Posttraumatic Stress Disorder Among Law Enforcement ... · prevalent anxiety and anxiety-related disorders (Connor & Butterfield, 2003). Projected lifetime prevalence of PTSD using

Forte Journal Of Neuroscience and Psychology Volume 1 Issue 3 2019

Review Article

Citation: Anish S. Shah. “Posttraumatic Stress Disorder Among Law Enforcement Officers: A Review of Risk Factors and Current Trends in Treatment”. Forte Journal Of Neuroscience and Psychology 1.3 (2019): 1-14

Page | 1

Posttraumatic Stress Disorder Among Law Enforcement Officers: A

Review of Risk Factors and Current Trends in Treatment

Anish S. Shah *1

1 MD, 480 B Tesconi Circle, Santa Rosa, California 95401

*Corresponding Author: Anish Shah, MD, 480 B Tesconi Circle, Santa Rosa, California 95401

E-mail: [email protected]

Received: October 01, 2019; Accepted: October 15, 2019; Published: November 10, 2019

Active duty law enforcement officers are at risk of

developing posttraumatic stress disorder (PTSD).

Concerns about job status might impede the individual

from seeking treatment. Relatively little is known about

the emergence and subsequent effects of PTSD among

active duty law enforcement officers. It is unclear

whether traditional treatment for the disorder is

appropriate in this unique population. The current

literature on PTSD among law enforcement officers is

reviewed using the Ovid Psych Info, Ovid Medline, and

NCBI PubMed databases. Data suggest that law

enforcement officers exhibiting poorer general

adjustment, past history of adversity, personal

psychiatric history, familial psychiatric history, and a

tendency to engage in cognitive avoidance of

distressing thoughts as well as memories about past

stressful events are at a greater risk for suffering from

PTSD. Further research is suggested to improve the

understanding of PTSD and its treatment within law

enforcement.

Keywords: Occupational trauma exposure, chronic

trauma exposure, posttraumatic stress disorder, law

enforcement, treatment.

Individuals employed in law enforcement are exposed

to a significant degree of job-related stress and

traumatic events. Law enforcement officers who

experience severe events or who are exposed to a high

number of traumatic situations are at greater risk for

developing symptoms of traumatic stress, such as

chronic sleep loss, intrusion and avoidance symptoms

such as flashbacks, and depression (Arble, Lumley,

Pole, Blessman, & Arnetz, 2016; Fleischmann, Strode,

Broussard, & Compton, 2016; Green, 2001; Holowka &

Marx, 2012; Kopel & Friedman, 1999; LeBlanc,

Regehr, Jelley, & Barath, 2007; Maia, Marmar, Metzler,

Nobrega, Berger, Mendlowicz et al., 2007; Neylan,

Brunet, Pole, Best, Metzler, Yehuda et al., 2004;

Regehr, Hill, Knott, & Sault, 2003; Rehehr, Johanis,

Dimitropoulos, Bartram, & Hope, 2003). Symptoms of

traumatic stress can have detrimental effects on the

individual’s occupational and/or academic functioning

Introduction

Abstract

mailto:[email protected]


Review Article


Page | 2

(Smith, Schnurr, & Rosenheck, 2005), their

interpersonal relationships (Bolton, Hill, O’Ryan,

Udwin et al., 2004), their marital relationship (Sayers,

Farrow, Ross, & Oslin, 2009), and even their overall

family functioning (Cohen, Zerach, & Solomon, 2011;

Sayers et al., 2009). Among law enforcement officers

untreated PTSD can have cumulative effects on

functioning and is a serious public health issue (Ellrich

& Baier, 2015; Violanti, 2014).

While both psychological and physiological responses

to intensely stressful and traumatic events have long

been recognized and studied, PTSD as a distinct

diagnostic category did not emerge until the 1980s,

when it first appeared in the third edition of the

Diagnostic and Statistical Manual of Mental Disorders

(DSM-III; American Psychiatric Association [APA],

1980). PTSD was not extensively studied prior to 1980,

and research on various treatment options and their

applicability to specific populations remains sparse.

There have also been changes to the diagnostic criteria

for PTSD in each subsequent manual (APA, 1980;

APA, 2013; APA, 2015).

Despite these subtle changes, a diagnosis of PTSD is

generally warranted when an individual exhibits

excessively recurrent distressing symptoms following

an episode of intense stress or trauma and causes the

individual some degree of impairment in their ability to

function on a day to day basis. Most recently, the DSM-

5 has adopted a four-cluster framework for categorizing

the individual symptoms of PTSD (APA, 2015). These

four symptom clusters recognized by the DSM-5

include: re-experiencing, avoidance, negative cognitive

and mood alterations, and hyperarousal (APA, 2015).

PTSD is under-recognized and often left untreated.

Undiagnosed and untreated PTSD is of particular

concern, given the degree of debilitation associated with

the condition. PTSD is among the most severe and

impairing of all psychiatric diagnoses (Bobo, Warner, &

Warner, 2007). Individuals employed in certain

occupations, where they are regularly exposed to

stressors and potential trauma, are believed to be at an

increased risk for developing symptoms of PTSD

(Adjeroh, McCanlies, Andrew, Burchfield, & Violanti,

2014). This is particularly true for active duty law

enforcement officers, who have regular involvement

with highly stressful and traumatic events throughout

their entire careers (Adjeroh et al., 2014; Bernard,

Driscoll, Kitt, West, & Tak, 2006). While it is relatively

uncommon for law enforcement officers to be called

upon to assist with emergency service work,

involvement in such work increases an officer’s risk for

exposure to potentially stressful and traumatic

situations. In general, the day-to-day duties of a law

enforcement officer are associated with increased

exposure to a wide variety of distressing and

emotionally challenging incidents, supporting law

enforcement’s reputation as one of the most stressful

occupations (Hetherington, 1993; Levy-Gigi, Richter-

Levin, & Kéri, 2014).

Relatively little is known about the emergence and

subsequent effects of PTSD among active duty law

enforcement officers (Arble et al., 2016). Much of the

existing data are based upon samples of military

veterans (Sayers et al., 2009). Current studies have

begun to emerge exploring PTSD within the law

enforcement population (Ellrich & Baier, 2015).

Findings from this literature might help explain why

many law enforcement officers suffer from unmanaged

symptoms of PTSD and inform treatment

recommendations for this specific population.


Review Article


Page | 3

A literature search was conducted in the databases Ovid

PsychInfo, Ovid Medline, and NCBI PubMed. Key

search terms included: post-traumatic stress disorder(s);

PTSD; law enforcement officer(s); law enforcement;

police; police officer(s). The literature search covered

the period 1995-2015. Only articles in English were

included. Articles on military personnel were excluded.

This search yielded 665 articles. A second selection

process was conducted, in which studies were included

that were considered of the highest scientific quality.

These types of studies included: longitudinal studies,

systematic reviews, cross-sectional studies, and clinical

studies. Case studies and other qualitative studies were

excluded. All manuscripts were published in peer-

reviewed journals.

Prevalence:

Twelve-month prevalence rates of PTSD across the

United States are estimated to be about 3.5% (APA,

2015). Lifetime prevalence of the disorder is 10% for

women and 5% for men, ranking it among the top most

prevalent anxiety and anxiety-related disorders (Connor

& Butterfield, 2003). Projected lifetime prevalence of

PTSD using DSM-IV criteria is estimated to be 8.7% at

age 75 (APA, 2015). Lower prevalence of the disorder

is found in Europe and most Asian, African, and Latin

American countries, where estimates are around 0.5%

to 1.0% of the population (APA, 2015). Some of the

highest prevalence rates of PTSD recorded are from the

more developing nations, while the lowest prevalence

estimates are seen across countries within Europe

(Atwoli, Stein, Koenen, & McLaughlin, 2015; Turnbull,

1998).

Law enforcement officers comprise a population that is

regarded at particular risk for developing PTSD, given

their regular exposure to highly stressful and traumatic

events across the entire course of their career. However,

not all individuals who have been exposed to a

traumatic event go on to later develop problems with

PTSD. Conditional risk of PTSD pertains to the

prevalence rate of PTSD only among those individuals

who have been exposed to trauma, rather than the broad

prevalence rate of PTSD regardless of whether the

individuals have a history of exposure to a traumatic

event or not (Adjeroh et al., 2014; Resick, Friedman, &

Keane, 2007). Rates of PTSD are highest among

veterans and individuals who are employed in positions

associated with greater exposure to traumatic

circumstances, including law enforcement officers,

firefighters, and other emergency medical personnel

(APA, 2015). Limited data are available on the

prevalence of PTSD among law enforcement officers,

in particular. Previous studies have reported rates of

between 7-19% within this population, though these

estimates are somewhat outdated and may be somewhat

higher (Carlier, Lamberts, & Gersons, 1997; Darius,

Heine, & Böckelmann, 2014; Robinson, Sigman, &

Wilson, 1997; West, Bernard, Mueller, Kitt, Driscoll, &

Tak, 2008; Yuan, Wang, Inslicht, McCaslin, Metzler,

Henn-Haase et al., 2011).

According to surveys conducted by World

Mental Health (WMH), relatively low conditional

prevalence rates of PTSD were identified across other

countries. The conditional prevalence of PTSD in South

Africa was 3.5%, which is quite similar to the 3.3%

conditional prevalence of PTSD in Spain, and

somewhat higher than the rate of 2.5% in Italy (Atwoli

et al., 2013; Ellrich & Baier, 2015; Kawakami et al.,

METHODS

RESULTS


Review Article


Page | 4

2014; Levy-Gigi, Richter-Levin, & Kéri, 2014). The

type of trauma also may play a role in the development

of PTSD symptoms, which is particularly relevant for

law enforcement officers. According to WMH surveys,

higher conditional prevalence rates of developing PTSD,

particularly in response to being exposed to sexual and

physical violence, were reported in Spain, Japan, and

Northern Ireland (Atwoli et al., 2013; Ellrich & Baier,

2015). In comparison to the general population, law

enforcement officers are much more likely to be

directly exposed to these types of trauma in the line of

duty, placing them at greater risk for developing

symptoms of PTSD.

Risk Factors:

A few studies exist which have examined the potential

risk factors for developing PTSD among law

enforcement officers, particularly those who are

involved in emergency service work. It seems that

officers who exhibit poorer general adjustment, past

history of adversity, personal psychiatric history,

familial psychiatric history, and a tendency to engage in

cognitive avoidance of distressing thoughts and

memories about past stressful events are at a much

greater risk for suffering from PTSD (Hetherington,

1993). Findings from a study conducted by Weiss and

colleagues (1995) suggested that officers in emergency

service who tended to dissociate were more at risk for

later developing symptoms of PTSD than their peers

who did not exhibit this same tendency toward

dissociation.

Other factors that place law enforcement

officers at increased risk for developing PTSD

symptoms following a traumatic event at work include

introversion, difficulty expressing feelings, insufficient

time off following the trauma exposure, dissatisfaction

with job support following trauma exposure, and a low

degree of job security (Carlier, Lamberts, & Gersons,

1997). By virtue of their job requirements, the natural

progression of the cognitive and emotional processing

that must occur following exposure to trauma may be

interrupted for law enforcement officers, given that they

may have to file multiple reports on details surrounding

the event and serve in court sometimes even years

following the incident (Ellrich & Baier, 2015). Law

enforcement officers must also routinely practice

emotional numbing in response to traumatic events in

order to more quickly resume action in the line of duty,

which can be stressful and also impede post-event

emotional processing (Weiss et al., 1995).

Several sociodemographic correlates for the

development of PTSD have also been identified and

should be considered as significant risk factors

compounding the risk for developing PTSD among

populations of law enforcement officers. Being female

was found to be associated with higher rates of PTSD

(in some countries almost double) than that of their

male counterparts in all of the countries around the

world. Males report being exposed to more general

traumatic experiences, while females are more likely to

be exposed to sexual trauma (Breslau et al., 2004). It is

important to understand why these differences would

emerge, as it is likely to have significant impacts on not

only treatment-seeking behavior, but also the particular

intervention that is employed (van der Meer et al.,

2016).

Other identified sociodemographic correlates

for developing symptoms of PTSD following exposure

to a traumatic event include: low educational attainment,

being over 65 years of age, unemployment, and

retirement (Breslau et al., 2004; Carlier, Lamberts, &

Gersons, 1997; Hetherington, 1993; McFarlane, 1988;

Weiss, Marmar, Metzler, & Ronfeldt, 1995). An

individual’s personality characteristics, including their


Review Article


Page | 5

general temperament, likely contribute to developing

symptoms of PTSD, as well as their likelihood of

getting treatment when symptoms become a problem.

It should be noted that it is reasonable to

expect emotional responses to trauma. Almost all

individuals will exhibit some degree of symptoms

shortly after a traumatic event. These responses, which

typically resolve within several days, several weeks, or

even a few months, are considered normal and non-

pathological (Atwoli et al., 2013; Bisson, Tavakoly,

Witteveen, Ajdukovic et al., 2010). It is believed that

these symptoms are part of the cognitive and emotional

processing of the event that must be completed in order

to move toward acceptance, greater resilience, and

posttraumatic growth. Continued work in reducing risk

factors for law enforcement is crucial, as prevalence

rates have been estimated to be as much as 13% for

PTSD symptoms among suburban law enforcement

officers (Yehuda, McFarlane, & Shalev, 1998).

Therefore, a large portion of active duty law

enforcement officers face exposure to potentially

stressful and traumatizing events on a regular basis.

Previous work on PTSD demonstrates that a dose-

response relationship exists between exposure to a

traumatic event or stressor and the development of

negative mental health outcomes (Heavey, Homish,

Andrew, McCanlies, Mnatsakanova, Violanti et al.,

2015). This means that the more severe the trauma

event, the greater likelihood there is for developing

symptoms of the disorder (APA, 2015). Fullerton and

colleagues (2004) found that first responders to the

September 11th attacks exhibited higher rates of acute

stress disorder, posttraumatic stress disorder, and

depressive disorder, than a comparison group. This is

often exacerbated by being assigned to atypical work

activities during a disaster, in which they may not have

received adequate training for, as well as strenuous

work hours, sleep deprivation, separation from family

and support, and home destruction (Bernard et al.,

2006).

Comorbid Conditions:

The rate of comorbidity between PTSD and other

psychiatric conditions within the general population is

quite high. Lifetime estimates have suggested that

between 70 and 80% of individuals suffering from

PTSD also have a co-occurring psychiatric condition

(Brady, Killeen, Brewerton, & Lucerini, 2000). Some of

the most common co-occurring psychiatric conditions

include: Generalized Anxiety Disorder (GAD),

Obsessive-Compulsive Disorder (OCD), Alcohol and

Drug abuse, Depression, and even Schizophrenia. The

link between PTSD and substance abuse disorders is

quite strong. Individuals who are diagnosed with PTSD

are 4.5 times more likely to subsequently develop a

substance abuse disorder (Kessler, Sonnega, Bromet,

Hughes, & Nelson, 1995). There are several possible

explanations to account for the high comorbidity

between PTSD and substance abuse disorders. Some

have postulated that individuals with PTSD use and

abuse substances as a way to escape their intense

feelings of discomfort associated with difficult

memories or flashbacks of the trauma (Araújo et al.,

2013). This framework for understanding the

comorbidity is known as the self-medicating model.

Another model that has been widely accepted in terms

of understanding the link between PTSD and substance

abuse disorders is the high-risk model. This model

suggests that individuals who experience more frequent

traumatic situations inherently take more risks and are

therefore more likely to abuse substances (Atwoli et al.,

2015).

Findings from several studies have suggested

that the rates of comorbidity within populations of law


Review Article


Page | 6

enforcement officers are similar to the comorbidity rates

observed within the general population (Breslau et al.,

1998; Kessler et al., 1995). More work is necessary in

this area to more carefully estimate the rates of

comorbidity among law enforcement officers, given the

differential prevalence rates of other conditions within

this unique population. Comorbidities that accompany

PTSD can lead to many distinct treatment challenges,

given the complex intertwining of the mental and

physical aspects of each of the conditions. This will be

described in more detail below.

Treatment:

As with many other mental health conditions presenting

to health care facilities, PTSD is under-recognized and

often left untreated. Undiagnosed and untreated PTSD

is of particular concern among individuals employed in

law enforcement, given the degree of debilitation

associated with the condition and the risk for chronic

exposure to traumatic events. Some have even

suggested that PTSD is among the most severe and

impairing of all psychiatric diagnoses (Bobo, Warner, &

Warner, 2007). The onset of symptoms for this

condition is often delayed weeks, months, or even years

following the significant traumatic event, which can

lead to longer delays in receiving adequate treatment,

while in most instances prevention and early

intervention are recommended (APA, 2015).

In guidelines published by the Department of

Veterans Affairs/Department of Defense (VA/DoD;

2010), it is recommended that reasonable efforts be

made to increase the psychological resilience of

workers who are employed in high-risk occupations

where the probability of trauma exposure is moderate or

high. While very little is known about the possibility of

adequately preparing an individual or community for

exposure to a traumatic event, several suggestions are

identified for pre-trauma preparation that take into

account theoretical models of the development of PTSD,

existing empirical work on risk factors for developing

symptoms of PTSD, and emerging evidence on

resiliency factors (Stergiopoulos, Cimo, Cheng, Bonato,

& Dewa, 2011; VA/DoD, 2010). These suggestions for

preparing individuals in these high-risk professions for

potential exposure to trauma include: a) Provide

realistic training with vicarious, simulated, or actual

exposure to traumatic stimuli likely to be encountered

as part of their work; b) Strengthen perceived coping

abilities through instruction and practice in the use of a

variety of coping skills (e.g., problem-solving strategies,

stress inoculation training, assertion, and cognitive

restructuring); c) Create supportive interpersonal

working environment; d) Develop and ongoing

cultivation of adaptive beliefs regarding the work role

and potential traumatic events; and e) Develop a

workplace-specific comprehensive traumatic stress

management program. Despite widespread distribution,

explicit implementation of these recommendations is

not commonly practiced in most workplaces, with the

exception of some military training environments, and

there is little evidence on the use of these prevention

strategies within law enforcement.

Recommendations have also been made for

steps to take following exposure to trauma (Baldwin,

Anderson, Nutt, Allgulander, Bandelow, den Boer et al.,

2014; CADTH, 2015; VA/DoD, 2010). For known

cases of exposure to trauma, it is important to assess the

exposure in terms of type, frequency, nature, and

severity. Not all individuals who have been exposed to

trauma and may be at risk for developing PTSD self-

identify as suffering from symptoms of the disorder.

Therefore, these guidelines also include provisions for

screening individuals for potential symptoms, while

also remaining sensitive to concerns regarding social


Review Article


Page | 7

stigma and adverse occupational effects from results of

the screen, both of which are particularly important for

individuals employed in law enforcement positions.

For individuals who have been identified as

meeting criteria for PTSD, recommendations include

both psychotherapy, specifically those that are

evidenced-based, and pharmacotherapy as potential

first-line treatments (Baldwin et al., 2014; CADTH,

2015; VA/DoD, 2010). In terms of psychotherapy

interventions that have received support for the

treatment of PTSD symptoms within the general public,

these methods include exposure-based therapy,

cognitive behavior therapy (CBT), eye movement

desensitization and reprocessing (EMDR), relaxation

techniques, imagery rehearsal therapy, brief

psychodynamic therapy, and hypnotic techniques. In

terms of pharmacotherapy, medications receiving the

strongest support include selective serotonin reuptake

inhibitors (SSRIs; fluoxetine, paroxetine, or sertraline),

or serotonin-norepinephrine reuptake inhibitors (SNRIs;

venlafaxine). Several other drugs have also been

suggested for the treatment of PTSD, including tricyclic

antidepressants and monoamine oxidase inhibitors.

While in most instances a combination of

psychotherapy and pharmacotherapy is recommended

as best practice, monotherapy with either psychotherapy

or pharmacotherapy is recommended as a first-line

treatment for PTSD (CADTH, 2015). Across all

guidelines, no specific provisions were identified for

working with individuals employed in law enforcement.

Moreover, there are relatively few studies available that

examine the effectiveness and applicability of these

interventions among populations of law enforcement

officers in particular and more work is necessary to

address this gap in the literature (Grauwiler, Barocas, &

Mills, 2008).

According to practice guidelines established by the

International Society for Traumatic Stress Studies,

PTSD is associated with significant impairments within

the workplace (Kessler et al., 1995). This is of

particular concern with regard to law enforcement,

given that they face emotionally taxing and traumatic

experiences regularly as part of their chosen career.

PTSD has been associated with approximately 3.6 lost

days of productivity at work every month across the

United States (Fox et al., 2012). This lost time emerges

primarily in the form of decreased productivity and

absenteeism. This highlights the need for appropriate

interventions to address the detrimental effects of PTSD

within the workplace in order to help the individual

effectively return to work (Evans, Pistrang, & Billings,

2013). Of note, the most important factor to consider

with regard to treatment for PTSD among law

enforcement officers is early intervention during the

acute phase immediately following a traumatic or

potentially traumatic event (Stergiopoulos et al., 2011;

VA/DoD, 2010). This is the period of time when the

individual begins to regain their emotional control over

the situation, restores interpersonal communications, re-

consolidates their identity, regains their sense of

empowerment through reengagement in work, and

begins to build their sense of hope and anticipation of

potential recovery (Crews & Landers, 1987; Heir,

Hussain, & Weisæth, 2008; Tumbull, 1998; Wessely &

Dandeker, 2010; Zohar, Sonnino, Juven-Wetzler, &

Cohen, 2009).

The Exposure and Response Prevention (E/RP)

component of Cognitive Behavior Therapy (CBT), in

particular, was thought to be ideal in treating the

impairing symptoms of PTSD. CBT alone is regarded

as the ‘gold standard’ for treating many different

anxiety disorders and has been shown to be more

effective in reducing symptoms of PTSD than


Review Article


Page | 8

medication (Bisson et al., 2010; Cusack et al., 2015;

Roberts, Kitchiner, Kenardy, & Bisson, 2009). This

treatment is regarded as well established, following

many empirical studies examining its effectiveness.

CBT is unique in that the emphasis is placed primarily

on the individual’s present situation and is more

problem-focused than most other treatments.

Individuals who participate in CBT learn skills in

identifying distorted patterns of thinking and how to

modify their beliefs. With the E/RP component,

individuals then begin to practice facing situations that

they previous avoided in a structured and graded way.

This treatment is based upon the idea that a person’s

thoughts and beliefs about a situation have a powerful

influence over the manner in which they feel and

behave in those types of situations. Individuals

gradually learn to face distressing thoughts and

memories of the traumatic event, which in turn reduces

the associated distress.

Another commonly recommended treatment

for managing symptoms of PTSD is Eye Movement

Desensitization and Reprocessing (EMDR) therapy.

This is an integrative approach which has received

some support for its effectiveness in treating symptoms

of PTSD. Hypnosis has also been used with some

success (Cusack et al., 2015). Medication may also be

prescribed for treating symptoms of PTSD. These

medications would be used to treat the impairing

symptoms of the condition, such as prolonged insomnia

and/or intense feelings of anxiety or panic. Though

currently available medications are not as effective as

participation in a course of CBT, some individuals may

prefer this treatment plan as taking medication is more

convenient than psychotherapy (Cusack et al., 2015).

Given the stigma that still exists in terms of mental

health, the law enforcement population, in particular,

may prefer medications given their discrete nature, as

they do not have to leave work in order to attend regular

weekly appointments.

According to clinical trials, selective serotonin

reuptake inhibitors (SSRIs) are considered the gold

standard for treating symptoms of PTSD (Brady et al.,

2000; Cusack et al., 2015; Marshall, Beebe, Oldham, &

Zaninelli, 2001). Both sertraline (brand name: Zoloft)

and paroxetine (brand name: Paxil) have received

approval from the Food and Drug Administration

(FDA) as a first-line treatment for PTSD (Brady et al.,

2000; Cusack et al., 2015; Friedman, Marmar, Baker,

Sikes, & Farfel, 2007; Marshall et al., 2001).SSRIs may

not be indicated for managing symptoms of PTSD and

alternative medications may be considered for

individuals exhibiting symptoms of comorbid

conditions such as bipolar disorder, as SSRIs have been

shown to induce manic episodes. Other medications can

be used off-label for treating PTSD and have received

some support from previous trials, though more work is

necessary to more fully explore their efficacy in treating

symptoms of PTSD. These medications include:

venlafaxine (brand name: Effexor), mirtazapine (brand

name: Remeron), nefazodone (brand name: Serzone),

topiramate (brand name: Topimax), lamotrigine (brand

name: Lamictal), carbamazepine (brand name:

Tegretol), and divalproex (brand name: Depakote).

Despite the availability of effective treatments,

law enforcement officers may be reluctant to seek

treatment owing to the stigma of mental health and fear

of repercussions at work. More work is necessary in

order to identify and reduce any potential barriers to

seeking treatment.


Review Article


Page | 9

PTSD is a complex disorder for which symptoms

emerge six months or more following exposure to an

intense and emotionally taxing or traumatic situation

and law enforcement officers may be at greatest risk for

developing difficulties with regard to PTSD, given their

regular exposure to traumatic events (Robinson, Sigman,

& Wilson, 1997; Zelazny & Simms, 2015). Law

enforcement officers suffering from untreated or

unmanaged PTSD are at an increased risk for

impairments at work, loss of productivity, and even

developing other comorbidity psychiatric conditions,

such as depression or substance use disorder. It may be

difficult for law enforcement officers to consider

seeking treatment, owing to limited time-off and stigma

surrounding mental health. Therefore, this population

brings a collection of unique barriers to receiving the

help that they need. The most recommended treatment

approach for PTSD among law enforcement officers is

CBT, which targets the individual’s experiential

avoidance of the traumatic event. Other treatments for

PTSD include EMDR and hypnosis, though more work

is necessary in order to provide adequate empirical

support for these techniques in their effectiveness in

treating the symptoms of PTSD.

1. Adjeroh, L. C., McCanlies, E. C., Andrew, M.

E., Burchfield, C. M., & Violanti, J. M. (2014).

Stressful life events and posttraumatic growth

among police officers. Annals of

Epidemiology, 24(9), 701.

2. Alexander, D. A., & Wells, A. (1991).

Reactions of police officers to body handling

after a major disaster: A before and after

comparison. British Journal of Psychiatry,

159(4), 517-555. doi: 10.1192/bjp.159.4.547

3. American Psychiatric Association. (1980).

Diagnostic and statistical manual of mental

disorders (3rd ed.). Washington, DC: Author.



disorders (4th ed.). Washington, DC: Author.



disorders (5th ed.). Washington, DC: Author.

6. Araújo, A. X., Berger, W., Coutinho, E. S.,

Marques-Portella, C., Luz, M. P., Cabizuca,

M.,…Mendlowicz, M. V. (2013). Comorbid

depressive symptoms in treatment-seeking

PTSD outpatients affect multiple domains of

quality of life. Comprehensive Psychiatry,

55(1), 56-63. doi:

10.1016/j.comppsych.2013.09.004

7. Arble, E., Lumley, M. A., Pole, N., Blessman,

J., & Arnetz, B. B. (2016). Refinement and

Preliminary Testing of an Imagery-Based

Program to Improve Coping and Performance

and Prevent Trauma Among Urban Police

Officers. Journal of Police and Criminal

Psychology, 1-10. doi:10.1007/s11896-016-

9191-z

8. Atwoli, L., Stein, D. J., Koenen, K. C., &

McLaughlin, K. A. (2015). Epidemiology of

posttraumatic stress disorder: Prevalence,

correlates and consequences. Current Opinion

in Psychiatry, 28(4), 307-311. doi:

10.1097/YCO.0000000000000167

9. Atwoli, L., Stein, D. J., Williams, D. R.,

McLaughlin, K. A., Petukhova, M., Kessler, R.

CONCLUSIONS

REFERENCES


Review Article


Page | 10

C., & Koenen, K. C. (2013). Trauma and

posttraumatic stress disorder in South Africa:

Analysis from the South African Stress and

Health Study. BMC Psychiatry, 13, 182. doi:

10.1186/1471-244X-13-182

10. Baldwin, D. S., Anderson, I. M., Nutt, D. J.,

Allgulander, C., Bandelow, B., den Boer, J. A.,

Christmas, D. M., Davies, S., Fineberg, N. et

al., (2014). Evidence-based pharmacological

treatment of anxiety disorders, post-traumatic

stress disorder and obsessive-compulsive

disorder: A revision of the 2005 guidelines

from the British Association for

Psychopharmacology. Journal of

Psychopharmacology, 28(5), 403-439. doi:

10.1177/0269881114525674

11. Bernard, B., Driscoll, R., Kitt, M., West, C.,

Tak, S. (2006). Health hazard evaluation of

police officers and firefighters after Hurricane

Katrina – New Orleans, Louisiana, October 17-

28 and November 30-December 5, 20005.

MMWR: Morbidity and Mortality Weekly

Report, 55(16), 456-458.

12. Bisson, J.I., Tavakoly, B., Witteveen, A. B.,

Ajdukovic, D. Jehel, L., Johansen, V. J.,…Olff,

M. (2010). TENTS guidelines: Development

of post-disaster psychosocial care guidelines

through a Delphi process. British Journal of

Psychiatry, 196(1), 69–74. doi:

10.1192/bjp.bp.109.066266

13. Bobo, W. V., Warner, C. H., & Warner, C. M.

(2007). The management of post traumatic

stress disorder (PTSD) in the primary care

setting. Southern Medical Journal, 100(8),

797–802.

14. Bolton, D., Hill, J., O’Ryan, D., Udwin, O.,

Boyle, S., & Yule, W. (2004). Long-term

effects of psychological trauma on

psychosocial functioning. Journal of Child

Psychology and Psychiatry, 45(5), 1007-1014.

doi: 10.1111/j.1469-7610.2004.t01-1-00292.x

15. Brady, K. T., Killeen, T. K., Brewerton, T., &

Lucerini, S. (2000). Comorbidity of psychiatric

disorders and posttraumatic stress disorder.

Journal of Clinical Psychiatry, 61(Suppl 7),

22-32.

16. Brady, K. T., Pearlstein, T., Asnis, G. M.,

Baker, D., Rothbaum, B., Sikes, C. R., &

Farfel, G. M. (2000). Efficacy and safety of

sertraline treatment of posttraumatic stress

disorder: A randomized controlled trial.

Journal of the American Medical Association,

283(14), 1837-1844.

doi:10.1001/jama.283.14.1837

17. Breslau, N., Kessler, R. C., Chilcoat, H. D.,

Schultz, L. R., Davis, G. C., & Andreski, P.

(1998). Trauma and posttraumatic stress

disorder in the community: The 1996 Detroit

Area Survey of Trauma. Archives of General

Psychiatry, 55(7), 626-632.

doi:10.1001/archpsyc.55.7.626

18. Breslau, N., Peterson, E. L., Poisson, L. M.

Schultz, L. R., & Lucia, V. C. (2004).

Estimating posttraumatic stress disorder in the

community: Lifetime perspective and the

impact of typical traumatic events.

Psychological Medicine, 34(5), 889–898.

19. Canadian Agency for Drugs and Technologies

in Health (2015). Treatment for post-traumatic

stress disorder, operational stress injury, or

critical incident stress: A review of guidelines

[Internet]. Ottawa (ON): CADTH Rapid

Response Reports. [Epub ahead of print]

20. Carlier, I. V., Lamberts, R. D., & Gersons, B.

P. (1997). Risk factors for posttraumatic stress

symptomatology in police officers: A


Review Article


Page | 11

prospective analysis. Journal of Nervous and

Mental Disorder, 185(8), 498–506.

21. Carlier, I. V., Lamberts, R. D., & Gersons, B.

P. (2000). The dimensionality of trauma: A

multidimensional scaling comparison of police

officers with and without posttraumatic stress

disorder. Psychiatry Research, 97, 29-39. doi:

http://dx.doi.org/10.1016/S0165-

1781(00)00211-0

22. Cohen, E., Zerach, G., & Solomon, Z. (2011).

The implication of combat-induced stress

reaction, PTSD, and attachment in parenting

among war veterans. Journal of Family

Psychology, 25(5), 688-698. doi:

10.1037/a0024065

23. Connor, K. M., & Butterfield, M. I. (2003).

Posttraumatic stress disorder. Focus, 1(3), 247-

262. doi: http://dx.doi.org/10.1176/foc.1.3.247

24. Crews, D. J., & Landers, D. M. (1987). A

meta-analytic review of aerobic fitness and

reactivity to psychosocial stressors. Medicine

and Science in Sports and Exercise, 19(5

Suppl), 114–120.

25. Cusack, K., Jonas, D. E., Formeris, C. A.,

Wines, C., Sonis, J., Middleton, J.

C.,…Gaynes, B. N. (2015). Psychological

treatments for adults with posttraumatic stress

disorder: A systematic review and meta-

analysis. Clinical Psychology Review. doi:

10.1016/j.cpr.2015.10.003 [Epub ahead of

print]

26. Darius, S., Heine, J., & Böckelmann, I. (2014).

Prevalence of symptoms of posttraumatic

stress disease in police officers in relation to

job-specific requirements. Psychotherapy and

Psychosomatic Medical Psychology, 64(9-10),

393-396. doi: 10.1055/s-0034-1387729

27. Department of Veterans Affairs, Department of

Defense. (2010). VA/DoD Clinical Practical

Guideline. Management of post-traumatic

stress. [Internet]. Available from:

http://www.healthquality.va.gov/guidelines/M

H/ptsd/cpg_PTSD-full-201011612.PDF

28. Ellrich, K., & Baier, D. (2015). Post-traumatic

stress symptoms in police officers following

violent assaults: A study on general and police-

specific risk and protective factors. Journal of

Interpersonal Violence. doi:

10.1177/0886260515586358 [Epub ahead of

print]

29. Evans, R., Pistrang, N., & Billings, J. (2013).

Police officers’ experiences of supportive and

unsupportive social interactions following

traumatic incidents. European Journal of

Psychotraumatology, 4. doi: 10.3402/ejpt.v4i0

[Epub ahead of print]

30. Fleischmann, M. H., Strode, P., Broussard, B.,

& Compton, M. T. (2016). Law enforcement

officers’ perceptions of and responses to

traumatic events: A survey of officers

completing Crisis Intervention Team training.

Policing and Society, 1-8. doi:

10.1080/10439463.2016.1234469

31. Fox, J., Desai, M. M., Britten, K., Lucas, G.,

Luneau, R., & Rosenthal, M. S. (2012).

Mental-health conditions, barriers to care, and

productivity loss among officers in an urban

police department. Connecticut Medicine,

76(9), 525-531.

32. Fullerton, C. S., Ursano, R. J., Wang, L.

(2004). Acute stress disorder, posttraumatic

stress disorder, and depression in disaster or

rescue workers. American Journal of

Psychiatry, 161(8), 1370-1376.

http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-full-201011612.PDF

http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-full-201011612.PDF


Review Article


Page | 12

33. Friedman, M. J., Marmar, C. R., Baker, D. G.,

Sikes, C. R., & Farfel, G. M. (2007).

Randomized, double blind comparison of

sertraline and placebo for posttraumatic stress

disorder in Department of Veterans Affairs

setting. Journal of Clinical Psychiatry, 68(5),

711-720.

34. Grauwiler, P. Barocas, B., & Mills, L. G.

(2008). Police peer support programs: Current

knowledge and practice. International Journal

of Emergency Mental Health, 10(1), 27-38.

35. Green, C. (2001). Human remains and the

psychological impact on police officers:

Excerpts from psychiatric observations.

Australasian Journal of Disaster and Trauma

Studies, 2001-2.

36. Heavey, S. C., Homish, G. G., Andrew, M. E.,

McCanlies, E., Mnatsakanova, A., Violanti, J.

M., & Burchfiel, C. M. (2015). Law

enforcement officers’ involvement level in

Hurricane Katrina and alcohol use.

International Journal of Emergency Mental

Health, 17(1), 267-273.

37. Heir, T., Hussain, A., & Weisæth, L. (2008).

Managing the after-effects of disaster

trauma—the essentials of early intervention.

European Psychiatric Review, 1(1), 66–69.

38. Hetherington, A. (1993). Traumatic stress on

the roads. Journal of Social Behavior and

Personality, 8(5), 369-378.

39. Holowka, D. W., & Marx, B. P. (2012).

Assessing PTSD-related functional impairment

and quality of life. In G. J. Beck & D. M.

Sloan (Eds.), Oxford handbook of traumatic

stress disorders. New York (NY): Oxford

University Press.

40. Kawakami, N., Tsuchiya, M., Umeda, M.,

Koenen, K. C., & Kessler, R. C. (2014).

Trauma and posttraumatic stress disorder in

Japan: Results from the World Mental Health

Japan Survey. Journal of Psychiatric Research,

53, 157-165. doi:

10.1016/j.jpsychires.2014.01.015

41. Kessler, R. C., Sonnega, A., Bromet, E.,

Hughes, M. & Nelson, C. B. (1995).

Posttraumatic stress disorder in the National

Comorbidity Survey. Archives of General

Psychiatry, 52(12), 1048–1060.

42. Kopel H., & Friedman, M. (1999). Effects of

exposure to violence in South African police.

In J. Violanti & D. Paton (Eds.), Police

Trauma: The Aftermath of Civilian Combat

(pp 99-112). Springfield (IL): Charles Thomas.

43. LeBlanc, V. R., Regehr, C., Jelley, R. B., &

Barath, I. (2007). Does posttraumatic stress

disorder (PTSD) affect performance? Journal

of Nervous and Mental Disorder, 195, 701-704.

44. Levy-Gigi, E., Richter-Levin, G., & Kéri, S.

(2014). The hidden price of repeated traumatic

exposure: Different cognitive deficits in

different first-responders. Frontiers in

Behavioral Neuroscience, 8. doi:

10.3389/fnbeh.2014.00281 [Epub]

45. Maia, D. B., Marmar, C. R., Metzler, T.,

Nóbrega, A., Berger, W., Mendlowicz, M. V.,

Coutinho, E. S., & Figueira, I. (2007). Post-

traumatic stress symptoms in an elite unit of

Brazilian police officers: Prevalence and

impact on psychosocial functioning and on

physical and mental health. Journal of

Affective Disorders, 97(1-3), 241-245. doi:

http://dx.doi.org/10.1016/j.jad.2006.06.004

46. Marshall, R. D., Beebe, K. L., Oldham, M., &

Zaninelli, R. (2001). Efficacy and safety of

paroxetine treatment for chronic PTSD: A

fixed-dose, placebo-controlled study.


Review Article


Page | 13

American Journal of Psychiatry, 158(12),

1982-1988. doi:

http://dx.doi.org/10.1176/appi.ajp.158.12.1982

47. McFarlane, A. C. (1988). The aethiology of

post-traumatic stress disorders following a

natural disaster. British Journal of Psychiatry,

152, 116-121.

48. Mumford, E. A., Taylor, B. G., & Kubu, B.

(2015). Law Enforcement Officer Safety and

Wellness. Police Quarterly, 18(2), 111-133.

49. Neylan, T. C., Brunet, A., Pole, N., Best, S. R.,

Metzler, T. J., Yehuda, R., & Marmar, C. R.

(2005). PTSD symptoms predict waking

salivary cortisol levels in police officers.

Psychoneuroendocrinology, 30(4), 373-381.

DOI:

http://dx.doi.org/10.1016/j.psyneuen.2004.10.0

05

50. Rabe-Hemp, C. (2008). Survival in an “all

boys club”: Policewomen and their fight for

acceptance. International Journal of Police

Strategies & Management, 31, 251-270.

51. Regehr, C., Hill, J., Knott, T., & Sault, B.

(2003). Social support, self-efficacy, and

trauma in new recruits and experienced

firefighters. Stress and Health, 19, 189-193.

52. Regehr, C., Johanis, D., Dimitropoulous, G.,

Bartram, C., & Hope, G. (2003). The police

officer and the public inquiry. Brief Treatment

and Crisis Intervention, 3, 383-396.

53. Resick, P. A., Friedman, M. J., & Keane, T. M.

(2007). Handbook of PTSD, Science and

Practice. New York: Guilford Press.

54. Roberts, N. P., Kitchiner, N. J., Kenardy, J., &

Bisson, J. I. (2009). Systematic review and

meta-analysis of multiple-session early

interventions following traumatic events.

American Journal of Psychiatry, 166(3), 293–

301. doi: 10.1176/appi.ajp.2008.08040590

55. Robinson, H. M., Sigman, M. R., & Wilson, J.

P. (1997). Duty-related stressor and PTSD

symptoms in suburban police officers.

Psychological Reports, 81(3 Pt 1), 835-845.

56. Sayers, S. L., Farrow, V. A., Ross, J., & Oslin,

D. W. (2009). Family problems among

recently returned military veterans referred for

a mental health evaluation. Journal of Clinical

Psychiatry, 70(2), 163-170. doi:

10.4088/JCP.07m03863

57. Smith, M. W., Schnurr, P. P., & Rosenheck, R.

A. (2005). Employment outcomes and PTSD

symptom severity. Mental Health Services

Research 7(2), 89-101. doi: 10.1007/s11020-

005-3780-2

58. Stergiopoulos, E., Cimo, A., Cheng, C.,

Bonato, S., & Dewa, C. S. (2011).

Interventions to improve work outcomes in

work-related PTSD: A systematic review.

BMC Public Health, 11, 838. doi:

10.1186/1471-2458-11-838

59. Turnbull, G. J. (1998). A review of post-

traumatic stress disorder. Part I: Historical

development and classification. Injury, 29, 87-

91. doi: http://dx.doi.org/10.1016/S0020-

1383(97)00131-9

60. van der Meer, C. A., Bakker, A., Smit, A. S.,

van Buschbach, S., den Dekker, M.,

Westerveld, G. J., ... & Olff, M. (2016).

Gender and Age Differences in Trauma and

PTSD Among Dutch Treatment-Seeking

Police Officers. The Journal of Nervous and

Mental Disease.

61. Violanti, J. M. (2014). Dying for the job:

Police work exposure and health. Charles C

Thomas Publisher.


Review Article


Page | 14

62. Weiss, D. S., Marmar, C. R., Metzler, T. J., &

Ronfeldt, H. M. (1995). Predicting

symptomatic distress in emergency service

personnel. Journal of Consulting and Clinical

Psychology, 63(3), 361-368. doi:

http://dx.doi.org/10.1037/0022-006X.63.3.361

63. Wessely, S., & Dandeker, C. (2010). King’s

Centre for Military Health Research: A Fifteen

Year Report. What Has Been Achieved by

Fifteen Years of Research into the Health of

the UK Forces? London: King’s College.

64. West, C., Bernard, B., Mueller, C., Kitt, M.,

Driscoll, R., & Tak, S. (2008). Mental health

outcomes in police personnel after Hurricane

Katrina. Journal of Occupational and

Environmental Medicine, 50, 689-695. doi:

10.1097/JOM.0b013e3181638685

65. Yehuda, R., McFarlane, A., & Shalev, A.

(1998). Predicting the development of

posttraumatic stress disorder from the acute

response to a traumatic event. Biological

Psychiatry, 44(12), 1305-1313. doi:

http://dx.doi.org/10.1016/S0006-

3223(98)00276-5

66. Yoo, H., & Franke, W. D. (2010). Stress and

cardiovascular disease risk in female law

enforcement officers. International Archives of

Occupational and Environmental Health, 84(3),

279-286. doi: 10.1007/s00420-010-0548-9

67. Yuan, C., Wang, Z., Inslicht, S. S., McCaslin,

S. E., Metzler, T. J., Henn-Haase, C., Apfel, B.

A., Tong, H., Neylan, T. C. et al. (2011).

Protective factors for posttraumatic stress

disorder symptoms in a prospective study of

police officers. Psychiatry Research, 188(1),

45-50. doi: 10.1016/j.psychres.2010.10.034

68. Zelazny, K., & Simms, L. J. (2015).

Confirmatory factor analysis of DSM-5

posttraumatic stress disorder symptoms in

psychiatric samples differing in Criterion A

status. Journal of Anxiety Disorders, 34, 15-23.

doi: 10.1016/j.janxdis.2015.05.009

69. Zohar, J., Sonnino, R., Juven-Wetzler, A., &

Cohen, H. (2009). Can posttraumatic stress

disorder be prevented? CNS Spectrums, 14(1

Suppl 1), 44–51.

Documents

Posttraumatic Stress Disorder Among Law Enforcement ... · prevalent anxiety and anxiety-related disorders (Connor & Butterfield, 2003). Projected lifetime prevalence of PTSD using