Abstract
Trauma exposure and posttraumatic stress disorder (PTSD) symptoms among firefighters are prevalent and well-documented. Insecure adult attachment style (AAS) and distress tolerance (DT) present two factors with demonstrated relevance to the etiology and maintenance of PTSD. Few studies have examined these constructs in relation to PTSD symptomatology among firefighter populations. The present investigation examined the indirect effect of insecure romantic AAS (i.e., anxious AAS, avoidant AAS) on PTSD symptom severity through DT among firefighters. Exploratory analyses examined this model with each of the PTSD symptom clusters as outcomes. The sample was comprised of 105 firefighters (Mage=40.43, SD=9.15, 95.2% male) recruited from various departments in the southern U.S. An indirect effect was calculated using 10,000 bootstrapped samples. Indirect effects models in the primary analyses were significant when both anxious AAS (β=.20, SE=.10, CI=.06–.43) and avoidant AAS (β=.28, SE=.12, CI=.08–.54) were evaluated as predictors. Effects were evident after accounting for gender, relationship status, years of fire service, and trauma load (i.e., number of potentially traumatic event types experienced). Exploratory analyses revealed that anxious and avoidant AAS are both indirectly related to the PTSD intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity symptom clusters through DT. Anxious AAS also demonstrated an indirect association with PTSD avoidance symptoms through DT. Attachment styles may influence PTSD symptoms among firefighters through a firefighter’s perceived ability to withstand emotional distress. This line of inquiry has potential to inform specialized intervention programs for firefighters. Clinical and empirical implications are discussed.
Keywords: adult attachment, distress tolerance, trauma, PTSD, firefighter
Introduction
Firefighters are repeatedly exposed to potentially traumatic events (PTEs) due to the nature of their work, and they therefore represent a population at high risk of developing posttraumatic stress disorder (PTSD) symptoms (Beaton et al., 1998; Meyer et al., 2012). Rates of PTSD among the general United States (US) population are estimated to be at 8.3%, whereas rates of the disorder among firefighters in the US are estimated to be as high as 32.4% (Kilpatrick et al., 2013; Tomaka et al., 2017). Given elevated rates of PTEs and PTSD among firefighters, it is important to understand clinically relevant factors, potentially targetable via intervention, that are associated with PTSD symptomatology.
Adult attachment style (AAS) is one such factor with relevance to understanding PTSD symptoms among firefighters. Romantic AAS can be categorized as either secure or insecure; and insecure AAS can be additionally sub-classified as either avoidant or anxious (Ainsworth, 1991; Mikulincer & Shaver, 2007). Avoidant AAS is defined by a fear of dependence and intimacy with romantic partners; whereas anxious AAS is characterized by a fear of rejection and/or abandonment (Collins & Read, 1990). The association between insecure AAS and PTSD symptomatology has been well-established (Bryant, 2016; Charuvastra & Cloitre, 2008; O’Connor & Elklit, 2008). Generally, individuals with secure AAS may respond to a PTE by seeking security in and support from others, whereas people with insecure AAS may struggle to make use of relationships and coping resources, responding to a PTE with anxiety and/or avoidance, as well as PTSD-related cognitions and behaviors, such as guilt, shame, and/or social mistrust (Bryant, 2016; Charuvastra & Cloitre, 2008). A meta-analysis found a modest effect size ( = .26) for the positive association between insecure AAS and PTSD severity (Woodhouse, Ayers, & Field, 2015). The meta-analysis additionally found that most of these studies have examined AAS with self-report measurements of romantic attachment (Woodhouse et al., 2015). No published studies to date have evaluated associations between romantic (or general) AAS and psychopathology among firefighters, generally, or with PTSD among firefighters, specifically. Given the established literature documenting insecure AAS-PTSD symptom associations, it is clinically relevant to understand the mechanisms that may underlie this association among firefighters.
Distress tolerance (DT), defined as the ability to tolerate negative emotional states (Leyro et al., 2010), is another promising factor with demonstrated relevance to PTSD (e.g., Banducci et al., 2017; Vujanovic et al., 2015; Vujanovic et al., 2016) and theoretical relevance to AAS-PTSD associations. An emerging literature has documented that perceived DT, indexed via self-report, is robustly and negatively (inversely) associated with PTSD symptomatology across studies of trauma-exposed adults, including firefighters (Banducci et al., 2016; Marshall-Berenz et al., 2010; Vujanovic, Bakhshaie, et al., 2017; Vujanovic, Dutcher, et al., 2017; Vujanovic et al., 2015; Vujanovic et al., 2016). Among firefighters, DT has been negatively associated with PTSD symptom severity in cross-sectional studies (e.g., Bartlett et al., 2018; Zegel et al., 2019). Emergent work has documented a positive association between DT, measured via the Distress Tolerance Scale (DTS; Simons & Gaher, 2005), and secure AAS, indexed via the Adult Attachment Scale (AAS; Collins & Read, 1990; Hazan & Shaver, 1987), in the context of marital relationship functioning (Mahmoudpour et al., 2018). No published studies to date have examined the link between AAS and DT in the context of psychological symptoms, generally, or within firefighter populations, specifically.
Theoretically, firefighters with insecure romantic AAS may experience greater PTSD symptom severity due to lower levels of DT. Romantic AAS is implicated in human stress regulation (Bretherton, 1992; Mikulincer, & Shaver, 2003). In stressful situations, individuals with avoidant AASs utilize de-activating strategies (maladaptively decreasing social proximity/engagement), whereas individuals with anxious AASs utilize over-activating strategies (maladaptively increasing social proximity/engagement) (Mikulincer & Shaver, 2007; Vrticka & Vuilleumier, 2012). The social cognitions and behaviors associated with these de-activating and over-activating strategies impair the individual’s ability to form and sustain supportive or validating relationships and, moreover, impair the individual’s ability to make use of relationships during times of stress, which can lead to issues with regulating negative emotions and, in turn, recovering from a PTE (Mikulincer & Shaver, 2012; Vrticka et al., 2012). Thus, both avoidant and anxious AAS are related to the development or maintenance of the perceived inability to withstand negative emotional states—distress intolerance. Trauma-exposed firefighters with insecure romantic AAS may experience greater PTSD symptom severity due to their lower perceived ability to tolerate negative emotional states. Furthermore, all four of the DSM-5 PTSD symptom clusters have been independently associated with both insecure AAS styles and DT in previous research (e.g., Banducci et al., 2017; Vujanovic et al., 2015; Vujanovic et al., 2016). Taken together, DT has a clear putative mechanistic association to the human stress response (see Trafton & Gifford, 2011), and it could be suggested that attachment-related stress responses may significantly influence one’s ability to tolerate perceived distress and that this may be related to PTSD symptom severity.
Thus, the objective of the present study was to investigate the relations of insecure romantic AAS with DT and PTSD severity among firefighters. No published studies have examined associations among AAS, DT, and PTSD symptom severity generally, or among firefighter populations, specifically. This research has the potential to inform the development of policy and clinical interventions for firefighters. Specifically, we hypothesized that both anxious and avoidant AAS will be indirectly related to PTSD symptom severity through lower DT (See Figure 1). Effects were expected after accounting for theoretically relevant covariates, including gender, relationship status, years of fire service, and trauma load (i.e., number of potentially traumatic event types experienced). The covariates were selected based on their associations with PTSD symptom severity in previous research among firefighter samples (Bartlett et al., 2018; Bartlett, Gallagher, Tran, & Vujanovic, 2019; Stanley et al., 2019). To examine whether anxious and avoidant AAS are related to specific PTSD symptom clusters through DT, exploratory analyses were conducted to evaluate each of the PTSD symptom clusters (i.e., intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity) as outcomes.
Figure 1.
Indirect effect of anxious and avoidant AAS on PTSD Symptom Severity through DT. Path “a” shows the direct effect of anxious AAS (ECRS-SF) on DT (DTS). Path “b” shows the direct effect of DT (DTS) on PTSD symptom severity (PCL-5). Path “c” shows the total effect of anxious AAS (ECRS-SF) on PTSD symptom severity (PCL-5). Path “c’” shows the direct effect of anxious AAS (ECRS-SF) on PTSD symptom severity (PCL-5) controlling for DT (DTS).
Method
Participants
This study was conducted as a secondary analysis of data from a larger project examining stress, resilience, and well-being among firefighters. The sample included 105 career and volunteer firefighters (Mage = 40.43, SD = 9.15, 95.2% male) recruited online from career, volunteer, and combination (i.e., volunteer and career) fire departments in a large metropolitan area in the southern United States. A total of nine fire departments were represented in the study, and over 4,800 firefighters were invited and eligible to participate. A total of 689 firefighters initiated the survey, and 105 firefighters completed all the measures utilized in the present study. Please see Table 1 for a summary of participant characteristics. Participants included full- or part-time career or volunteer firefighters, including those who also provide emergency medical services (EMS). Inclusion criteria required participants to be 18 years of age or older, to currently work as a firefighter in a career, combination, or volunteer fire department, and to consent to participating in the completion of all online questionnaires. For the present analysis, participants must have endorsed at least one PTSD Criterion A traumatic life event per DSM-5 (American Psychiatric Association, 2013)
Table 1.
Sample characteristics.
| Variable | N | % |
|---|---|---|
| Gender | -- | -- |
| Male | 100 | 95.2 |
| Female | 4 | 3.8 |
| Transgender | 1 | 1.0 |
| Race | -- | -- |
| White | 78 | 74.3 |
| Black or African American | 7 | 6.7 |
| American Indian or Alaskan Native | 7 | 6.7 |
| Asian | 0 | 0 |
| Native Hawaiian or other Pacific Islander | 1 | 1.0 |
| Other | 12 | 11.4 |
| Ethnicity | -- | -- |
| Hispanic/Latino | 25 | 23.8 |
| Non-Hispanic/Latino | 80 | 76.2 |
| Education | -- | -- |
| Some High School (or GED Equivalent) | 43 | 41.0 |
| High School Graduate | 0 | 0 |
| Some College | 52 | 49.5 |
| College Graduate | 10 | 9.5 |
| Relationship Status | -- | -- |
| Married | 78 | 74.3 |
| Living with a partner | 6 | 5.7 |
| Single | 14 | 13.3 |
| Widowed | 0 | 0 |
| Divorced | 7 | 6.7 |
| Probable PTSD (PCL-5) | 10 | 9.5 |
| Potentially traumatic event types endorsed (LEC-5) | -- | -- |
| Natural disaster | 98 | 93.3 |
| Happened to me | 74 | -- |
| Witnessed it | 60 | -- |
| Learned about it | 42 | -- |
| Part of my job | 82 | -- |
| Fire or explosion | 98 | 93.3 |
| Happened to me | 32 | -- |
| Witnessed it | 53 | -- |
| Learned about it | 37 | -- |
| Part of my job | 88 | -- |
| Transportation accident | 98 | 93.3 |
| Happened to me | 66 | -- |
| Witnessed it | 66 | -- |
| Learned about it | 46 | -- |
| Part of my job | 88 | -- |
| Serious accident at work/home/during recreational activity | 91 | 86.7 |
| Happened to me | 46 | -- |
| Witnessed it | 51 | -- |
| Learned about it | 45 | -- |
| Part of my job | 75 | -- |
| Exposure to a toxic substance | 81 | 77.1 |
| Happened to me | 47 | -- |
| Witnessed it | 32 | -- |
| Learned about it | 41 | -- |
| Part of my job | 73 | -- |
| Physical assault | 93 | 88.6 |
| Happened to me | 62 | -- |
| Witnessed it | 57 | -- |
| Learned about it | 47 | -- |
| Part of my job | 71 | -- |
| Assault with a weapon | 88 | 83.8 |
| Happened to me | 35 | -- |
| Witnessed it | 43 | -- |
| Learned about it | 42 | -- |
| Part of my job | 76 | -- |
| Sexual assault | 72 | 68.6 |
| Happened to me | 10 | -- |
| Witnessed it | 14 | -- |
| Learned about it | 42 | -- |
| Part of my job | 65 | -- |
| Other unwanted/uncomfortable sexual experience | 54 | 51.4 |
| Happened to me | 19 | -- |
| Witnessed it | 14 | -- |
| Learned about it | 31 | -- |
| Part of my job | 45 | -- |
| Combat or exposure to war | 16 | 15.2 |
| Happened to me | 11 | -- |
| Witnessed it | 8 | -- |
| Learned about it | 31 | -- |
| Part of my job | 10 | -- |
| Forced captivity | 16 | 15.2 |
| Happened to me | 2 | -- |
| Witnessed it | 6 | -- |
| Learned about it | 28 | -- |
| Part of my job | 14 | -- |
| Life-threatening illness or injury | 80 | 76.2 |
| Happened to me | 20 | -- |
| Witnessed it | 50 | -- |
| Learned about it | 41 | -- |
| Part of my job | 68 | -- |
| Severe human suffering | 76 | 72.4 |
| Happened to me | 8 | -- |
| Witnessed it | 43 | -- |
| Learned about it | 41 | -- |
| Part of my job | 68 | -- |
| Sudden, violent death | 92 | 87.6 |
| Happened to me | 6 | -- |
| Witnessed it | 35 | -- |
| Learned about it | 46 | -- |
| Part of my job | 86 | -- |
| Sudden, accidental death | 91 | 86.7 |
| Happened to me | 8 | -- |
| Witnessed it | 38 | -- |
| Learned about it | 48 | -- |
| Part of my job | 83 | -- |
| Serious injury/harm/death you caused to someone else | 21 | 20.0 |
| Happened to me | 10 | -- |
| Witnessed it | 7 | -- |
| Learned about it | 8 | -- |
| Part of my job | 11 | -- |
| Common ‘worst’ traumatic event types endorsed (LEC-5) | -- | -- |
| Sudden, violent death | 17 | -- |
| Life-threatening illness or injury | 11 | -- |
| Transportation accident | 10 | -- |
Note. N=105. Probable PTSD diagnosis based on a clinical cut-off score of 33 or greater on the PCL-5 (Blevins et al., 2015).
Measures
Demographic questionnaire.
Participants were asked to provide demographic information including sociodemographic characteristics and firefighter service history. Gender, relationship status, and years in the fire service will be included as covariates in the present analyses.
Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013).
The LEC-5 is a self-report questionnaire used to screen for potentially traumatic events experienced throughout the lifespan. Respondents were provided a list of 16 potentially traumatic events, as well as an additional item assessing for ‘other’ potentially traumatic events not listed and were 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 an event was endorsed as “happened to me,” “witnessed it,” or “part of my job,” this was coded as positive exposure to that particular type of potentially traumatic event. Exposures were summed to produce a ‘trauma load’ variable, which indicates the total number of potentially traumatic life event types experienced. Trauma load was included as a covariate in the current study.
PTSD Checklist for DSM-5 (PCL-5; Blevins et al., 2015).
The PCL-5 is a 20-item self-report measure designed to assess past month PTSD symptom severity, per DSM-5 criteria (American Psychiatric Association, 2013). Respondents were asked to complete the PCL-5 with regard to the “worst” traumatic event endorsed on the LEC-5. Participants are asked to rate each item on a 5-point scale (0 Not at all to 4 Extremely) to indicate how much they have been bothered by the symptom in the past month. Total symptom severity scores range from 0 to 80 with higher scores indicating greater symptom severity. The measure can be scored to yield severity scores of each of the DSM-5 PTSD symptom clusters: intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The PCL-5 has consistently demonstrated strong psychometric properties (Blevins et al., 2015). The PCL-5 total score (α = .96) and negative alterations in cognitions and mood symptom cluster (α = .91) demonstrated excellent internal consistencies in the current sample, while the intrusions (α = .89), avoidance (α = .89), and alterations in arousal and reactivity (α = .88) symptom clusters demonstrated good internal consistencies. The PCL-5 total score was evaluated as a criterion variable, and the symptom cluster scores were evaluated as criterion variables in post hoc exploratory analyses.
Experiences in Close Relationships Scale - Short Form (ECRS-SF; Wei et al., 2007).
The ECRS-SF is a 12-item self-report measure designed to assess insecure adult attachment styles. Respondents were asked to indicate the degree to which they agree with statements about their general experiences in romantic relationships on a 7-point scale (1 strongly disagree to 7 strongly agree). Items are equally divided between two subscales assessing anxious (e.g., “I find that my partner(s) don’t want to get as close as I would like”) and avoidant (e.g., “I try to avoid getting too close to my partner”) AAS, with subscale scores ranging from 6 to 42. A higher score for the anxious attachment subscale indicates a greater fear of rejection and/or abandonment, whereas a higher score for the avoidant attachment subscale indicates a greater fear of dependence and intimacy. Anxious attachment and avoidant attachment subscales were evaluated as predictors in the present analysis and demonstrated good (α = .81) and acceptable (α = .72) internal consistencies, respectively.
Distress Tolerance Scale (DTS; Simons & Gaher, 2005).
The DTS is a 15-item self-report measure that evaluates the extent to which respondents believe they can withstand distressing emotional states, rated on a 5-point scale (1 strongly agree to 5 strongly disagree). Total scores range from 15 to 75, with higher values indicating greater levels of distress tolerance (i.e., greater perceived ability to withstand distress). The DTS demonstrates good psychometric properties (Simons & Gaher, 2005). In the present study, the DTS total score demonstrated excellent internal consistency (α = .94) and was examined as a statistical mediator.
Procedure
Participants were recruited for through career, volunteer, or combination fire departments in the southern US. A department-wide email was sent to current firefighters in participating career, combination (career and volunteer), and volunteer fire departments notifying them of the opportunity to complete an online research survey for a chance to win one of several raffle prizes (e.g., assorted gift cards). Current firefighters in career departments were notified of the study when accessing their continuing education (CE) online portal and were similarly told they had a chance to win raffle prizes by participating. Notably, although a CE portal was utilized for notification about the study in career departments, no CE credits were offered for participating in the study. Once firefighters accessed the survey, they were provided with a description of the survey and the choice to review the informed consent form. Participants who indicated that they were interested in participating (by clicking ‘yes’) were directed to the beginning of the survey. Once firefighters electronically signed the consent form, they were presented with the online survey in Qualtrics, which they could complete at a time and place of their choosing. The total amount of time required for participation in this study was estimated to be 30–45 minutes. Firefighters could discontinue participation at any time without penalty. The study protocol was approved by the university Institutional Review Board and all participating fire departments.
Data Analytic Plan
Statistical analyses were conducted using IBM SPSS version 27.0. First, data were evaluated for multivariate outliers, normality, and missingness. Less than 3% of the data across all variables were missing, which was handled via list-wise deletion. Second, descriptive statistics and bivariate correlations were examined among all study variables. Third, regression analyses were conducted using the PROCESS Macro for SPSS (Hayes, 2017) to examine the indirect association between insecure AAS (anxious and avoidance) and PTSD symptom severity through DT. Indirect effects were calculated using 10,000 bootstrapped re-sampling (Hayes, 2017; Preacher & Hayes, 2008). A bootstrap confidence interval (CI) that does not include zero provides evidence of a significant indirect effect (Preacher & Hayes, 2008). Effect sizes (R2) were calculated for each indirect effect (small, 0.01; medium, 0.09; large, 0.25; Preacher & Kelley, 2011). Gender, relationship status, years in the fire service, and trauma load were included as covariates in the models due to their established associations with variables of interest in firefighter samples (e.g., Simons & Gaher, 2005; Zegel et al., 2019). Post hoc exploratory analyses were conducted, following the same procedures as the main analyses, to examine the indirect association between anxious and avoidant AAS and each of the four PTSD symptom clusters (i.e., intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity), separately, via DT.
Results
Descriptive statistics and bivariate correlations for all study variables are presented in Tables 1 and 2, respectively. Anxious and avoidant AAS were significantly negatively correlated with DT. Anxious AAS was significantly positively correlated with total PTSD symptom severity, as well as the negative alterations in cognitions and mood and alterations in arousal and reactivity symptom clusters. Avoidant AAS was significantly positively correlated with total PTSD symptom severity and each of the symptom clusters. Years in the fire service was negatively correlated with avoidant AAS, while trauma load was positively correlated with DT, total PTSD symptom severity, and each of the PTSD symptom clusters.
Table 2.
Bivariate correlations.
| 1. | 2. | 3. | 4. | 5. | 6 | 7 | 8 | 9 | 10 | 11 | 12 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. Gender | -- | |||||||||||
| 2. Relationship status | .11 | -- | ||||||||||
| 3. Years in the fire service | −.04 | .19* | -- | |||||||||
| 4. Trauma load | −.09 | .15 | .22* | -- | ||||||||
| 5. Anxious adult attachment style | −.10 | .10 | .07 | .18 | -- | |||||||
| 6. Avoidant adult attachment style | −.01 | −.05 | −.20* | −.06 | .24* | -- | ||||||
| 7. Distress tolerance | .02 | −.01 | .13 | .20* | −.32** | −.45** | -- | |||||
| 8. PTSD symptom severity | −.01 | .13 | −.06 | .26** | .25* | .26** | −.31** | -- | ||||
| 9. PTSD Intrusions | .04 | .05 | −.05 | .23* | .18 | .21* | −.29** | .89** | -- | |||
| 10. PTSD Avoidance | .04 | .04 | .11 | .21* | .18 | .12* | −.17 | .82** | .81** | -- | ||
| 11. PTSD Neg Alt in Cog/Mood | −.03 | .14 | −.05 | .25** | .27** | .23* | −.32** | .93** | .75** | .67** | -- | |
| 12. PTSD Alt in Arousal/Reactivity | −.04 | .16 | −.12 | .25* | .23* | .28** | −.23** | .94** | .77** | .68** | .84** | -- |
| Mean | -- | -- | 15.01 | 10.22 | 19.51 | 16.17 | 59.75 | 11.42 | 2.27 | 1.40 | 3.50 | 4.26 |
| SD | -- | -- | 8.53 | 3.37 | 8.90 | 7.13 | 13.28 | 14.51 | 3.38 | 2.05 | 5.07 | 5.42 |
| Range | -- | -- | 1–43 | 1–17 | 6–40 | 6–34 | 17–75 | 0–59 | 0–16 | 0–8 | 0–24 | 0–19 |
Note.
p < .05;
p < .01;
Gender coded as 1 = male, 0 = non-male [female, transgender], Relationship Status coded as 0 = single/divorced/widowed; 1 = married/living with partner), Years in the fire service = Total number of years served as a firefighter; Trauma load = Life Events Checklist for DSM-5 (LEC-5) total score; Anxious adult attachment style = Experiences in Close Relationships Scale - Short Form (ECRS-SF) anxious subscale score; Avoidant adult attachment style = ECRS-SF avoidant subscale score; Distress tolerance = Distress Tolerance Scale total score; PTSD symptom severity = PTSD Checklist for DSM-5 (PCL-5) total score; PTSD Intrusions = PCL-5 PTSD intrusions symptom cluster score; PTSD Avoidance = PCL-5 PTSD avoidance symptom cluster score; PTSD Neg Alt in Cog/Mood = PCL-5 PTSD negative alterations in cognitions and mood symptom cluster score; PTSD Alt in Arousal/Reactivity = PCL-5 PTSD alterations in arousal and reactivity symptom cluster score
Main Analyses
Analyses of indirect effects are summarized in Table 3. Controlling for covariates, anxious and avoidant AAS demonstrated significant negative associations with DT (path a). Further, DT was significantly negatively associated with PTSD symptom severity (path b). Regarding the associations of anxious and avoidant AAS with PTSD symptom severity, the total effects (path c) were statistically significant and the direct effects (path c’) were not statistically significant, indicating full statistical mediation. Furthermore, anxious and avoidant AAS demonstrated significant indirect effects on PTSD symptom severity via DT (a*b).
Table 3.
Standard regression coefficients for main analyses (1–2) and exploratory post hoc models (3–10).
| Model | R 2 | β | p | Bootstrapped 95% CI | |
|---|---|---|---|---|---|
| Main Analysis | |||||
| 1 | Anxious AAS → DT (a) | .18*** | −.55 | <.001 | −0.83 – −0.28 |
| DT → PTSD Severity (b) | .23*** | −.37 | <.001 | −0.58 – −0.16 | |
| Anxious AAS → PTSD Severity (c) | .14** | .34 | .011 | 0.03 – 0.65 | |
| Anxious AAS → PTSD Severity (c’) | .13 | .401 | −0.17 – 0.46 | ||
| Anxious AAS → DT → PTSD Severity (a*b) | .20 | 0.06 – 0.43 | |||
| 2 | Avoidant AAS → DT (a) | .24*** | −.82 | <.001 | −1.15 – −0.49 |
| DT → PTSD Severity (b) | .24*** | −.34 | <.01 | −0.56 – −0.12 | |
| Avoidant AAS → PTSD Severity (c) | .16** | .54 | <.01 | 0.16 – 0.92 | |
| Avoidant AAS → PTSD Severity (c’) | .26 | .203 | −0.14 – 0.67 | ||
| Avoidant AAS → DT → PTSD severity (a*b) | .28 | 0.08 – 0.54 | |||
| Post Hoc Analyses | |||||
| PTSD Intrusions | |||||
| 3 | Anxious AAS → DT (a) | .18*** | −.55 | <.001 | −0.83 – −0.28 |
| DT → PTSD Intrusions (b) | .18** | −.08 | .001 | −0.14 – −0.03 | |
| Anxious AAS → PTSD Intrusions (c) | .09 | .06 | .124 | −0.02 – 0.13 | |
| Anxious AAS → PTSD Intrusions (c’) | . 01 | .761 | −0.06 – 0.09 | ||
| Anxious AAS → DT → PTSD Intrusions (a*b) | .05 | 0.01 – 0.10 | |||
| 4 | Avoidant AAS → DT (a) | .24*** | −.82 | <.001 | −1.15 – −0.49 |
| DT → PTSD Intrusions (b) | .18** | −.08 | .004 | −0.13 – −0.03 | |
| Avoidant AAS → PTSD Intrusions (c) | .11* | .10 | .032 | 0.01 – 0.19 | |
| Avoidant AAS → PTSD Intrusions (c’) | .04 | .476 | −0.06 – 0.13 | ||
| Avoidant AAS → DT → PTSD Intrusions (a*b) | .06 | 0.02 – 0.12 | |||
| PTSD Avoidance | |||||
| 5 | Anxious AAS → DT (a) | .18*** | −.55 | <.001 | −0.83 – −0.28 |
| DT → PTSD Avoidance (b) | .11 | −.03 | .054 | −0.06 – 0.001 | |
| Anxious AAS → PTSD Avoidance (c) | .08 | .03 | .133 | −0.01 – 0.08 | |
| Anxious AAS → PTSD Avoidance (c’) | .02 | .484 | −0.03 – 0.07 | ||
| Anxious AAS → DT → PTSD Avoidance (a*b) | .02 | 0.004 – 0.04 | |||
| 6 | Avoidant AAS → DT (a) | .24*** | −.82 | <.001 | −1.15 – −0.49 |
| DT → PTSD Avoidance (b) | .13* | −.03 | .136 | −0.06 – 0.01 | |
| Avoidant AAS → PTSD Avoidance (c) | .10* | .07 | .020 | 0.01 – 0.12 | |
| Avoidant AAS → PTSD Avoidance (c’) | .05 | .143 | −0.02 – 0.11 | ||
| Avoidant AAS → DT → PTSD Avoidance (a*b) | .02 | −0.002 – 0.05 | |||
| PTSD Negative Alterations in Cognitions and Mood | |||||
| 7 | Anxious AAS → DT (a) | .18*** | −.55 | <.001 | −0.83 – −0.28 |
| DT → PTSD Neg Alt in Cog/Mood (b) | .23*** | −.13 | <.001 | −0.20 – −0.05 | |
| Anxious AAS → PTSD Neg Alt in Cog/Mood (c) | .14** | .13 | .019 | 0.02 – 0.24 | |
| Anxious AAS → PTSD Neg Alt in Cog/Mood (c’) | .06 | .284 | −0.05 – 0.17 | ||
| Anxious AAS → DT → PTSD Neg Alt in Cog/Mood (a*b) | .07 | 0.02 – 0.16 | |||
| 8 | Avoidant AAS → DT (a) | .24*** | −.82 | <.001 | −1.15 – −0.49 |
| DT → PTSD Neg Alt in Cog/Mood (b) | .23*** | −.13 | .002 | −0.20 – −0.05 | |
| Avoidant AAS → PTSD Neg Alt in Cog/Mood (c) | .14** | .17 | .016 | 0.03 – 0.30 | |
| Avoidant AAS → PTSD Neg Alt in Cog/Mood (c’) | .06 | .388 | −0.08 – 0.20 | ||
| Avoidant AAS → DT → PTSD Neg Alt in Cog/Mood (a*b) | .10 | 0.02 – 0.21 | |||
| PTSD Alterations in Arousal and Reactivity | |||||
| 9 | Anxious AAS → DT (a) | .18*** | −.55 | <.001 | −0.83 – −0.28 |
| DT → PTSD Alt in Arousal/Reactivity (b) | .23*** | −.13 | .002 | −0.21 – −0.05 | |
| Anxious AAS → PTSD Alt in Arousal/Reactivity (c) | .15** | .12 | .048 | 0.001 – 0.23 | |
| Anxious AAS → PTSD Alt in Arousal/Reactivity (c’) | .05 | .440 | −0.07 – 0.16 | ||
| 10 | Anxious AAS → DT → PTSD Alt in Arousal/Reactivity (a*b) | .07 | 0.02 – 0.14 | ||
| Avoidant AAS → DT (a) | .24*** | −.82 | <.001 | −1.15 – −0.49 | |
| DT → PTSD Alt in Arousal/Reactivity (b) | .25*** | −.11 | .009 | −0.20 – −0.03 | |
| Avoidant AAS → PTSD Alt in Arousal/Reactivity (c) | .19** | .21 | .004 | 0.07 – 0.35 | |
| Avoidant AAS → PTSD Alt in Arousal/Reactivity (c’) | .12 | .121 | −0.03 – 0.27 | ||
| Avoidant AAS → DT → PTSD Alt in Arousal/Reactivity (a*b) | .09 | 0.03 – 0.17 | |||
Note.
p < .001
p < .01
p <.05.
The 95% CI was obtained via 10,000 bootstrapped resampling. Anxious AAS = Experiences in Close Relationships Scale - Short Form (ECRS-SF) anxious subscale score; Avoidant AAS = ECRS-SF avoidant subscale score; DT = Distress Tolerance Scale total score; PTSD Severity = PTSD Checklist for DSM-5 (PCL-5) total score; PTSD Intrusions = PCL-5 PTSD intrusions symptom cluster score; PTSD Avoidance = PCL-5 PTSD avoidance symptom cluster score; PTSD Neg Alt in Cog/Mood = PCL-5 PTSD negative alterations in cognitions and mood symptom cluster score; PTSD Alt in Arousal/Reactivity = PCL-5 PTSD alterations in arousal and reactivity symptom cluster score. All total, direct, and indirect paths were calculated controlling for the variance accounted for by theoretically relevant covariates, including gender, relationship status, years in the fire service, and trauma load.
Post Hoc Exploratory Analyses
Post hoc exploratory analyses were conducted to examine the indirect effects of anxious and avoidant AAS on each of the PTSD symptom clusters through DT, as summarized in Table 3. For the PTSD intrusions models, DT was significantly negatively associated with PTSD intrusions (path b). Regarding the associations of anxious and avoidant AAS with PTSD intrusions, the total effects (path c) were statistically significant only for the avoidant AAS model, and the direct effects (path c’) were not statistically significant for either model. Furthermore, anxious and avoidant AAS demonstrated significant indirect effects on PTSD intrusions via DT (a*b).
For the PTSD avoidance models, DT was not significantly associated with PTSD avoidance (path b). Regarding the associations of anxious and avoidant AAS with PTSD avoidance, the total effects (path c) were statistically significant only for the avoidant AAS model, and the direct effects (path c’) were not statistically significant for either model. Only anxious AAS demonstrated significant indirect effects on PTSD avoidance via DT (a*b).
For the PTSD negative alterations in cognitions and mood models, DT was significantly negatively associated with PTSD negative alterations in cognitions and mood (path b). Regarding the associations of anxious and avoidant AAS with PTSD negative alterations in cognitions and mood, the total effects (path c) were statistically significant and the direct effects (path c’) were not. Furthermore, anxious and avoidant AAS demonstrated significant indirect effects on PTSD negative alterations in cognitions and mood via DT (a*b).
For the PTSD alterations in arousal and reactivity models, DT was significantly negatively associated with PTSD alterations in arousal and reactivity (path b). Regarding the associations of anxious and avoidant AAS with PTSD alterations in arousal and reactivity, the total effects (path c) were statistically significant and the direct effects (path c’) were not statistically significant. Furthermore, anxious and avoidant AAS demonstrated significant indirect effects on PTSD alterations in arousal and reactivity via DT (a*b).
Discussion
The objective of the present study was to investigate, among firefighters, the relations of insecure romantic AAS, DT, and PTSD symptom severity. Consistent with hypotheses, both anxious and avoidant AAS were indirectly associated with PTSD symptom severity through DT, after controlling for theoretically relevant covariates of gender, relationship status, years of fire service, and trauma load. Both anxious and avoidant AAS were negatively, incrementally associated with DT. Findings indicate that insecure AAS among trauma-exposed firefighters is related to lower DT, which in turn, is related to higher levels of PTSD symptoms. Although these findings are cross-sectional, results are consistent with a growing body of work suggesting that insecure AAS among trauma-exposed individuals is related to PTSD symptom severity through maladaptive stress regulation processes (Bryant, 2016; Charuvastra & Cloitre, 2008). Trauma-exposed firefighters with heightened insecure AAS reported lower perceived abilities to withstand negative emotional states. These findings extend preliminary prior research showing associations between insecure AAS and DT (Mahmoudpour et al., 2018) and replicate a well-established literature demonstrating negative associations between DT and PTSD symptoms (e.g., Akbari et al., in press; Vujanovic & Zegel, 2020).
Post hoc exploratory analyses revealed that anxious and avoidant AAS are both related to the PTSD symptom clusters of intrusions, negative alterations in cognitions and mood, and alterations in arousal and reactivity through DT. Anxious AAS demonstrated an indirect effect on PTSD avoidance symptoms through DT, as well. The significant associations of anxious and avoidant AAS with these PTSD symptom clusters through DT could potentially be explained by emotion regulatory processes. Risk and resilience outcomes following a PTE are significantly shaped by AAS, and one of the primary mechanisms related to the association between insecure AAS and PTSD is an individual’s ability to regulate emotions (Charuvastra & Cloitre, 2008). Theoretically, emotion regulation capacity develops in the context of secure attachment to caregivers and, thus, it may be compromised in adults with insecure AAS (Coan, 2011; Mikulincer & Shaver, 2012). An individual with insecure AAS may therefore perceive themselves as impaired in terms of emotion regulation, translating to lower perceived DT.
Social cognitive schemas associated with insecure AAS have been linked with risk of developing PTSD following a PTE in theoretical (Nietlisbach & Maercker, 2009; Sharp et al., 2012) and empirical (Venta et al., 2017) research. From a theoretical standpoint, insecure attachment-based schemas are associated with impairments in the ability to understand one’s own and others’ behavior as being driven by underlying mental states (and accurately identify those mental states) which, in turn, is associated with increased risk for PTSD (Charuvastra & Cloitre, 2008; Sharp et al., 2012). Indeed, in empirical research, insecure attachment to caregivers and romantic partners was associated with deficient social cognition which explained increased PTSD symptoms (Ortigo et al., 2013; Venta et al., 2017). It may be that deficient or anomalous social cognition increases risk for PTSD by thwarting social support, compounding the association between insecure AAS and decreased social support. Critical to the current study, social support and camaraderie in the fire service are protective factors against PTSD symptom severity, and further investigation is needed to understand the exact nature of these associations and how insecure AAS may compromise these protective factors (Leonard & Vujanovic, 2021; Stanley et al., 2019). For example, future research should advance this line of inquiry, using longitudinal and experimental methods, to better understand the temporal relations of AAS, DT, and PTSD in firefighters so as to inform evidence-based psychological interventions to prevent and treat PTSD in this frequently trauma-exposed population. Additionally, since the conceptualization of AAS in this present study relates to romantic attachment, marital or couples counseling interventions for firefighters may be fruitful to bolster secure attachment and improve DT and PTSD outcomes.
The findings in the current investigation should be considered in light of study limitations. First, the study employed a cross-sectional research design to test statistical mediation, which impedes any conclusions about the causality or temporality of associations among the variables of interest. Bi-directional, transactional, and/or interactive associations among the variables of interest are feasible. Longitudinal and/or experimental designs are necessary to better understand directionality of these associations. Second, the investigation relied exclusively on self-report measures, administered via online survey. Interview-based measures of PTSD symptoms and behavioral or physiological indices of insecure AAS and DT (e.g., Bryant & Datta, 2019; Mitchell et al., 2004) should be employed in future work to build upon the current findings. Relatedly, the avoidant attachment subscale of the ECRS-SF evinced only acceptable internal consistency (α = 0.72). Future research might evaluate the psychometric properties of various AAS measures in the fire service to inform future work in this area. Further, additional research should endeavor to examine AAS broadly, rather than limited to romantic partners, and to utilize interview-based measures of attachment known to differ from self-report instruments (Roisman et al., 2007). Relatedly, the ‘trauma load’ variable created by summing LEC-5 items is not suited to evaluating the frequency or severity of PTEs experienced by firefighters. Future research should develop and utilize measures that more accurately assess PTEs not only based on the number of categories of traumatic events experienced, but also by the total number of events within each category and the intensity of each. In addition, future research with firefighter populations should assess information about the index traumatic event(s) (i.e., most distressing events) in greater detail, including the dates of occurrence and whether the events were experienced ‘on the job’. Third, future research with firefighter populations should also examine firefighter employment status (e.g., volunteer versus career; full-time versus part-time) as a potential correlate of behavioral health. For example, volunteer firefighters, as compared to career firefighters, may report greater mental health disturbances, including PTSD symptoms and more barriers to treatment access (Johnson et al., 2020; Stanley et al., 2017; Vujanovic & Tran, 2021). Fourth, the sample is comprised of a subset of potentially eligible firefighters across nine fire departments sampled. Issues of self-selection bias and social desirability bias thus cannot be ruled out, as findings are based on information provided by those firefighters who wished to participate. Finally, these results were based on a sample of predominantly white (74.3%) and male (95.2%) firefighters, which is broadly consistent with the sociodemographic composition of firefighters nationally (Haynes & Stein, 2017). Nevertheless, future work should select firefighters who identify as members of historically underrepresented populations (e.g., women, LGBTQIA+ individuals, black or African American, Hispanic or Latino) as relatively little is known about the behavioral health needs of minority populations within the fire service (Vujanovic & Tran, in press).
Overall, results of this study provide preliminary evidence to suggest that insecure AAS may influence PTSD symptoms among firefighters through a firefighter’s perceived ability to withstand emotional distress. As the first study to examine associations among insecure AAS, DT, and PTSD symptom severity, the findings provide an incremental contribution to the developing literature. Social-emotional functioning among firefighters is a clinically relevant area for future study, especially given its relevance to trauma-related risk and resilience as well as camaraderie and social support that is important for fire service occupational outcomes (Chu et al., 2016). Ultimately, this area of research has the potential to inform evidence-based intervention and prevention efforts for PTSD among firefighters.
Acknowledgements
Research reported in this publication was supported 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.
Footnotes
Disclosure Statement
The authors have no conflicts of interest to declare.
Contributor Information
Samuel J. Leonard, University of Houston
Maya Zegel, University of Houston
Amanda Venta, University of Houston
Anka A. Vujanovic, University of Houston
Data Availability Statement
We have not included data with this submission in accordance with Institutional Review Board guidelines and our agreement with the fire departments who participated in the study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
We have not included data with this submission in accordance with Institutional Review Board guidelines and our agreement with the fire departments who participated in the study.