Firefighting is inherently dangerous. If you don’t believe me, just look at the warning labels in your turnouts.
Every time you turn out, you willingly accept the risks that come with the occupation of firefighting. You took an oath and swore that you would respond if called. By climbing on that rig, you accept that other people are worth the risk, even if that means putting yourself in harm’s way and risking your life so they may live.
What an honor and a privilege that is to call this your “job.”
Your time of service to your community will not come without a cost. For some, physical or mental health will decline. For most, it will be a combination of both as firefighters willingly sacrifice their minds and bodies for the opportunity to serve our communities.
For those who continually push the limits throughout the lifespan of their career, the constant stress of chasing excellence in the fire service can lead to burnout and other issues. As those issues mount, they create a cocktail of impairments that can leave the best in our business disabled and disarmed, often without them even knowing what’s happening before it’s too late. That’s what this article is about—bringing awareness of what some may be experiencing but, until now, couldn’t find the answers for why they didn’t feel like themselves or why they couldn’t push through like they used to. If this sounds familiar, you may be dealing with what Chris Frueh, Ph.D., calls “Firefighter Syndrome.”
Dr. Chris Freuh and Firefighter Syndrome
Chris Frueh, Ph.D., is a clinical psychologist and professor of psychology at the University of Hawaii, Hilo. He has more than 30 years of professional experience working with military veterans, active-duty personnel, and our nation’s most elite high performers and special operators widely considered to be at the “tip of the spear.” He has co-authored more than 300 scientific publications and in 2020 published a research paper in The International Journal of Psychiatry Medicine titled, “Operator Syndrome: a unique constellation of medical and behavioral health-care needs of military special operation forces.”1
In the paper, he describes a list of interrelated health and functional impairments resulting from prolonged chronic stress and physical demands of a career in military special operations. Recognizing similar, but different, impairments in firefighters, Dr. Frueh adapted his original framework to understand the accumulation of these physiological, physical, psychological, and neuroendocrine injuries, characterized by symptoms consistently occurring together that make up what he calls “Firefighter Syndrome.” By taking a whole-systems approach to addressing each of these conditions, we may better be able to support the complex needs of firefighters in hopes of tackling the health crisis that is plaguing the American fire service today.
Conditions Associated With Firefighter Syndrome
Traumatic Brain Injury (TBI) and Toxic Exposures
“People with TBI are more likely to experience memory and cognitive impairments, chronic pain and headaches, depression, and suicide.”1
The standard issue helmet as part of our PPE ensemble is designed specially to protect us from high-impact forces experienced from falling debris, flying projectiles, and other events that can result in a concussion. These events are cumulative over time, and along with toxic exposures to poisonous gases, hazardous materials, and even the protective gear we wear, they can cause significant damage to the brain, leading to negative downstream effects on every other bodily system.2
Hormonal Dysfunction
“TBI has a powerful dysregulating effect on the endocrine system.”1
Chronic and acute stress, commonly experienced in the fire service, can dysregulate the endocrine system via the hypothalamic-pituitary-adrenal (HPA) axis leading to low testosterone, as well as an increase in the stress hormones cortisol and norepinephrine. These stress hormones, when left unchecked, can have a cascade of effects on our sleep cycles, making it difficult to fall asleep or stay asleep. Hormonal dysfunction can also lead to other serious complications when it comes to mood, cognition, and energy.2
Sleep Disturbance
Sleep disturbance is unfortunately a universal evil we all face in the fire service. Regardless of the time of day, we swore an oath and promised our community that “we will come for you” when they call for us in their time of greatest need. “Chronic sleep deprivation contributes to the increased risk of impaired immune functioning, Type 2 diabetes, heart disease, obesity, and chronic pain.”1 Even if we can go back to sleep after returning from our last call, we may not be able to get adequate time in critical sleep stages that can act as protective measure against TBI and aid in our body’s natural ability to heal and recover from the physical and mental toll associated with shift work.
Obstructive Sleep Apnea/Central Sleep Apnea Disturbances
“Obstructive sleep apnea is caused by a blockage of the airways during sleep, while central sleep apnea is caused by the brain failing to send appropriate signal to the muscles that control breathing”2 Signs and symptoms may include snoring, gasping for air, and even lapses in breathing while you are asleep, which can lead to further cognitive and physical impairments. “If untreated, it can lead to a number of serious health problems including high blood pressure, strokes, heart failure, headaches, diabetes, and depression.”1
Chronic Pain, Orthopedic Problems, Headaches
Due to the very nature of the job, many firefighters have a long history of injuries. By a show of hands at the dinner table, one might even conclude that this job has a 100 percent risk of injury, with many resulting in the need for orthopedic surgery and significant time lost due to the long recovery that follows. “Research shows a connection between TBI, PTSD (post-traumatic stress disorder), and pain severity.”1 As these symptoms accumulate, firefighters may find it increasingly difficult to manage chronic pain and rely on unhealthy coping means.
Substance Abuse
“Alcohol is the most common type of substance abuse among firefighters.”2 Whether used to cope with stress, depression, or anxiety, long-term habitual drinking and substance abuse can lead to a wide range of physical, cognitive, emotional, and relationship troubles—along with further disruption to their sleep.
Post-Traumatic Stress Disorder (PTSD)
“A body of research suggests a strong link between TBI and PTSD, including biological explanations of how TBI weakens working memory, increasing vulnerability to developing PTSD.”1 Defined by American Psychiatry and expressed as a formula, it can look like this:
PTSD = Depression + Anxiety + Fear Reactivity with Possible Avoidance3
“Firefighters are at a heightened risk for PTSD due to the traumatic nature of their work”2 and “there is a relationship between TBI and PTSD.”1
Depression
“Depression is defined as a persistent feeling of sadness, hopelessness, mood swings, a loss of pleasure or inability to feel pleasure, low self-esteem or negative thoughts about the self, changes in appetite and weight, and suicidal thoughts or behaviors.”2 Suicide is a significant concern in the fire service, as the National Fallen Firefighters Foundation estimates there are between 100 and 200 firefighter deaths by suicide each year, which is double the rate of the general population.4
Anger
“Anger is closely tied to trauma and PTSD and is often a response used to cope and maintain a sense of control.”2 This can manifest itself in the form of physical aggression and outbursts, while the physiological responses like rapid heart rate, muscle tension, and negative thoughts and beliefs can remain largely unseen to those around us.
Worry, Restlessness, Stress Reactivity, Panic Attacks
“The chronic stressors of firefighting can lead to anxiety. Common indicators are restlessness or the inability to relax, heightened reactivity to minor stresses, and excessive rumination or worrying.”2 The demands of the job can place one in an increased state of arousal. When they go home, it may be difficult to manage these symptoms even in the safety of their own home.
Marital and Family Dysfunction
“The firefighting profession has a high divorce rate, due in part to physical, emotional, interpersonal, and financial stressors.”2 Marital and family dysfunction can develop as depression, anger, and the inability to regulate oneself, which takes a toll on their relationships.
Sexual Health and Intimacy Issues
“Stressors from firefighting can lead to an increased risk of intimacy issues and sexual dysfunction.”2 Hormonal dysfunction can lead to a lack of drive while impairments due to TBI and PTSD may cause isolation and the inability to connect with their partner, resulting in a lack of intimacy in what was once a very loving relationship.
Hypervigilance
While being “on guard” is important when we’re on duty, if you can’t shut it off, hypervigilance can cause further sleep disruption and make it challenging to relax when you don’t need to be ready for the next call. “Hypervigilance sustained for long periods of time becomes exhausting to maintain and can cause cascading physical and emotional concerns.”2
Memory, Concentration, Cognitive Impairments
“Many aspects of firefighting can lead to cognitive impairments.”2 Sleep deprivation, TBI, and symptoms associated with PTSD can all lead to issues with poor memory, impulsivity, and impaired planning and problem solving, making it difficult to operate in one of the most dangerous environments in the world–the fireground. This can lead to poor decision making that could get somebody injured or even killed.
Perceptual System Impairments
“Issues with perception and the sensory system can develop in connection with TBI, toxic exposure, and other physiological stressors.”2 Whether we’re in the driver seat responding to a call or performing a search under hostile conditions, the loss of hearing, double vision, or balance and coordination difficulties could lead to catastrophic events resulting in injury or death.
Disrupted Hydration and Nutrition
“Observable shifts in nutrition needs and symptoms of dehydration are common.”2 Shift work and the never-ending supply of “thank you for your service” cakes and cookies make it difficult to reach for that healthy snack when a handful of bon bons is readily available and a quick and easy “fix.” Hydration needs are elevated because the sweat loss during fireground operations is exponentially higher due to the inability of our protective gear to dissipate body heat effectively.
Home-to-Work Transition Challenges
For many, it is difficult to not “bring the work home” with you. Exposure to traumatic events is often not easy to forget and can require professional help to work through. There can also be a lack of decompression when one heads straight home without downtime to regulate and reset before walking through the front door, inundated with household chores and kids who have been anxiously waiting your return.
Existential Concerns
“Existential concerns can arise after experiencing traumatic events such as the death of a comrade or being unable to save a down/trapped responder or a citizen considered viable.”2 Many of the calls we respond to do not always end with a positive result. No matter the level of training and preparation, sometimes it’s just not in our control. These types of experiences can lead firefighters to feel guilt, lack of motivation, and loss of personal identity or mission that can have devastating downstream effects on one’s mindset and future outlook.
| Summary of Symptoms & Conditions related to Firefighter Syndrome | ||
| Traumatic Brain Injury (TBI) and Toxic Exposures | Hormonal Dysfunction | Sleep Disturbance |
| Obstructive Sleep Apnea / Central Sleep Apnea Disturbances | Chronic Pain, Orthopedic problems, headaches | Substance Use |
| Post-Traumatic Stress Disorder (PTSD) | Depression | Anger |
| Worry, restlessness, stress reactivity, panic attacks | Martial and family dysfunction | Problems with sexual health and intimacy |
| Being “on guard” and hypervigilant | Memory, concentration, cognitive impairments | Perceptual system impairments |
| Disrupted hydration and nutrition | Home-to-work transition difficulties | Existential concerns |
So Now What?
Chris Frueh, Ph.D., and his team developed the “Firefighter Syndrome Questionnaire” to help educate and guide firefighters back to safety. “While each component of Firefighter Syndrome can be evaluated separately by medical professionals, there is incredible value in having a simple, realistic, self-report measure that can be used to evaluate each of the elements.”2
Start by taking the self-assessment and see if you are dealing with any of the conditions. Following the questionnaire, get an honest assessment from someone close to you, who you trust and who knows you well. This may be illuminating as they may identify many of the conditions you exhibit on a daily basis but are unable to witness yourself. If your assessment is alarming in any or all the domains, seek professional help so you don’t waste any more time and can get back on track to who you used to be or want to be.
Finding the specialists you need may be difficult to do on your own, so include your primary care physician in your search by sending your questionnaire and resources like Frueh’s Research paper1 and his article “Firefighter Syndrome: A proposed whole systems framework.” This may help the physician better understand the entirety of what’s going on instead of treating each condition in isolation. Ideally, it calls for a whole systems, multidisciplinary approach that would include a team of specialty clinical experts working together to address your complex needs as Frueh outlines in his most recent book3, research paper2, and article.1
Each individual condition can be tracked over time, which may be a useful tool to use throughout your career. While you might not be experiencing any impairments now, a career in the fire service makes you more susceptible to the conditions referenced in this article. If at any point you see things trending in the wrong direction, the Firefighter Syndrome Questionnaire can help with early detection before it’s too late. At the very least, if someone you know is struggling, share this information with them, as they might be looking for answers and this could be the helping hand they need to find their way back.
Frueh’s 2020 research paper laid the foundation and framework for understanding “Firefighter Syndrome”. His book “Operator Syndrome” which takes an in depth look into the symptoms was published in 2024.
Resources:
- Firefighter Syndrome: https://chrisfrueh.com/firefighter-syndrome/
- Chris Frueh, Phd: https://chrisfrueh.com/
- Marcus Brain Institute of Brain Health: https://medschool.cuanschutz.edu/mibh
Firefighter Syndrome Works Cited
- Frueh BC, Madan A, Fowler JC, Stomberg S, Bradshaw M, Kelly K, Weinstein B, Luttrell M, Danner SG, Beidel DC. “Operator syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med. 2020 Jul;55(4):281-295. doi: 10.1177/0091217420906659. Epub 2020 Feb 13. PMID: 32052666.
- Frueh, C., Miller, J., O’Neill, M. L., Wylie, B., Zingray, I., Rudine, G., & Madan, A. (2023, August 9). Firefighter syndrome: A proposed whole systems framework. CRACKYL Magazine. https://crackyl.com/health/mental/firefighter-syndrome/
- Frueh, C. (2024). Operator Syndrome. Ballast Books.
- Roberts, N. F. (2023, March 20). Sounding the alarm: Firefighters remain more likely to die by suicide than on duty. Forbes. https://www.forbes.com/sites/nicoleroberts/2023/03/19/sounding-the-alarm-firefighters-remain-more-likely-to-die-by-suicide-than-on-duty/
Bio:
Eric Haskins is a Senior Firefighter for the Nampa (ID) Fire Protection District, currently assigned to “Roosevelt’s Rough Riders” on Engine 6 and was Idaho’s first graduate of the Georgia Smoke Diver program. Prior to joining the American Fire Service in 2016, he was a U.S. Project Gold Snowboard Team member and competed internationally for six years in pursuit of Olympic Gold. Retiring in 2009, he played ice hockey for Boise State University while earning his bachelor’s degree in exercise science, specializing in exercise physiology. Haskins is a National Strength and Conditioning Association-Certified Strength & Conditioning Specialist(CSCS), Tactical Strength & Conditioning Facilitator(TSAC-F), and Westside Barbell Conjugate Tactical coach. Haskins is the Head Coach of Firehouse Strength & Conditioning, an online strength & conditioning program designed specifically for firefighters.
