HEALTHMentalFirefighter Syndrome: A Proposed Whole Systems Framework

Firefighter Syndrome: A Proposed Whole Systems Framework

By: Chris Frueh, PhD, Jadie Miller, Michelle L. O’Neill, Hon. BSc, ND, Brad Wylie, Isabella
Zingray, Gina Rudine, Alok Madan, PhD, MPH 

A career in firefighting involves inherent risks and dangers, including short- and long-term medical, psychological, and social strains.

Firefighters respond to and mitigate a vast range of emergency situations. These include entering burning buildings, applying emergency first aid and CPR, deconstructing vehicles to access trapped civilians, 24-hour shifts, and many other critical duties to protect and rescue the communities they serve. They risk their lives and their health every day on the job.  

Despite the debt that we (as a society) owe to firefighters, there is a profound lack of medical research examining their health risks and trajectories over time. For example, a search of MedLine (an index of all medical journal articles) found only 499 medical articles about firefighters published in 2021, compared to 15,299 for veterans. That makes firefighters one of the least well understood highly-at-risk populations. Or to say it another way: We know very little about the comprehensive health, wellness, and functioning of our firefighters. 

We suggest taking a whole systems approach for firefighters that we have adapted from a  framework applied toward military special operators, known as “Operator Syndrome.”1 

1 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 healthcare needs of military special operations forces. The International  Journal of Psychiatry in Medicine 2020; 55:281-295.

A Proposed Whole Systems Framework for “Firefighter Syndrome” 

A career in firefighting involves regular exposure to chronic stress, lethal risks, and potential for a wide range of injuries, including traumatic brain injuries and toxic exposures. The accumulation of these physiological, physical, psychological, and neuroendocrine injuries (i.e., high allostatic load) can lead to profound physiological changes upon the individual. This load is different from, but similar to, that borne by military special operators (e.g., Army Green Berets,  Navy SEALs, Air Force PJs). We believe it leads to a profession-specific constellation of interrelated medical, social, and psychological conditions. A whole systems framework can help us better  understand and address the complex needs of firefighters: 

1. Traumatic Brain Injury (TBI) and Toxic Exposures 

Firefighters face high risks of traumatic brain injuries, including (a) impact force injuries, and (b) toxic exposures. Impact force injuries, such as concussions, may occur due to falls, slips, structure collapse, and flying projectiles, among other events. Such closed head injuries are cumulative over the course of a lifetime. Toxic environments from chemical, industrial, and residential fires and hazardous material can include among others: smoke, benzene, toluene, carbon monoxide, natural gas, carbon dioxide, oxygen-deficient atmospheres, and potentially even the bunker gear protective equipment worn. All of these can cause profound and cumulative damage to the brain and every other bodily system. 

2. Hormonal dysfunction 

Many common components of the firefighting profession can lead to a disruption of healthy hormonal function. Traumatic brain injuries and chronic stress can dysregulate the endocrine system via the hypothalamic-pituitary-adrenal (HPA) axis (i.e., governing brain structures), causing hormonal dysfunctions such as low testosterone in men. Additionally, acute and chronic stress contribute to the dysfunction in this process, leading to increased secretions of the stress hormones 

cortisol and norepinephrine, which has a cascading effect on the sleep cycle and other vital physical processes. Dysfunction of the endocrine system can manifest as low testosterone, abnormal human growth hormone (HGH) levels, abnormal thyroid issues, abnormal estrogen levels, irregular stress hormone levels (cortisol and norepinephrine), and adrenal dysfunction. These hormonal imbalances can lead to serious complications with sleep, mood, cognition, and energy. 

3. Sleep disturbance 

Sleep disturbance is a regular component of the firefighter’s lifestyle, as sleep schedules are frequently disrupted, shifts are at irregular hours, and a call to action can come in at any given moment. Common disturbances faced by firefighters include insomnia, trouble falling and/or staying asleep, insufficient REM and/or slow-wave deep sleep, chronic sleep deprivation, night sweats, and nightmares. 

4. Obstructive sleep apnea / Central sleep apnea disturbances 

Sleep apnea is another common condition for firefighters, likely due to TBI. 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 signals to the muscles that control breathing. This leads to heavy snoring, gasping for air, and/or breathing lapses during sleep, all of which disrupt the sleep cycle and cognitive processes. Sleep apnea can lead to severe health problems if untreated, including high blood pressure, strokes, heart failure, headaches, diabetes, and depression. Although a continuous positive pressure airway (CPAP) machine may be prescribed to improve breathing, disturbances can still occur with CPAP use. 

5. Chronic pain, orthopedic problems, headaches 

Due to the nature of the job, firefighters often have an increased incidence of physical injuries, both acute and chronic, such as joint, neck, or back pain and/or immobility, as well as headaches and migraines. Research shows a connection between TBI, PTSD, and pain severity.

6. Substance use 

Substance abuse is a common habit that can contribute to a wide range of physical,  cognitive, emotional, legal, and interpersonal difficulties. Problematic substance use includes daily alcohol use, binge drinking, use of recreational drugs, and/or prescription drugs. It is common for  

substance abuse to develop as a form of self-medicating to cope with stress, depression, anxiety, and pain. Alcohol is the most common type of substance abuse among firefighters. 

7. Post-traumatic stress disorder (PTSD) 

Firefighters are at a heightened risk for PTSD due to the traumatic nature of their work. Symptoms may include distressing and intrusive memories about traumatic events, physiological reactions to thoughts of traumatic experiences (such as a racing heart, chest pain, or sweating), avoidance of reminders or triggers of the traumatic experiences, such as certain people, places, situations, or activities, and chronic arousal. Hypervigilance is a major characteristic of PTSD, as well as other behavioral changes such as irritability, hostility, self-destructive behaviors, and social isolation. Mood changes can occur, ranging from emotional detachment and depressed mood to severe anxiety and heightened reactions, with common feelings of guilt, fear, mistrust, and/or loneliness. There is a relationship between TBI and PTSD. 

8. Depression 

Depression is defined as persistent feelings 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. Depressive symptoms contribute to a worsening range of emotional, behavioral, and physical difficulties. There is an increased risk of depression in those with a history of PTSD or TBI.

9. Anger 

Anger is closely tied to trauma and PTSD and is often a response used to cope and maintain a sense of control. It can manifest physically as hyperarousal, with muscle tension and increased heart rate. Anger can certainly be expressed in the form of physical aggression (towards self, others, inanimate objects). It can also affect thoughts and beliefs, and manifest as irritation, impulsivity, verbal aggression, self-destructive or reckless behavior, and self-loathing.  

10. Worry, restlessness, stress reactivity, panic attacks 

The chronic stressors of firefighting can lead to anxiety. Common indicators are restlessness or an inability to relax, heightened reactivity to minor stresses, excessive rumination or worrying,  fear of separation or abandonment, claustrophobic feelings or a strong desire to flee the scene, and panic attacks.  

11. Marital and family dysfunction 

The firefighting profession has a high divorce rate, due in part to physical, emotional,  interpersonal, and financial stressors. Marital or family dysfunctions can develop due to anger,  depression, anxiety, discomfort with emotional intimacy, sexual dysfunctions, the desire for social isolation, etc. Family difficulties can aggravate other areas of life and have cumulative effects on issues with sleep, substance abuse, anxiety, depression, PTSD, and pain. 

12. Problems with sexual health and intimacy 

Stressors from firefighting can lead to an increased risk of intimacy issues and sexual dysfunction. Sexual dysfunction can present as having a low sex drive, genital or erectile dysfunction,  or other issues related to endocrine dysfunction such as low testosterone. Other physical and mental  

challenges mentioned here can also affect this area and lead to risky sexual behavior, changes in sexual behavior, or discomfort with sexual intimacy.

13. Being “on guard” and hypervigilant 

Hypervigilance is a vital tool for firefighters on the scene of a call – because they need to stay alert to dangers – but can be challenging to turn off outside of emergency situations.  Hypervigilance outside of high-intensity situations can be noted with feelings of being on guard, aggressive, or hyper-aroused at home, in public, in non-emergent work settings (e.g., at the firehouse), and even while driving or walking. It can be challenging to relax in safe situations or to wind down for sleep. Hypervigilance sustained for long periods of time becomes exhausting to maintain and can cause cascading physical and emotional concerns. 

14. Memory, concentration, cognitive impairments 

Many aspects of firefighting can lead to cognitive impairments. Long-term shift work, sleep deprivation, toxin inhalation, exposure to trauma, TBI, depression/PTSD, and substance abuse can all play a role in the development of cognitive deficits. Some noticeable issues include poor memory, poor attention and concentration, impulsivity, impaired planning and problem-solving, sudden confusion, and easily getting lost. These problems in turn affect stress, adaptability, and performance both at work and at home, increasing the risk of accidents and injuries to the self or to others. 

15. Perceptual system impairments 

Issues with perception and the sensory system can develop in connection to TBI, toxic exposure, and other physiological stressors. Common impairments include difficulties with balance,  dizziness, vertigo, blurry and double vision, hearing loss, tinnitus (ringing in the ears), and an altered sense of smell. 

16. Disrupted hydration and nutrition 

Observable shifts in nutrition needs and symptoms of dehydration are common. This can lead to a wide range of disturbed physical states, including chronic muscle cramping, unusual headaches, frequent heart palpitations (that are not anxiety-related), frequent decreased urine output, 

frequent fast urination after fluid intake, gout, digestive disorders, unexpected changes in weight or body shape, a decrease in muscle mass, urological problems, and constipation or the development of bowel disorders. Each of these has the potential to do both short- and long-term harm to physical health and functioning. 

17. Home-to-work transition difficulties 

Challenges often arise in the transition between home and work life. Some firefighters can feel disconnected from home life and miss the intensity and adrenaline rush of work, or face other difficulties with civilian culture, such as having trouble with daily routines or being overwhelmed by family demands. It can also be complicated to detach from work between shifts, such as “bringing the work home with you.”  

18. 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. Such experiences can lead to feelings of survivor’s guilt, remorse, a fear of death, a loss of personal identity/mission, a loss of concern for personal life safety, and a mindset that discounts the future. 

Part 2 – A Guide Back to Safety: The “Firefighter Syndrome” Questionnaire

These accumulating conditions of Firefighter Syndrome present like thermal layers, found in a flashover, banking down on an unsuspecting firefighter, threatening injury and death.  For this reason, we need tools developed for firefighters to guide them in their healing. The Firefighter Syndrome Questionnaire—developed by our team—is intended 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.  This public-domain assessment measure may be used by professionals (clinicians, medical researchers) and may also be used directly by firefighters to participate and have control over achieving a positive outcome towards their own health and functioning by allowing them to:

  1. Learn about the domains of Firefighter Syndrome;
  2.  Informally evaluate yourself on each of the syndrome domains – and to reach a better understanding of your health, wellness, and functioning;
  3. To facilitate conversations with yourself and your partner/loved ones;
  4. Initiate and guide conversations with your primary care provider and other medical specialists.
Part 3 – I may be injured, so now what: The Treatment of “Firefighter Syndrome”

The increasingly specialized and consequently fragmented healthcare system around the world is not designed to meet firefighter’s complex healthcare needs.  Symptoms are frequently compartmentalized; conditions are treated independently and in isolation from other conditions. Specialists rarely communicate with one another and can offer conflicting medical advice.  We also believe that few medical care providers have a contextual understanding of what it means to have a career in the firefighting profession. They do not understand the culture or the demands.  For these reasons, we offer a short, practical “how-to” guide for seeking care for “Firefighter Syndrome” within current medical systems. Consider these suggestions a guide for where to begin and how to sequence your care.

Step 1: Suicide Risk Assessment:  If you are suicidal, please call 911, go to the nearest emergency room, or call 988 to access the 24-hour suicide and crisis lifeline.

Step 2:  Enlist Social/Peer Support:  Discuss with and enlist your network (spouse, partner, family, friends, co-worker) to support you.  Share this article with them!

Step 3: Primary Care Provider (PCP):  Schedule an appointment with your primary care provider.  If you do not have one you must get one.  At your first appointment educate your PCP about Firefighter Syndrome.  Complete the Firefighter Syndrome Questionnaire and bring it, along with this article, to your appointment to help educate your provider.  Request the following: 

  1. A general physical evaluation to begin building a baseline measure of your health and functioning; 
  2. A blood test to examine your hormones (if you have not had one recently);
  3. A sleep study to learn if you have sleep disorders (if you have not had one recently);
  4. A referral to neurology for evaluation of traumatic brain injuries;
  5. A referral for a mental health evaluation (if that seems relevant); 
  6. A referral for couples or family counseling; 
  7. Testing for heavy metals, toxic chemicals, and other harmful exposures;
  8. If necessary, orthopedic, pain management, chiropractic, or physical therapy referrals.

Step 4: Review Lifestyle and Social Support: Consider your lifestyle and daily routines both on and off duty where you may need to implement changes to support treatment and maintain recovery (e.g., substance use, diet, exercise, relaxation, relationships, work, sleep).  

  1. Assess your sleep habits, learn about “sleep hygiene,” and make any necessary adjustments;
  2. Learn about an anti-inflammatory lifestyle (look it up!) and make modifications as necessary.  This generally means eating a diet of actual whole foods – no fast food, junk food, processed food, or added sugars;
  3. Be honest with yourself about your use of alcohol, cannabis, nicotine, pre-workout, caffeine, and all other recreational and prescription medications;
  4. Consider complementary medicine practices, such as Jiu-Jitsu, yoga, meditation, Tai Chi, acupuncture/acupressure, etc.  

Step 5:  Follow-Up Appointments & Care:  Follow through with appointments and treatments.  Continue to monitor your health and functioning.  This applies to on- and off-duty – and for the rest of your life.  Keep track of conditions that do not respond to treatment, as well as new conditions as they arise. 

If you want to learn more about recent novel or experimental treatments (in many cases not FDA-approved), you can read about stellate ganglion block therapy, ketamine infusions, vestibular therapy, hyperbaric oxygen therapy, psychedelic medicines (psilocybin, ibogaine, ayahuasca, 5-MEO-DMT, MDMA), stem cells, exomes, peptides, float therapy, and transcranial magnetic stimulation.  

The specific intervention(s) used for the conditions above may be adapted for individual firefighters’ needs and the medical care available to them.  Moreover, while it is possible to treat these conditions independently, we believe “Firefighter Syndrome” is best addressed with a comprehensive whole system approach that addresses the entire person synchronously.  In an ideal world, we would have specialty clinics or programs for firefighters.  Such a program would have a swift intake process, administer intensive outpatient care, and use comprehensive assessments (labs, scans, functional testing) and treatments.  Care would be multidisciplinary, involving the necessary range of specialty clinical experts – general medicine, nursing, neurology, endocrinology, naturopathy, osteopathy, psychology, psychiatry, social work, physical therapy, etc.  Providers would understand the culture and treatment needs of career firefighters.


Firefighters experience chronic stress, dysregulated sleep schedules, physical danger, and potentially traumatic experiences as an inherent aspect of their profession. The whole systems framework we propose considers multiple relevant and interrelated domains of health, wellness, and function. Modern medicine and society have placed too much emphasis on PTSD, but that is only a small part of a much larger problem. “Firefighter Syndrome” involves pathophysiological injuries at the molecular and cellular level of every system in the body, interacting adversely with behavioral and social functioning. 

Each of the individual conditions we describe can be evaluated and tracked over the course of a firefighter’s career. Moreover, each condition can be addressed via lifestyle modifications and professional treatments. In other words, there are clinically actionable targets if we are paying attention. Pragmatic approaches involving wearable technology, lab tests (e.g., blood and other biomarkers), tracking of signal events (head injuries, types of calls, etc.), and periodic symptom questionnaires combined with machine-learning analytics could be used to establish individual benchmarks, monitor health and functioning, track potential changes over time, and inform individual firefighters when interventions are necessary. 

Benefits to firefighters would include individualized feedback to enhance performance, early identification of developing health and social problems (potentially to include life-threatening illnesses such as cancers, respiratory diseases, autoimmune disorders), improved quality of life, and better health. Improved health and performance of firefighters will bring cost-benefit savings to departments and society, including improved firefighter performance, better civilian protection, career longevity, intra-crew relationships and crew efficiency, reduced absenteeism, and savings in long-term medical and disability costs. Obviously, much more research is needed to delineate and refine this framework, and to develop the solutions required. 

Barros B, Oliveira M, Morais S. Firefighters’ occupational exposure: Contribution from  biomarkers of effect to assess health risks. Environment International 2021; 156: 106704. Frueh BC, Madan A, Fowler JC, et al. “Operator Syndrome”: A unique constellation of  medical and behavioral healthcare needs of military special operations forces. The International Journal  of Psychiatry in Medicine 2020; 55:281-295.

Torres VA, Strack JE, Dolan S et al. Identifying frequency of mild traumatic brain injury in firefighters. Workplace Health and Safety 2020; 68: 468-475. 

About the Authors:
Chris Frueh, PhD is professor of psychology, University of Hawaii-Hilo, and Co-Founder &
Scientific Director, PYROC; Jadie Miller is Founder & CEO, PYROC, Co-Founder of 360 Care
Clinic, and Firefighter (16 years); Michelle L. O’Neill, Hon. BSc, ND is Co-Founder of 360 Care
Clinic; Brad Wylie is Co-Founder & Strategic Development Director, PYROC; Isabella Zingray is a
project manager; Gina Rudine is a graduate student in counseling psychology; Alok Madan, PhD,
MPH is vice-chairman of psychiatry and behavioral health, Houston Methodist Hospital. Portions
of this article were adapted from Dr. Frueh’s forthcoming Operator Syndrome (forthcoming in
February 2024).

Contests & Promotions

Fire Science Nutrition Contest/Promotion
West Broad Contest
Burn Box promotion/contest