatic stress disorder (PTSD) among first responders – resulting in health problems, higher departmental healthcare costs, poor job performance, and difficulties with work and personal relationships.
However, one area that also remains overlooked in PTSD and trauma is its toll on the first responder’s cognitive health. This article unpacks the symptoms of PTSD and what the latest research reveals concerning trauma and cognition. We also highlight an exclusive interview with Dr. Heather Twedell, a licensed psychologist specializing in working with first responders, and her thoughts on trauma, cognition, and effective ways to combat these mental health issues within this heroic community.
The Toll & Prevalence of PTSD on First Responders
First responders are consistently exposed to traumatic events, including potentially life-threatening situations, serious injuries, and civilian deaths. Evidence indicates that PTSD is substantially higher among first responders than the average population due to these re-occurring events. For example, one report measuring mental health among active-duty officers found 47 percent of the sample screened positive for PTSD. This number is 9 to 10 times greater than the prevalence of PTSD in the general population. According to another study, 69 percent of EMS professionals have never had enough time to recover between traumatic events. As a result, depression, stress and posttraumatic stress symptoms, suicidal ideation, and a host of other functional and relational conditions have been reported.
According to the American Psychiatric Association (APA), posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape, or who have been threatened with death, sexual violence or serious injury. More in-depth information on the diagnostic criteria for PTSD can be found through the DSM-5. According to the Mayo Clinic, PTSD symptoms are grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person, including:
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Recurrent distressing memories of the traumatic event.
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Flashbacks of the traumatic event.
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Severe emotional, physical reactions to something that reminds the person of the traumatic event.
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Avoiding people, activities, or places that remind the individual of the traumatic event.
Symptoms of changes in physical/emotional reactions (also called arousal symptoms) may include being easily startled, irritability, and overwhelming guilt or shame. More comprehensive PTSD symptom information can be found through the latest version of the DSM-5.
A Deeper Look into Trauma
We spoke to Dr. Heather Twedell, a licensed psychologist, to get a deeper understanding of PTSD symptoms. Her tireless work with first responders and her family ties to law enforcement gives her a strong knowledge of these heroes’ culture and stressors. When asked about the most common symptoms of the trauma she sees in her patients, she reveals, “These humans have a front-row seat to some of life’s most horrific events, with minimal recovery time and the guarantee that future exposure awaits. The result? A dysregulated nervous system flooded with incoming information shaping how the first responder views him/herself, others, and this world. This can manifest as unhealthy coping skills, health issues, inconsistent functioning, impairment to on-duty performance, and negative impacts on their closest relationships.”
Twedell also reveals that some of the most common reactions and symptoms she sees in her office are when first responders bury their trauma. She states, “In this line of work, the expectation is to do the job, do it well, and move forward to the next call while somehow dodging any human responses to what they’ve witnessed and experienced. With research and an understanding of how trauma impacts the brain/body connection, these expectations are unrealistic. Trauma doesn’t just go away because the next call comes in or because a few days, months, or even years have passed. The first responder may continue to carry his/her traumas alone, discounting their human reactions, and feeling the tension as each call piles on top of the next.” Twedell goes on to add, “What I might hear from family members is ‘he’s just different’ or ‘the job has changed her.’ I might commonly hear from first responders that they feel on edge and easily snap at family members. They may carry guilt for the calls they couldn’t change and the human life they couldn’t save. They may report they’re not sleeping or they’re drinking more because alcohol helps them feel ‘normal.’ They also may report there’s a ‘rolodex’ of trauma calls in their brains that they’re resistant to access for fear they won’t be able to ‘make it stop.’ This is the impact of trauma.”
The Cognitive Toll of PTSD
Brain areas most commonly implicated in the stress response include the prefrontal cortex, amygdala, and hippocampus. Trauma is associated with lasting changes in these brain areas, including issues with memory and cognition. According to a review in Frontiers in Integrative Neuroscience, the hallmark symptoms of PTSD involve alterations to cognitive processes such as memory, attention, planning, and problem-solving, underscoring the detrimental impact of negative emotions on cognitive functioning.
Over the past decade, research is finally providing evidence that PTSD and cognitive impairment are common to first responders. One recent study out of the International Journal of Environmental Research and Human Health found that several years after the World Trade Center attacks, PTSD and depression are related to first responders’ cognitive issues. Those deficits include difficulty recalling names and words and greater reliance on written reminders. Another study out of Stony Brook University also indicated that World Trade Center first responders are at risk for cognitive decline and potentially developing dementia. Specifically, it found that PTSD was broadly associated with worse cognitive performances across measures linked to neurodegenerative disease risk, including reaction speed, processing speed, and memory. These studies suggest interventions targeting PTSD may have additional value in mitigating the cognitive decline in first responders.
How Trauma Hacks Emotional Regulation
We asked Twedell what cognitive issues she sees in patients with PTSD and how these problems affect their everyday lives. She states, “Some may think of trauma exposure and immediately think of the emotional aftermath for that human being. However, it’s vital to note that these intensely emotional experiences can have long-term cognitive effects such as memory, planning, problem-solving, and attention.” She also adds, “Trauma alters key brain regions involved in not only cognitive processing but emotional regulation as well. When the prefrontal cortex (the rational part of the brain) fails to inhibit an overactive amygdala (the part of the brain associating emotion with experience), what you have is a first responder that may appear on edge, irritable, and stuck in a constant fear response. This physiological response fuels anxious and fear-oriented thought patterns, which then further activates a physiological response. This cycle can be exhausting for the first responder and extremely frustrating for their family members.”
Exercise as Targeted Therapy in First Responders
When asked what kind of treatments Dr. Twedell uses with her patients, she states, “The first responder can experience more traumas in one shift than the average person may experience in a lifetime. This is why every first responder must learn the necessary skills to increase self-efficacy and promote resiliency for occupational and personal dynamics. Healing from trauma and threat is a process that is best approached by utilizing multiple methods for optimal recovery.” In addition to seeking evidence-based treatment from culturally competent providers for debriefs, trauma processing, and skills training, Twedell believes the first responder must engage in their own wellness outside of the therapy room – this includes exercise. She adds, “As long as they are in this line of work, there will always be threat and trauma exposure, which means their limbic systems will continue to be on high alert with a primitive call to survive. Chronic stress has altered the first responder at the cellular level, and some of the most powerful ingredients to regulate the nervous system and battle cell death are released when one engages in exercise.”
Twedell believes that exercise, specifically aerobic, must become a part of the first responder’s resiliency and recovery regimen. She suggests, “I tend to agree with the world-renown psychiatrist, Dr. John J. Ratey, and his book Spark: The Revolutionary New Science of Exercise and the Brain, that ‘exercise is the most powerful tool you have to optimize your brain function.’ It is a tool that forms new neurons in the brain. Given what we know about the detriments of chronic stress on the brain, the first responder’s battle against repetitive trauma and threat exposure can be navigated more efficiently if exercise is part of the equation. Furthermore, the added physical benefits of exercise will help protect the first responder from other conditions this population knows all too well, including sudden cardiac arrest, strokes, cancers, and injuries.”
In addition to rebuilding and rewiring the brain, Twedell believes that exercise can teach the system a different outcome; she states, “If the physical symptoms of on-duty fight-or-flight are only associated with trauma, threat, and stress, the first responder may learn to fear those responses when the same symptoms are activated off-duty. This can lead to anxious thoughts that only fuel the physical sensations further. With exercise, the body is experiencing those same on-duty symptoms except that exercise is positive and within their control. The brain needs this balance for healthy and new associations.”
Mindfulness, Equine Therapy, & Hope for the Future
Twedell mentions other techniques to help regulate the nervous system of first responders. These methods include respiratory training (breathwork), mindfulness, sensory awareness with activation, cold water exposure, and slow movement forms such as tai chi, yoga, and martial arts. She also adds, “It is also critical to have healthy eating habits, good sleep hygiene, maintain hobbies, getting outdoors, and any form of connection (with self, others, animals, and nature). One of my personal favorites is witnessing the power of horses with first responders during OurWatch equine wellness workshops.” Twedell is a member of this nonprofit in North Texas providing equine-assisted resiliency training to first responders and their family members. Working with horses helps first responders address the emotional, mental, and physiological challenges associated with high-stress exposure. The horse acts as a therapeutic tool to help the client see and experience themselves. When the immediacy of this experience is brought into self-awareness, healing happens.
To bring the prefrontal area of the brain (executive function) back online, Twedell suggests for the first responder to share their sensations, thoughts, and emotions with others through journaling. She states, “First responders are notorious for not talking about the horrific events they witness to protect their loved ones. By carrying the trauma alone, it manifests in ways that actually can push their loved ones away. Sharing their feelings and how they have been struggling can go a long way in their healing process.” Twedell also adds that departments can support their first responders by investing in wellness programs and resiliency training, including implementing peer support programs. She believes that psychoeducation must be provided on day one at the academy and throughout the career so that the first responder and their family members can identify and understand these responses, make a plan, and work together to achieve optimal functioning and support.
As Twedell beautifully states, “Yet, despite it all, the first responder will push forward. They will continue to serve their communities. As a first responder psychologist and family member, I have the utmost respect for these sacrifices; but witnessing this trauma exposure cycle can be devastating. However, with awareness, skills training, and support, first responders can gain the right tools to navigate their career and still maintain a quality of life.”