Associations between Lower-Order Anxiety Sensitivity Facets and PTSD Symptomatology among Trauma-Exposed Firefighters

Abstract

Firefighters are chronically exposed to potentially traumatic events, augmenting their risk of developing posttraumatic stress disorder (PTSD). The current study aimed to examine the incremental associations of lower-order dimensions of anxiety sensitivity (AS), examined concurrently, and PTSD symptom severity among a sample of trauma-exposed firefighters. We hypothesized that AS physical and cognitive concerns would be strongly associated with all PTSD symptom clusters and overall symptom severity, after controlling for theoretically relevant covariates (trauma load; years in fire service; alcohol use severity; depressive symptom severity). Participants were comprised of firefighters (N = 657) who completed an online questionnaire battery and endorsed PTSD Criterion A trauma exposure. Results revealed that the AS cognitive concerns, but not AS physical concerns, was significantly and robustly associated with overall PTSD symptom severity, intrusion symptoms, and negative alterations in cognitions and mood (∆R²’s = .028–.042; p’s < .01); AS social concerns was incrementally associated with PTSD avoidance (∆R² = .03, p < .01). Implications for firefighter-informed, evidence-based interventions are discussed.

Keywords

trauma posttraumatic stress PTSD lower-order anxiety sensitivity facets AS transdiagnostic factors firefighters

Introduction

Firefighters are chronically exposed to potentially traumatic events (e.g., natural disasters, car accidents) due to the nature of their work (Meyer et al., 2012; Skeffington et al., 2017). Given that many firefighters are involved in both fire suppression and emergency medical services, they may be disproportionally affected by repeated trauma exposure, and as such, have increased vulnerability for developing posttraumatic stress disorder (PTSD) and subclinical PTSD symptomatology (Tomaka et al., 2017). Indeed, prevalence rates for PTSD among firefighters in the United States (U.S.) are estimated to be more than three times greater than those found in the general population (8.3%; Kilpatrick et al., 2013; 32.4%; Tomaka et al., 2017), with many more firefighters experiencing subclinical PTSD symptoms (i.e., symptoms that do not meet the categorical diagnostic threshold). PTSD is associated with high levels of functional impairment, as evidenced by high rates of disability, mortality, and adverse health outcomes (Greene et al., 2016; Lohr et al., 2015; Turner et al., 2020). The public health burden and healthcare costs of PTSD are substantial (Fink et al., 2018; Morgan-Lopez et al., 2020; Zlotnick et al., 2002) and underscore the need for effective intervention strategies. Therefore, examining malleable cognitive risk and maintenance factors that may contribute to the development and maintenance of PTSD symptomatology can provide a clinically meaningful avenue for addressing these limitations and improving treatment outcomes.

A promising cognitive factor with clinical relevance to PTSD and PTSD symptomatology is anxiety sensitivity (AS). AS is defined as the fear of anxiety and anxiety-related sensations (Reiss, 1991; Reiss et al., 1986); it is a relatively stable yet malleable transdiagnostic factor (Hovenkamp-Hermelink et al., 2019) associated with increased risk and maintenance of various psychiatric disturbances, including PTSD. AS is comprised of three lower-order facets, including physical concerns (e.g., “it scares me when my heart beats rapidly”), cognitive concerns (e.g., “I worry that I might be going crazy”), and social concerns (e.g., “I worry that other people will notice my anxiety”; Taylor et al., 2007). Elevated AS has been shown to be incrementally and prospectively associated with PTSD symptom severity (Elwood et al., 2009; Feldner et al., 2006; Mitchell et al., 2014). For example, elevated AS was uniquely associated with the Diagnostic and Statistical Manual of Mental Disorders-fourth Edition (DSM-IV) PTSD hyperarousal symptoms in trauma-exposed tobacco users, which also coincides with previous findings (Gutner et al., 2013; Simpson et al., 2006). More contemporary work, utilizing the Diagnostic and Statistical Manual of Mental Disorders-fifth Edition (DSM-5) PTSD criteria among combat-exposed veterans, revealed similar results, where heightened AS was positively associated with each PTSD symptom cluster (Overstreet et al., 2018). Moreover, AS and PTSD have evinced reciprocal, bidirectional associations, with baseline levels of AS predicting future PTSD symptom severity and vice versa (Marshall et al., 2010). Given AS-PTSD associations, it is important to elucidate the incremental associations of lower-order dimensions of AS, examined concurrently, on PTSD symptomatology as to inform targeted and tailored care for firefighters.

The extant literature posits distinct associations between lower-order dimensions of AS and PTSD symptom clusters. Among trauma-exposed women, AS cognitive concerns was significantly related to overall PTSD symptom severity and the severity of each DSM-IV PTSD symptom cluster (Lang et al., 2002). Relatedly, among trauma-exposed, community-recruited adults, AS cognitive concerns was uniquely associated with DSM-IV PTSD avoidance symptoms (Vujanovic et al., 2008). In active-duty police officers, AS physical concerns has exhibited unique, significant associations with DSM-IV PTSD re-experiencing and avoidance symptoms (Asmundson & Stapleton, 2008). Recently, among a sample of military veterans, Raines et al. (2017) found incremental associations between AS cognitive concerns, but not AS physical concerns, and overall PTSD symptom severity as well as severity of each DSM-5 PTSD symptom cluster. Thus, associations between AS physical concerns and PTSD symptomatology may manifest differentially across populations and may be less relevant among populations, such as military veterans and first responders, that undergo intensive physical training to endure bodily discomfort and manage physiological fear-related sensations.

To the best of our knowledge, few published studies (e.g., Boffa et al., 2018; Lebeaut et al., 2020; Paulus et al., 2018; Stanley et al., 2017) have examined AS-PTSD relations in firefighter populations. Notably, Boffa et al. (2018) examined the mediating role of AS facets between PTSD symptom clusters and suicide risk among a subsample (N = 214) of male firefighters endorsing suicidal ideation and behaviors, covarying for depressive symptom severity. In this study (Boffa et al., 2018), all AS facets were related to PTSD symptom severity and symptom cluster severity at the bivariate level. Furthermore, after controlling for depressive symptoms, AS cognitive concerns and AS social concerns were related to PTSD symptom severity and severity of each PTSD symptom cluster, while AS physical concerns was related to all PTSD clusters except PTSD avoidance. Notably, this study focused upon a subsample of trauma-exposed firefighters with non-zero scores on the Suicidal Behaviors Questionnaire-Revised (Osman et al., 2001) and did not account for additional theoretically relevant covariates, including trauma load, years of service as a firefighter, and alcohol use severity, which have all evinced unique associations with PTSD symptomatology and AS (Arbona & Schwartz, 2016; Carey et al., 2011; Harvey et al., 2016; Lebeaut et al., 2020; Murphy et al., 1999; Paulus et al., 2018; Paulus et al., 2017). Moreover, while previous work among firefighters (e.g., Lebeaut et al., 2020; Paulus et al., 2018; Stanley et al., 2017), has accounted for theoretically relevant psychiatric and demographic covariates and examined lower-order dimensions of AS as well as overall AS, these studies did not examine the incremental influence of AS and its lower-order dimensions across PTSD symptom clusters. Therefore, extending this line of inquiry is warranted in order to expand our understanding of the concurrent and incremental contribution of AS lower order facets in relation to PTSD symptoms, after controlling for the variance accounted for by commonly co-occurring symptoms among firefighters as well as theoretically relevant demographic covariates.

Specifically, the current study aimed to examine the incremental associations of lower-order dimensions of AS (i.e., physical, cognitive, and social concerns), examined concurrently, with regard to both PTSD symptom and cluster severity (i.e., intrusion, avoidance, negative alterations in cognitions and mood, and arousal/reactivity symptoms) among a sample of trauma-exposed, urban firefighters. It was hypothesized that AS physical and cognitive concerns would be incrementally associated with (a) overall PTSD symptom severity and (b) severity of each PTSD symptom cluster. All effects were expected above and beyond the variance accounted for by commonly co-occurring psychological symptoms among firefighters, namely alcohol use (Haddock et al., 2012) and depression (Chiu et al., 2011; Tak et al., 2007), and the theoretically relevant covariates of trauma load (i.e., number of traumatic event types endorsed) and number of years in the fire service, as consistent with past work examining PTSD symptoms among firefighters (Carey et al., 2011; Harvey et al., 2016).

Methods

Participants

This study is a secondary analysis of data collected from a large project examining stress and health-related behaviors among urban firefighters. Participants included 657 professional firefighters (93.3% male; M_age = 38.8; SD = 8.56) recruited from a fire department in a large metropolitan area in the southern U.S. Please see Table 1 for a summary of the sociodemographic characteristics of this sample. All firefighters in this department provide emergency medical services in addition to fire suppression. Study inclusion criteria required participants to be over 18 years of age, current firefighters, and have provided consent to completion of all online questionnaires. Exclusionary criteria consisted of an inability or unwillingness of consenting to complete the online questionnaires. To be included in the current analyses, participants must have endorsed experiencing at least one PTSD Criterion A traumatic life event (American Psychiatric Association, 2013).

Table 1.

Sample characteristics (N = 657).

Variable	Mean (SD)/n (%)
Gender^a
Male	613 (93.3%)
Female	39 (5.9%)
Transgender	5 (0.8%)
Race^a
White	512 (77.9%)
Black/African American	71 (10.8%)
Other	50 (7.6%)
American Indian or Alaskan Native	12 (1.8%)
Asian	11 (1.7%)
Native Hawaiian or other pacific islander	1 (0.2%)
Ethnicity^a
Hispanic/Latino	170 (25.9%)
Non-Hispanic/Latino	487 (74.1%)
Age^a	38.75 (8.56)
Education^a
GED (or equivalent)	1 (0.2%)
High school	53 (8.1%)
Some college	306 (46.6%)
Bachelor’s degree	294 (44.7%)
Marital status^a
Married	446 (67.9%)
Single	123 (18.7%)
Living with a partner	36 (5.5%)
Divorced	50 (7.6%)
Widowed	2 (0.3%)
Armed service history (yes)^a	150 (22.8%)
Years of fire service^a	13.41 (8.79)
Trauma exposure^b	11.58 (3.78)
Transportation accident	640 (97.4%)
Fire or explosion	632 (96.2%)
Natural disaster	623 (94.8%)
Serious accident	568 (86.5%)
Sudden violent death	550 (83.7%)
Sudden accidental death	542 (82.5%)
Physical assault	540 (82.2%)
Exposure to toxic substance	525 (79.9%)
Assault with a weapon	490 (74.6%)
Any other stressful event or experience	485 (73.8%)
Severe human suffering	453 (68.9%)
Life-threatening illness or injury	446 (68.9%)
Sexual assault	387 (58.9%)
Other unwanted or uncomfortable sexual experience	284 (43.2%)
Serious injury, harm, or death you caused to someone else	231 (35.2%)
Combat or exposure to a war-zone	119 (18.1%)
Captivity	96 (14.6%)
Probable PTSD^c	64 (9.7%)
Probable AUD^d	150 (22.8%)
Probable clinical depression^e	69 (10.5%)
Normative anxiety sensitivity^f	558 (84.9%)
Moderate anxiety sensitivity^f	43 (6.5%)
High anxiety sensitivity^f	56 (8.5%)

Demographics questionnaire.

Life events checklist for DSM-5: number of events endorsed as “happened to me,” “witnessed it,” and/or “part of my job”.

PTSD checklist for DSM-5.

Alcohol use disorders identification test.

Center for epidemiologic studies depression scale.

Anxiety sensitivity index-3 (ASI-3); cutoff scores for anxiety sensitivity (AS) derived from Allan et al. (2014), using ASI-3 total score (High AS = ASI-3 total score ≥23; Moderate AS = ASI-3 total score >23 and ≥ to 17; normative AS = ASI-3 total >17).

Measures

Demographic questionnaire

Participants were asked to self-report demographic and medical history information, including sociodemographic characteristics and firefighter service history. In the present analyses, years in the fire service was included as a covariate.

Life events checklist version-5 (LEC-5; Weathers et al., 2013)

The LEC-5 is a self-report questionnaire used to screen for potentially traumatic events experienced at any time throughout the lifespan. Respondents are provided a list of 16 potentially traumatic events (e.g., combat, sexual assault, transportation accident) as well as an additional item assessing for “other” potentially traumatic events not listed. Respondents are asked to indicate (via check mark) whether each listed event “happened to me,” “witnessed it,” “learned about it,” “part of my job,” or “not sure.” If participants endorsed that an event “happened to me,” “witnessed it,” or “part of my job,” this was coded as positive exposure to that particular type of traumatic event. The total number of trauma exposure types was summed to produce a “trauma load” variable indicating the total number of traumatic life event types experienced. Trauma load was included as a covariate in the current study.

Alcohol use disorders identification test (AUDIT; Saunders et al., 1993)

The AUDIT is a 10-item self-report, Likert-style screening instrument developed by the World Health Organization to identify individuals presenting with alcohol-related problems. The AUDIT has demonstrated strong psychometric properties (Garcia Carretero et al., 2016; Hildebrand & Noteborn, 2015; Saunders et al., 1993). The internal consistency for the AUDIT in the current sample was good (α = 0.85). The AUDIT total score was used as a covariate in the present study.

Center for epidemiologic studies depression scale (CES-D; Radloff, 1977)

The CES-D is a 20-item self-report questionnaire used to examine symptoms of depression. Each item is measured on a 3-point Likert-type scale (0 = Rarely or none of the time [less than 1 day], 3 = Most or all of the time [5–7 days]). CES-D symptom severity scores range from 0 to 60, with higher total scores indicating greater depressive symptom severity in the past week. The CES-D has demonstrated strong psychometric properties in past work (Björgvinsson et al., 2013; Cosco et al., 2017; Yang et al., 2015) and good internal consistency in the current study (α = 0.85). The CES-D total score was used as a covariate in the current study.

Anxiety sensitivity index–3 (ASI-3; Taylor et al., 2007)

The ASI-3 is an 18-item self-report measure designed to assess the degree to which individuals fear the potentially negative consequences of anxiety-related symptoms and/or sensations (Reiss, 1991; Reiss et al., 1986). Each item is measured on a 5-point Likert-type scale (0 = Very little, 4 = Very much). The ASI-3 is made up of one higher order factor (ASI-3 total score) scored as a single sum across all items, and three lower-order dimensions: physical, cognitive, and social concerns. The ASI-3 total score may range from 0 to 72, while each of the scores for the three lower-order dimensions may range from 0 to 24. The ASI-3 has good internal consistency and good convergent, discriminant, structural, and criterion-related validity (Kemper et al., 2012; Osman et al., 2010; Taylor et al., 2007). In the present study, internal consistency for the ASI-3 total score was excellent (α = .92). Internal consistencies for the three lower-order dimensions were in the acceptable to excellent range: physical (α = .88), cognitive (α = .91), and social concerns (α = .80). The three lower-order dimension (i.e., physical, cognitive, and social concerns) scores were included as predictors in the current analyses.

PTSD checklist for DSM-5 (PCL-5; Blevins et al., 2015)

Respondents were asked to complete the PCL-5 with regard to the “worst” traumatic event endorsed on the LEC-5. The PCL-5 is a 20-item self-report questionnaire designed to measure each of the DSM-5 PTSD symptom criteria (American Psychiatric Association, 2013). Participants were asked to rate each item on a 5-point Likert-type scale (0 = Not at all to 4 = Extremely) to indicate how much they have been bothered by the symptom in the past month. In the current study, PCL-5 total and subscale scores (for the four DSM-5 symptom clusters) were calculated by summing the respective items. PTSD total symptom severity scores range from 0 to 80, with higher scores indicating greater symptom severity. The PCL-5 has demonstrated good psychometric properties (Blevins et al., 2015; Bovin et al., 2016; Briere, 2001; Morey, 2007). In the present study, internal consistency for the PCL-5 total score was excellent (α = .97). Internal consistencies for the four symptom cluster severity subscales were excellent: intrusions (α = .93; PCL-5 items 1-5), avoidance (α = .92; PCL-5 items 6-7), negative alterations in cognitions/mood (α = .92; PCL-5 items 8-14), and arousal/reactivity (α = .90; PCL-5 items 15-20). The PCL-5 total score and symptom cluster subscale scores were evaluated as outcomes in the current analyses.

Procedure

All firefighters were recruited for participation in the parent study through one fire department. A fire department-wide email was sent to all firefighters, notifying them of the opportunity to complete an online research survey for one continuing education (CE) credit and a chance to win one of several raffle prizes (e.g., movie tickets, restaurant gift certificates). Notification emails indicated that the purpose of the survey was to better understand how firefighters cope with stress and how much firefighters engage in health-related behaviors. Firefighters were given access to the informed consent form and survey through an online fire department CE portal. Once firefighters accessed the portal, they were provided with a description of the survey and the choice to review the informed consent form, which delineated all aspects of the study. Those who did not wish to participate or consent to the study were given the option to indicate (by clicking “no”) that they did not wish to participate. The total amount of time required for participation in this study was estimated at 45–60 min. Firefighters could discontinue participation at any time without penalty. Firefighters who considered completion of the online survey, by clicking “yes” or “no”, received one CE credit for participation.

Data Analytic Plan

All analyses were conducted using IBM SPSS version 26.0 (IBM Corporation, 2017). First, descriptive statistics and bivariate correlations among study variables were examined (see Tables 1 and 2). A series of hierarchical regression analyses was then conducted. Covariates entered in Step 1 included years in the fire service, trauma load (LEC-5 total), alcohol use severity (AUDIT total), and depression symptom severity (CES-D total). At Step 2, each of the three lower-order dimensions of AS (i.e., physical, cognitive, and social concerns) were concurrently entered as predictor variables. This approach therefore ensures that potential observed effects at Step 2 of the hierarchical regression models are distinct from the variance accounted for by the other theoretically relevant factors at Step 1 and the unique effect of each lower-order dimension of AS at Step 2 (Cohen & Cohen, 1983). The analyses independently evaluated the associations of the aforementioned variables with regard to five PTSD symptom-related outcomes: (1) PTSD total symptom severity (PCL-5 total score), (2) PTSD intrusions symptom cluster severity total score (PCL-5 items 1-5), (3) PTSD avoidance symptom cluster severity total score (PCL-5 items 6-7), (4) PTSD negative alterations in cognitions/mood symptom cluster severity total score (PCL-5 items 8-14), and (5) PTSD arousal/reactivity symptom cluster severity total score (PCL-5 items 15-20). A Bonferroni correction was applied in all five planned analyses (α = 0.05/5 = .01) to control for the Type I error rate. Exploratory, binary logistic regressions were conducted to further explore the unique effect of lower-order dimensions of AS and global AS (i.e., ASI-3 total score) on the likelihood that participants met probable diagnostic criteria for PTSD, per the recommended PCL-5 total score diagnostic cutoff of 33 (Bovin et al., 2016) and controlling for all covariates.

Table 2.

Descriptive statistics and bivariate correlations between study variables (N = 657).

	1	2	3	4	5	6	7	8	9	10	11	12
1. Years of fire service^a	–
2. Trauma load^b	.04	–
3. AUDIT total^c	−.03	.10*	–
4. CES-D total^d	.02	.05	.30**	–
5. AS physical^e	.07	.10**	.16**	.33**	–
6. AS cognitive^e	−.02	.11**	.23**	.52**	.71**	–
7. AS social^e	−.03	.16**	.20**	.35**	.57**	.64**	–
8. PCL-5 total^f	.02	.12**	.39**	.66**	.35**	.51**	.39**	–
9. PCL-5 intrusions^f	.02	.11**	.34**	.56**	.32**	.45**	.32**	.92**	–
10. PCL-5 avoidance^f	−.01	.13**	.32**	.51**	.27**	.41**	.35**	.86**	.80**	–
11. PCL-5 NACM^f	.03	.11**	.37**	.67**	.34**	.53**	.40**	.96**	.84**	.80**	–
12. PCL-5 arousal^f	.02	.11**	.38**	.62**	.33**	.47**	.37**	.92**	.76**	.71**	.84**	–
Mean	13.41	11.58	5.52	10.33	1.18	1.76	4.58	10.47	2.60	1.22	3.20	3.45
SD	8.79	3.78	5.04	8.07	3.36	3.57	4.50	14.14	3.80	1.85	4.97	4.67
Range	0–40	1–17	0–40	0–60	0–24	0–24	0–24	0–80	0–20	0–8	0–28	0–24

Note. AS: anxiety sensitivity; SD: standard deviation.

Demographics questionnaire.

Life events checklist for DSM-5 total score.

Alcohol use disorders identification test total score.

Center for epidemiologic studies depression scale total score.

Anxiety sensitivity index-3 total score and lower-dimension facets (AS physical concerns, AS cognitive concerns, and AS social concerns) subscale scores.

PTSD checklist for DSM-5 total score, PCL-5 intrusions subscale score, PCL-5 avoidance subscale score, PCL-5 negative alterations in cognitions and mood (NACM) subscale score, PCL-5 arousal and reactivity subscale score.

p < .05. **p < .01.

Results

Descriptive Statistics and Bivariate Correlations

Descriptive statistics and bivariate correlations among all study variables are shown in Tables 1 and 2, respectively. The average number of traumatic event types endorsed was 11.58 (SD = 3.78), with approximately 9.7% of the sample meeting probable diagnostic criteria for PTSD per the recommended PCL-5 total score diagnostic cutoff of 33 (Bovin et al., 2016), 22.8% meeting criteria for potentially hazardous drinking per the recommended AUDIT total score cutoff of 8 (Babor et al., 1992), and 10.5% meeting probable criteria for clinical depression per the recommended CES-D total score cutoff of 22 (Tak et al., 2007). All correlations between ASI-3 total score and ASI-3 subscale scores with the PCL-5 total score and PCL-5 symptom cluster subscale scores were positive and significant (see Table 2). Years of fire service was not correlated with any study variables. Trauma load was positively and significantly correlated with all study variables with the exception of depressive symptom severity. Depressive symptom severity was positively and significantly correlated with all study variables, whereas alcohol use severity was positively and significantly correlated with all study variables with the exception of years in the fire service.

Hierarchical Regression Analyses

Results of hierarchical regression analyses are shown in Table 3. A Bonferroni correction (α = 0.05/5 = .01) was implemented across analyses. With regard to PTSD symptom severity, Step 1 accounted for a significant 47.4% of variance (p < .001), and alcohol use severity and depressive symptom severity emerged as significant predictors (p’s < .001). Step 2 of the model accounted for an additional significant 3.6% of unique variance (p < .001), with only AS cognitive concerns emerging as a significant incremental predictor (p < .001).

Table 3.

Elevated anxiety sensitivity predicts PTSD symptom cluster severity among firefighters (N = 657).

Variable	ΔR²	t	β	sr²	p
Variable	PTSD symptom severity	t	β	sr²	p
Step 1	.47				<.001
Years of fire service		0.33	.01	.00	.874
Trauma load		2.49	.07	.01	.013
Alcohol use severity		6.80	.20	.04	<.001
Depression severity		19.76	.59	.31	<.001
Step 2	.04				<.001
AS physical concerns		−0.17	−.01	.00	.868
AS cognitive concerns		3.73	.18	.01	<.001
AS social concerns		1.90	.07	.00	.058
Variable	ΔR²	t	B	sr²	p
Variable	PTSD intrusions	t	B	sr²	p
Step 1	.35				<.001
Years of fire service		0.41	.01	.00	.685
Trauma load		2.07	.07	.00	.039
Alcohol use severity		5.56	.19	.03	<.001
Depression severity		14.92	.50	.22	<.001
Step 2	.03				<.001
AS physical concerns		0.70	.03	.00	.482
AS cognitive concerns		3.02	.16	.01	.003
AS social concerns		0.42	.02	.00	.672
Variable	ΔR²	t	β	sr²	p
Variable	PTSD avoidance	t	β	sr²	p
Step 1	.30				<.001
Years of fire service		−0.61	−.02	.00	.540
Trauma load		2.82	.09	.01	.005
Alcohol use severity		5.14	.18	.03	<.001
Depression severity		13.00	.45	.18	<.001
Step 2	.03				<.001
AS physical concerns		−0.58	−.03	.00	.561
AS cognitive concerns		2.12	.12	.00	.034
AS social concerns		2.72	.12	.01	.007
Variable	ΔR²	t	β	sr²	p
Variable	PTSD NACM	t	β	sr²	p
Step 1	.48				<.001
Years of fire service		0.57	.02	.00	.571
Trauma load		2.10	.06	.00	.036
Alcohol use severity		5.86	.18	.03	<.001
Depression severity		20.54	.61	.34	<.001
Step 2	.04				<.001
AS physical concerns		−1.34	−.05	.00	.181
AS cognitive concerns		4.86	.23	.02	<.001
AS social concerns		2.02	.07	.00	.044
Variable	ΔR²	t	β	sr²	p
Variable	PTSD arousal and reactivity	t	β	sr²	p
Step 1	.43				<.001
Years of fire service		0.29	.01	.00	.769
Trauma load		2.04	.06	.00	.042
Alcohol use severity		6.71	.21	.04	<.001
Depression severity		17.87	.55	.28	<.001
Step 2	.03				<.001
AS physical concerns		0.51	.02	.00	.614
AS cognitive concerns		2.30	.113	.00	.022
AS social concerns		1.88	.073	.00	.061

Note. β: standardized beta weight; AS: anxiety sensitivity; Demographics questionnaire; life events checklist for DSM-5 total score; Anxiety sensitivity index-3 total score and lower-order facets (AS physical concerns, AS cognitive concerns, and AS social concerns) subscale scores (ASI-3; Taylor et al., 2007); PTSD checklist for DSM-5 total score, PCL-5 intrusions subscale total score, PCL-5 avoidance subscale score, PCL-5 negative alterations in cognitions and mood (NACM) subscale score, PCL-5 arousal and reactivity subscale score.

In terms of PTSD intrusion symptom severity, Step 1 accounted for a significant 34.7% of variance (p < .001), and alcohol use severity and depressive symptom severity emerged as significant predictors (p’s < .001). Step 2 of the model accounted for an additional, significant 3.6% of unique variance (p < .001), with only AS cognitive concerns emerging as a significant incremental predictor (p = .003).

In terms of PTSD avoidance symptom severity, Step 1 accounted for a significant 29.7% of variance (p < .001), and trauma load, alcohol use severity, and depressive symptom severity emerged as significant predictors (p = .005, p < .001, and p < .001, respectively). Step 2 of the model accounted for an additional significant 2.8% of unique variance (p < .001), with only AS social concerns emerging as a significant incremental predictor (p = .007).

In terms of PTSD negative alterations in cognitions and mood symptom severity, Step 1 accounted for a significant 47.8% of variance (p < .001), and alcohol use severity and depressive symptom severity emerged as significant predictors (p’s < .001). Step 2 of the model accounted for an additional significant 4.2% of unique variance (p < .001), with only AS cognitive concerns emerging as a significant incremental predictor (p < .001).

In terms of PTSD alterations in arousal and reactivity symptom severity, Step 1 accounted for a significant 43.1% of variance (p < .001), and alcohol use severity and depressive symptom severity emerged as significant predictors (p’s < .001). Step 2 of the model accounted for an additional significant 2.6% of unique variance (p < .001); but none of the AS facets evinced a significant main effect.

Exploratory Post Hoc Analyses

Binary logistic regression analyses revealed that global AS (χ²[5] = 149.68, p < .001), but not lower-order dimensions of AS (χ²[7] = 151.85, p’s = .055–.716), significantly predicted probable PTSD diagnosis. The global AS model explained 43.2% (Nagelkerke R²) of the variance in probable PTSD diagnoses and correctly classified 92.5% of cases.

Additionally, as noted above, depression symptom severity was a significant predictor in each model and accounted for a large portion of the overall variance across models. When depression symptom severity was removed as a covariate, lower-order dimensions of AS yielded 12.0% to 21.3% of additional variance.

Discussion

The present study aimed to provide a rigorous test of the incremental and concurrent associations of lower-order dimensions of AS with PTSD symptom severity and PTSD symptom cluster severity among a sample of trauma-exposed firefighters. Hypotheses were partially supported, and all effects were documented after accounting for theoretically relevant covariates (i.e., trauma load, years in the fire service, alcohol use severity, depressive symptom severity). Notably, all bivariate correlations between AS facets and PTSD symptoms were positive and significant (r’s = .27–.52), indicating moderate levels of associations at the zero-order level.

Consistent with hypotheses, AS cognitive concerns was robustly, incrementally associated with overall PTSD symptom severity, which is consistent with extant literature (Boffa et al., 2018; Lang et al., 2002; Raines et al., 2017; Vujanovic et al., 2008) and extends previous findings. AS cognitive concerns was also robustly associated with PTSD intrusion severity and PTSD negative alterations in cognition and mood severity. Notably, with regard to these PTSD symptom clusters, AS cognitive concerns contributed 3%–4% of unique variance above and beyond theoretically relevant covariates that accounted for 35%–48% of the overall variance in PTSD intrusion and PTSD negative alterations in cognitions and mood models. Consistent with cognitive models of PTSD (Ehlers & Clark, 2000; Sachschal et al., 2019), these findings suggest that AS cognitive concerns, or the fears related to having uncontrolled anxious thoughts, may amplify specific PTSD symptoms in trauma-exposed firefighters, particularly intrusive symptoms and negative alterations in cognitions and mood. Alternatively, heightened PTSD symptoms may exacerbate AS cognitive concerns in firefighters (e.g., “When I cannot keep my mind on a task, I worry that I might be going crazy”). For instance, AS cognitive concerns may increase trauma-related maladaptive cognitions (e.g., “I am unsafe”) and the severity of trauma-related intrusions and negative cognitions and mood in trauma-exposed firefighters, and in turn, cause, perpetuate and/or maintain PTSD symptoms over time. Although these results further elucidate the robust association AS with PTSD symptoms (e.g., Marshall et al., 2010), while controlling for relevant covariates, prospective and longitudinal research methodologies are needed to replicate and support these findings, especially among firefighter populations.

Contrary to hypotheses, AS physical concerns was not significantly associated with either overall PTSD symptom severity or any of the four DSM-5 PTSD symptom clusters. The past literature regarding associations between AS physical concerns and PTSD symptomatology is mixed, wherein previous work has found significant relations (e.g., Asmundson & Stapleton, 2008; Naragon-Gainey, 2010; Zahradnik et al., 2009), while other work has found no relations between these two constructs (Lang et al., 2002; Raines et al., 2017). Conversely, AS physical concerns may be uniquely associated with PTSD symptom severity and DSM-5 PTSD cluster severity among firefighters with non-zero suicide risk (Boffa et al., 2018). These findings suggest that firefighters may be particularly unaffected by anxiety-related interoceptive concerns (e.g., fears related to increased heart rate) perhaps due to the nature of their profession. Specifically, firefighters complete extensive training to manage physical discomfort related to carrying heavy equipment and gear (e.g., self-contained breathing apparatuses, fire-resistant turnout jackets and pants) and function in arduous environments (Peterson et al., 2008). It is therefore plausible that, among firefighters, AS physical concerns may have a limited impact on intensifying PTSD-related distress among firefighters and/or that PTSD symptoms do not amplify AS physical concerns (e.g., “When my chest feels tight, I get scared that I won’t be able to breathe properly”), perhaps due to the intensive training to endure physical strain in the fire service. The strenuous aspects of firefighter-specific training may also help explain convergent findings among military veteran populations (Raines et al., 2017) and divergent findings across other populations, such as police officers (Asmundson & Stapleton, 2008), regarding AS physical concerns-PTSD associations. However, this is the first study to concurrently examine the incremental associations of AS facets with regard to PTSD symptom severity among this population, and thus, further research is needed better elucidate these results and conclusions.

Although not predicted, AS social concerns evinced a significant and incremental association with PTSD avoidance symptoms. This aligns with previous meta-analytic work that found incremental relations between AS social concerns and DSM-IV PTSD avoidance symptoms (Naragon-Gainey, 2010) and with work in firefighters that documented associations between AS-social concerns and PTSD avoidance. Although not replicated in this study, past research among military veterans has also documented associations between AS social concerns and DSM-5 PTSD negative alterations in cognitions and mood symptoms (Raines et al., 2017). These results suggest that trauma-exposed firefighters may be acutely sensitive to fears associated with publicly observable anxiety behaviors (e.g., “I worry that other people will notice my anxiety”) and that such beliefs may either amplify trauma-related avoidance or that heightened avoidance may increase social concerns over time possibly due to the shame or stigma that often surrounds perceived mental health issues in the fire service (Henderson et al., 2016; Johnson et al., 2020). Indeed, given the importance of exuding confidence among firefighter populations, particularly in high-risk situations (e.g., an apartment fire), it is possible that noticeable anxiety-related behaviors can be construed as a lack of fitness to work. As such, elevated AS social concerns may intensity the perceived social consequences of PTSD symptomatology among firefighters, which may further exacerbate trauma-related avoidance (Raines et al., 2017). Therefore, interventions that target AS facets may be particularly efficacious for trauma-exposed firefighters.

Notably, approximately 9.7% of the firefighters in this sample met probable criteria for PTSD, 22.8% met probable criteria for alcohol use disorder (AUD), and 10.5% met probable criteria for clinical depression. Interestingly and consistent with the well-established literature, both alcohol use severity as well as depressive symptom severity were significant correlates of all PTSD symptom outcomes, accounting for 30%–48% of the overall variance. Regarding alcohol use severity, the extant literature has consistently demonstrated strong associations between PTSD and alcohol use (e.g., Brown et al., 1999; Kessler et al., 1995), particularly within firefighter populations (e.g., Arbona & Schwartz, 2016; Harvey et al., 2016; Paulus et al., 2017; Tomaka et al., 2017). Past work suggests that there is a functional relationship between PTSD symptoms and alcohol use, where individuals experiencing PTSD symptoms use alcohol to cope with PTSD-related distress (Hawn et al., 2020; Simpson et al., 2014). Past work has found significant overlap between depressive symptomatology and PTSD symptoms (Rytwinski et al., 2013), as demonstrated in first-responder populations (Asmundson & Stapleton, 2008; Fullerton et al., 2004), including firefighters (Meyer et al., 2012). In the present study, depression symptom severity accounted for a large portion of the overall variance in each model. In fact, when depression symptom severity was removed as a covariate, lower-order dimensions of AS yield an average of 16.3% of additional variance (vs 3.4% when covarying for depression symptom severity). Given the robust interrelations between PTSD, depression, and anxiety sensitivity (e.g., Jakupcak et al., 2006; Mitchell et al., 2014; Panagioti et al., 2012), covarying for depression symptom severity serves to strengthen the methodological rigor of the above models and demonstrate the unique variance accounted for by anxiety sensitivity, as evinced by study findings.

Clinical Implications

Various empirically-supported, “gold standard” treatments have been developed and rigorously tested for PTSD, including prolonged exposure therapy (Foa et al., 2013), cognitive processing therapy (Resick et al., 2016), and adjunctive pharmacological interventions (e.g., prazosin; Lancaster et al., 2016). However, despite their time-tested efficacy (Lewis et al., 2020), these interventions are too often marked by poor retention and high dropout rates (Imel et al., 2013; Najavits, 2015). AS may be a promising intervention target to address these shortcomings.

Specifically, AS is a modifiable cognitive vulnerability risk factor (Hovenkamp-Hermelink et al., 2019) that can be targeted through a variety of treatment modalities. Specialized, brief (i.e., 1-4 sessions) interventions that include psychoeducation, cognitive restructuring, and interoceptive exposure exercises (Smits et al., 2008) have been developed and can also be clinician-administered or computer-based (Keough & Schmidt, 2012) to foster dissemination and implementation. A growing body of work has also focused on integrating components of motivational interviewing (e.g., Burke, Arkowitz, & Menchola, 2003) in AS-focused interventions, which may help increase motivation to change and commit to treatment (Korte & Schmidt, 2015). Moreover, among trauma-exposed populations, brief AS reduction programs have yielded durable decreases in both AS and PTSD symptoms (Mitchell et al., 2014; Short et al., 2020; Vujanovic et al., 2012). Taken together, integrating AS-focused interventions as either standalone or adjunct treatment to existing PTSD protocols in the fire service could potentially improve treatment outcomes for both AS as well as PTSD. To date, few randomized controlled clinical trials investigating the prevention and treatment of PTSD have been conducted among firefighters (Mithoefer et al., 2018; Skeffington et al., 2016) and no specialized interventions to target AS have been developed for firefighters.

Limitations and Future Directions

Several limitations should be considered in light of study findings. First, this study employed self-administered measures among a convenience sample of firefighters. Therefore, we cannot preclude the influence of reporting and self-selection biases as well as the effect of method variance on participant responses. Accordingly, future research should incorporate clinician-administered measures (e.g., semi-structured interviews) to validate PTSD symptomatology and extend these findings. Second, although study confidentiality was ensured, it is possible that firefighters with PTSD and/or elevated AS may have underreported the presence and severity of their symptoms due to potential stigma, as previous research among firefighter populations has found that mental health concerns are heavily stigmatized (e.g., Haugen et al., 2017; Johnson et al., 2020). Third, this study’s sample was sociodemographically homogenous—comprised primarily of white, male, career firefighters from a large urban fire department. Given the influence of sociodemographic factors on firefighter mental health (Johnson et al., 2020), it is crucial for future research to recruit more volunteer and rural firefighters as well as firefighters who identify as women and racial/ethnic minorities. Finally, the study employed a cross-sectional research design, and therefore, interpretations regarding the temporality or causality of outcomes is limited. Research methodologies that implement longitudinal or experimental methodologies should be prioritized to examine potential temporal and/or casual associations between AS and PTSD.

Conclusions

The firefighting profession is associated with increased risk for trauma exposure and the development of PTSD. Examining clinically relevant risk factors that influence both the development and maintenance of PTSD symptomatology among firefighters, such as AS, can help inform care for this understudied and underserved population. To date, this is the first study to concurrently examine the unique influence of lower-order dimensions of AS on DSM-5 PTSD symptom clusters among trauma-exposed firefighters, while covarying for theoretically relevant covariates, which include commonly co-occurring symptoms (i.e., alcohol use, depressive symptoms). Study findings revealed that AS cognitive concerns is robustly and incrementally associated with overall PTSD symptom severity as well as three of the four DSM-5 PTSD symptom clusters. Furthermore, AS social concerns is incrementally related to PTSD avoidance symptoms. In light of the malleability of AS, extending this line of inquiry and developing firefighter-specific, evidence-based interventions to target AS and AS-PTSD relations can potentially yield promising outcomes for this unique population.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported, in part, by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) to the University of Houston under Award Number U54MD015946. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iDs

Antoine Lebeaut

Nathaniel Healy

Amanda M. Raines

Anka A. Vujanovic

Author Biographies

Antoine Lebeaut, MA. Antoine is a third-year doctoral student in the University of Houston’s clinical psychology program and a graduate research assistant in the Trauma and Stress Studies Center. He is currently completing a year-long clinical practicum at the Houston Fire Department.

Samuel J. Leonard, MS. Sam is a second-year doctoral student in the University of Houston’s clinical psychology program and a graduate research assistant in the Trauma and Stress Studies Center.

Nathaniel Healy, BA. Nathaniel is a second-year doctoral student in the University of Houston’s clinical psychology program and a graduate research assistant in the Trauma and Stress Studies Center.

Amanda M. Raines, PhD. Dr. Raines is a Clinical Scientist at the Southeast Louisiana Veterans Health Care System and a Core Investigator with the South Central Mental Illness Research, Education and Clinical Center. She holds an academic appointment as an Assistant Professor of Psychiatry in the Section of Community and Population Medicine at Louisiana State University.

Sam J. Buser, PhD. Dr. Buser is a Staff Psychologist and clinical supervisor for the Houston Fire Department in Houston, Texas. He has served as past-president of both the Houston and Texas Psychological Associations and was formally the Director of the Family Therapy Program at the Houston Veterans Administration Medical Center.

Anka A. Vujanovic, PhD. Dr. Vujanovic is an Associate Professor of Psychology and Behavioral and Social Sciences at the University of Houston. She is a licensed clinical psychologist and Director of the Trauma and Stress Studies Center.

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