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The term “” became publicized during the aftermath of the terrorist attack on the World Trade Towers and Pentagon on September 11, 2001. First Responders are trained persons who respond to an emergency or crisis call. They may be police officers, fire fighters, emergency medical technicians, mental health counselors and psychologists, medical staff and doctors, crime scene technicians, child protective services workers, security guards, first-line soldiers in combat, and in some cases, office managers and school teachers.

A common question posed to every mental health expert by the “person on the street” is “Who is really normal?” The answer to the question is very complex and one that is open to significant areas of disagreement among professionals. To understand the issue more clearly, let us first consider the concept of normality and abnormality in the area of physical health and disease.

The first two chapters in this book have attempted to describe how complex it is to define a mental illness as opposed to a simple physical illness. It is common knowledge that if people cough and sneeze, their throats hurt, and they have a slight fever, they may have a cold, allergy or other similar disease. Many of the (what can be observed) and (what is experienced) that accompany mental illnesses overlap and make them more complicated to diagnose. Some of these signs and symptoms, albeit at a milder level, are with us from time to time. For example, most of us have felt anxious, sad or depressed at times. Some students reading this book who expect to take an examination afterwards may feel some anxiety as they read and study, especially if there are new terms that must be learned. If others watched as that student studied, they might notice signs such as a tic, hand wringing, the twist of a piece of paper, a rash or other physical indication of anxiety. Those persons might also feel symptoms of nervousness, upset stomach, or headache, but unless they disclosed these feelings to others, they might not be known. Most people are more forgetful and inattentive, and they cannot concentrate as well when something is bothering them. They may even have a sleepless night or two. Children may wake up with nightmares or night terrors from time to time, but that doesn’t give them a mental illness.

Our brain and nervous system is the basic organ system that regulates our mental functions of thinking, feeling, and acting. We can divide the nervous system into two parts, the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). The brain is located in the CNS while the neurons that deliver messages to and from the brain and the rest of the body are in the PNS. The PNS is divided into two major systems, the Somatic Nervous System that regulates our voluntary movements and the Autonomic Nervous System (ANS) that regulates our involuntary movements such as our emotions, breathing, heart rate, and blood pressure. The ANS is further divided into two sections, the sympathetic which expends energy and the parasympathetic which conserves energy. These systems all work together in a coordinated way, telling the body when to manufacture more or fewer neurochemicals called neurotransmitters that will facilitate or shut down the messages that go to and from the brain and make our body work.

is undoubtedly the most well known and most severely debilitating of all the psychiatric illnesses known to people. It will typically have devastating impact on the individual, on his or her family and, indirectly, on society and its gatekeepers. The approximate lifetime incidence is 1%, meaning that the risk of any person’s developing this disease during his or her lifetime is about one in one hundred. In its 2006 report, the National Institute of Mental Health noted that approximately 2.4 million people 18 years and older will have this disorder in any given year. In 1990, direct and indirect costs were estimated to be $33 billion, accounting for 2.5% of the healthcare dollar. Schizophrenic patients occupy as many as 25% of all hospital beds at any given time. Lost productivity in the United States is estimated to be as high as $20 billion per year, a completed suicide rate at approximately 10%, and premature death from poor self care, substance abuse, poverty and homelessness all represent the tremendous cost of this psychotic disorder.

Our mood involves a pervasive and sustained emotion that colors our perceptions of the world. We feel sadness and joy, anger and anxiety in reaction to our interaction with others, to successes and failures we experience, and in reaction to our internal, psychological self explorations. Emotions like sadness and joy occur as part of everyday life and occur in reaction to normal life events such as the loss of loved ones, failures and disappointments as well as successes that all of us encounter at some time in our lives. First Responders who face life and death situations on a daily basis are at risk for exaggerated emotional reactions after involvement in a shooting incident, after witnessing catastrophic accidents, or after losing a victim that they have tried to save. Grief or mild depressive reactions in these situations may result in feelings of guilt, sadness, sleeplessness and restlessness that are quite predictable and likely to resolve quickly. We may experience the “blues”, feeling “bummed out” or simply “down” in response to some or frustration in our lives or in reaction to a holiday or anniversary that ignites memories of an earlier sad or traumatic time. All of these reactions and emotions, including sadness and joy, are quite normal and universal and do not usually result in a clinical mood disorder. However, when these mood states are exaggerated, persistent and recurrent, when they occur in the absence of any environmental event or stressor, and/or result in significant social, occupational or interpersonal impairment, they rise to the level of a clinical and diagnosable disorder.

The experience of anxiety and fear is a common one for personnel involved in dangerous, high risk situations with life and death consequences. In fact, First Responders benefit from the increased autonomic nervous system response that accompanies anxiety and fear and that mobilizes their resources to flee from a dangerous scene or remain and aggressively confront it. In the early 1900s, researcher Walter Cannon described this reaction to danger as the “fight or flight response.” Some degree of anxiety facilitates performance in many areas. It helps to focus our attention, to anticipate possible negative consequences of our behavior, and generally to keep us “up” to face difficult emergency situations, perform well on tests or even respond thoughtfully to an attorney’s aggressive cross examination. This chapter, however, will focus primarily on anxiety that has reached exaggerated and self defeating levels that impair performance, cause significant impairment in functioning, and reach the threshold for a formal psychiatric disorder. Additionally, we will touch briefly on those psychological disorders in which the individuals suffer from concern over physical symptoms or a belief that they have a disease for which no identifiable medical basis can be found. These disorders are labeled Somatoform disorders. Emergency medical personnel may occasionally deal with such patients.

All previous chapters exploring pathological mental disorders have represented symptom oriented conditions, often characterized by their intermittent course with periods of remission and exacerbation and described by clinicians as “medical conditions.” Schizophrenia and bipolar illness, for instance, often develop in early adulthood, and result in acute periods of severe symptoms at different points in the course of the disorders that respond to therapeutic intervention, whether through medication or psychotherapy. The lists these disorders on Axis I in the multiaxial system and notes that they are the focus of our clinical treatment. In contrast to the Axis I disorders described in earlier chapters, personality disorders are diagnosed on Axis II; they are always chronic, unremitting, develop in childhood and adolescence and are highly resistant to any kind of therapeutic intervention. Many clinical disorders, from major depression and panic disorder to substance use disorders, often affect more well- circumscribed areas of daily functioning than personality disorders that tend to impact every area of one’s life. As one might expect, clinical disorders like depression, schizophrenia, or hypochondriasis cause the patient significant distress and psychological pain. In contrast, individuals diagnosed with a personality disorder are generally free of significant anxiety, depression, or other subjective distress, but more commonly cause conflict and distress to others who must interact with them.

First Responders and law enforcement personnel are more likely to encounter individuals suffering from substance intoxication, abuse and/or dependence than any other psychiatric impairment. Use of all psychoactive substances in this country, including caffeine and nicotine, has a staggering impact on our economy, on the health of our citizens, and on the incidence of crime, violence, and homelessness in our cities. Statistics from the Bureau of Justice as well as several research studies indicate that alcohol and illicit drug users report increased criminal involvement, criminal records, and crime related violence than nonusers. In an article entitled “Psychoactive Substances and Violence,” published in 1994 by The Institute of Justice in its journal, , Jeffrey Roth notes that in recent years alcohol use by the perpetrator and/or the victim of a crime immediately preceded at least 50% of all violent episodes studied. Additionally, research he cites indicates that chronic drinkers and drug users are more likely to have histories of violence, and more likely to commit assaults and robberies, than non-users as well as criminals who do not use drugs or alcohol. There is no doubt that there is a strong relationship among violence, criminality, and use of psychoactive substances, and for this reason alone, understanding the nature of addiction and the common effects of drugs and alcohol is critical for First Responders.

When thoughts of a crisis arise, September 11, 2001 is a date that is emblazoned in the minds of most people around the world, especially Americans. That date is also contemporaneous with the start of the current War on Terrorism being led by the United States. It is not common for people to have experienced a violent collective trauma such as a war, or a natural disaster such as an earthquake, a tsunami, or a hurricane personally, although most of us have experienced these disasters secondhand by watching television. However, most people have experienced smaller crises in their lives, such as violence in their family. The devastation of the gulf coast of Mississippi, Alabama, and Louisiana and the total destruction of the city of New Orleans from hurricane Katrina in September of 2005 sent over 500,000 people fleeing for their lives across the entire United States. Just a few weeks later, Hurricane Rita caused another million people to leave Texas and the surrounding gulf areas, while the already crippled levees finally gave way and once again flooded many parts of New Orleans. Then, South Florida, already dealing with the aftermath of Katrina when it swept through there before going on to the gulf coast, experienced Hurricane Wilma, causing further destruction and fear. There has been a good deal of study into the psychological effects of these experiences on survivors, and comparisons have been made between those effects and the effects on those who have experienced more common traumas such as physical and sexual abuse in the family and between intimate partners.