Cumulative Trauma Exposure,Emotion Regulation,and Posttraumatic Stress Disorder Among Incarcerated Women

Incarcerated women report high rates of trauma exposure and posttraumatic stress disorder (PTSD). Emotion regulation has been identified as a potential mechanism that contributes to the association between trauma exposure and PTSD severity. The present study examined associations among cumulative trauma exposure, emotion regulation difficulties, and current (30‐day) PTSD in 152 randomly selected women in prison. Utilizing structural equation modeling (SEM), results indicated cumulative trauma was significantly associated with emotion regulation difficulties, β = .31, SE = .13, p  = .005; and PTSD symptom severity, β = .41, SE = .14, p  = .005. We identified a significant indirect effect, 0.11, z = 2.37, p = .018, of emotion regulation on the association between cumulative trauma exposure and severity of current PTSD symptoms. These findings are consistent with previous longitudinal research suggesting that emotion regulation is significantly affected by trauma exposure, and they support previously identified associations between emotion regulation difficulties and severity of PTSD. Further, these findings have the potential to inform current efforts to identify and implement effective PTSD‐focused interventions with incarcerated women. In particular, it appears that emotion regulation skills may be an important component of effective PTSD focused interventions for this population.     

The Hong Kong Survey on the Epidemiology of Trauma Exposure and Posttraumatic Stress Disorder

This study examined the epidemiology of trauma exposure (TE) and posttraumatic stress disorder (PTSD) among community‐dwelling Chinese adults in Hong Kong. Multistage stratification sampling design was used, and 5,377 participants were included. In Phase 1, TE, probable PTSD (p‐PTSD), and psychiatric comorbid conditions were examined. In Phase 2, the Structured Clinical Interview for the DSM‐IV (SCID‐I) was used to determine the weighted diagnostic prevalence of lifetime full PTSD. Disability level and health service utilization were studied. The findings showed that the weighted prevalence of TE was 64.8%, and increased to 88.7% when indirect TE types were included, with transportation accidents (50.8%) reported as the most common TE. The prevalence of current p‐PTSD among participants with TE was 2.9%. Results of logistic regression suggested that nine specific trauma types were significantly associated with p‐PTSD; among this group, severe human suffering, sexual assault, unwanted or uncomfortable sexual experience, captivity, and sudden and violent death carried the greatest risks for developing PTSD, odds ratio (OR) = 2.32–2.69. The occurrence of p‐PTSD was associated with more mental health burdens, including (a) sixfold higher rates for any past‐week common mental disorder, OR = 28.4, (b) more mental health service utilization, p < .001, (c) poorer mental health indexes in level of symptomatology, suicide ideation and functioning, p < .001, and (d) more disability, ps < .001–p = .014. The associations found among TE, PTSD, and health service utilization suggest that both TE and PTSD should be considered public health concerns.     

Trauma Exposure and Posttraumatic Stress Disorder in Adolescents: A National Survey in Switzerland

There are a limited number of epidemiological studies that have focused on trauma exposure and prevalence of posttraumatic stress disorder (PTSD) in representative general population samples of adolescents, especially outside of the United States. We therefore aimed to assess the lifetime prevalence of traumatic events (TEs) and current prevalence of PTSD, and to examine demographic risk factors for TEs and PTSD in a representative sample of adolescents. Data were collected by a school survey among a sample of 6,787 9th‐grade students in Switzerland. Roughly 56% of the adolescents (females 56.6%; males 55.7%) reported having experienced at least 1 TE. Non‐Swiss nationality (OR = 1.80), not living with both biological parents (OR = 1.64), and lower parental education (OR = 1.18) were associated with a higher risk of trauma exposure. The current prevalence of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000) criteria was 4.2% (females 6.2%; males 2.4%). Female gender (OR = 2.70), not living with both biological parents (OR = 1.47), lower parental education (OR = 1.51), and exposure to multiple TEs (OR = 9.56) were significant risk factors for PTSD. Results suggest considerably high rates of TEs and PTSD among adolescents. Intervention efforts must be intensified to reduce trauma exposure and treat PTSD.     

Emotion Dysregulation Prospectively Predicts Posttraumatic Stress Disorder Symptom Severity 3 Months After Trauma Exposure

Despite growing evidence in support of emotion dysregulation as a risk factor for the development of posttraumatic stress disorder (PTSD) following trauma exposure, few studies have examined temporal relations between emotion dysregulation and the onset and/or worsening of PTSD symptoms over time. The aim of the present study was to extend research on temporal associations between emotion dysregulation and PTSD in a sample of individuals recruited from hospital emergency departments soon after a traumatic event. Adult participants (N = 85; 62.4% female) completed self-report measures of emotion dysregulation and PTSD symptoms within 2 weeks of experiencing a traumatic event. Symptoms of PTSD were assessed approximately 3 months posttrauma. The results of a hierarchical linear regression analysis demonstrated that the inclusion of emotion dysregulation accounted for a significant amount of unique variance, β = .23, ΔR² = .04, p = .042, in 3-month PTSD symptom severity over and above other risk factors and baseline PTSD symptoms. No specific facet of emotion dysregulation emerged as a significant predictor of 3-month PTSD symptoms when all facets were included on the same step of the model, βs = −.04–.33, ps = .133–.954. These results demonstrate that posttraumatic emotion dysregulation may predict PTSD symptoms 3 months after trauma exposure. These findings are consistent with a growing body of literature that speaks to the relevance of emotional processes to the onset and maintenance of PTSD following exposure to a traumatic event.     

Trauma Exposure,Posttraumatic Stress Disorder Symptoms Trajectory,and Disability Level Among Hospitalized Injury Survivors in Kenya

Potentially traumatic events (PTEs) have been consistently associated with posttraumatic stress disorder (PTSD). However, the extent of association and attribution to subsequent disability has varied, with limited studies conducted in urban low‐income contexts. This longitudinal study estimated the trajectory of PTSD symptoms up to 7 months after hospitalization and the associated disability level among adult patients who had been hospitalized due to injury. Adult injury patients (N = 476) admitted to Kenyatta National Hospital in Nairobi, Kenya, were interviewed in person in the hospital, and via phone at 1, 2–3, and 4–7 months after hospital discharge. Using latent growth curve modeling, two trajectories of PTSD symptoms emerged: (a) persistently elevated PTSD symptoms (9.2%), and (b) low PTSD symptoms (90.8%). Number of PTEs experienced remained moderately associated with the elevated trajectory after controlling for in‐hospital depressive symptoms. Having previously witnessed killings or serious injuries, AOR = 2.32, 95% CI [1.07, 5.05]; being female, AOR = 4.74, 95% CI [4.53, 4.96]; elevated depressive symptoms during hospitalization, AOR = 2.96, 95% CI [1.28, 6.83]; and having no household savings/assets, AOR = 1.28, 95% CI [1.13, 1.44], were associated with the elevated PTSD symptoms trajectory class after controlling for other risk factors. Latent membership in the elevated PTSD trajectory was associated with a significantly higher level of disability several months after hospital discharge, p < .001, after controlling for injury and demographic characteristics. These results underline the associations among in‐hospital depressive symptoms, witnessing atrocities, and poverty, and an elevated PTSD symptoms trajectory.     

Positive Emotion Dysregulation Among Community Individuals: The Role of Trauma Exposure and Posttraumatic Stress Disorder

Existing literature has provided support for an association between posttraumatic stress disorder (PTSD) and emotion dysregulation. However, few studies have examined the relation between PTSD and emotion dysregulation that stems from positive emotions. Moreover, the role of trauma exposure, per se, on positive emotion dysregulation is unknown. Addressing these limitations, the current study compared levels of positive emotion dysregulation among (a) individuals without trauma exposure, (b) trauma-exposed individuals without probable PTSD, and (c) trauma-exposed individuals with probable PTSD. Participants were 400 community-dwelling individuals (M age = 43.76 years, 68.6% female; 24.2% Asian, 23.7% Black, 24.5% Hispanic, 27.6% White). Lower levels of positive emotion dysregulation were found among trauma-exposed participants without probable PTSD compared to trauma-exposed participants with probable PTSD, ds = 0.66–0.73, and unexposed participants, ds = 0.58–0.64. The present findings suggest the potential protective role of low levels of positive emotion dysregulation following trauma exposure. If replicated in longitudinal studies, these results may indicate the utility of enhancing skills for regulating positive emotions among individuals at risk for trauma exposure.     

Relationships Among Trauma Exposure,Chronic Posttraumatic Stress Disorder Symptoms,and Self-Reported Health in Women: Replication and Extension

Fifty-two women who served during the Vietnam era were assessed for war-zone exposure, traumatic life events, posttraumatic stress disorder (PTSD), and self-reported health status. Symptoms of PTSD were examined as mediators in the relationship between traumatic exposure and subsequent reports of health problems. Results showed that PTSD symptoms accounted significantly for variance in health problems reported by women with prior traumatic stressor exposure. When the cardinal symptom domains of PTSD (reexperiencing, numbing, avoidance, hyperarousal) were analyzed separately, the symptom cluster representing hyperarousal accounted uniquely for the variance associated with health complaints, beyond that contributed by other symptom clusters. Discussion of the results focuses on mechanisms underlying the relationship between specific symptoms of PTSD and self-reported health. Implications for intervention within the medical system are also considered.     

Gender as Potential Moderator of Associations Among Trauma Exposure,Posttraumatic Stress Disorder Symptoms,and Alcohol Use Disorder Symptoms in Young Adults

Traumatic events (TEs), posttraumatic stress disorder (PTSD) symptoms, and alcohol use disorder (AUD) symptoms can significantly impair functioning, yet little is known about whether associations among these variables differ between men and women within young adult samples. The current study conducted a path analysis of archival, longitudinal data from the Drug Use Trajectories: Ethnic/Racial Comparisons 1998–2002 (DUT) study (Turner, 2011) to examine gender differences as a possible moderator of the relations between TEs, PTSD symptoms, and AUD symptoms among 1,076 young adults (aged 18–23 years) residing in South Florida. The sample included 580 male (53.9%) and 496 female (46.1%) participants, whose ethnicity was self‐reported as African American (n = 280, 26.0%), non‐Hispanic White (n = 268, 24.9%), other Hispanic (n = 267, 24.8%), and Cuban (n = 261, 24.3%). Significant positive associations were found between TEs and PTSD symptoms, βs = .08–.30; PTSD and AUD symptoms, βs = .09 – .10; PTSD symptoms over time, β = .52; and AUD symptoms over time, β = .46. In addition, for male but not female participants, a higher frequency of PTSD symptoms at Wave I was related to more AUD symptoms at Wave II, β = .09. Findings build upon existing research to further elucidate the role of gender as a potential moderator of the associations among TEs, PTSD symptoms, and AUD symptoms for young adults and provide important implications for future research and clinical practice, including informing mental health prevention and treatment efforts.     

Client Compliance with Exposure Treatments for Posttraumatic Stress Disorder

Clients with posttraumatic stress disorder (PTSD) do not wish to “relive” their trauma, but exposure based treatments try to ensure that they do. While such treatments have proven efficacy in controlled outcome studies, how acceptable are they in routine clinical practice? The attempted clinical application of two such exposure treatments is briefly reported here. In the first, only 1 of 14 clients completed the image habituation procedure for homework in the manner described by its authors. In the second (N = 37), only 57% complied with an audiotape exposure treatment, and compliance was related to initial symptom severity and to severity of comorbid depression. Exposure based treatments are not ‘treatment of choice’ for some clients.     

The Complex Trauma Inventory: A Self‐Report Measure of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder

The work group revising the criteria for trauma‐related disorders in the International Classification of Diseases (ICD‐11) made several changes. Specifically, they simplified the criteria for posttraumatic stress disorder (PTSD) and added a new trauma disorder called complex PTSD (CPTSD). These proposed changes to taxonomy require new instruments to assess these novel constructs. We developed a measure of PTSD and CPTSD (the Complex Trauma Inventory; CTI) according to the proposed domains, creating several items to assess each domain. We examined the factor structure of the CTI in two separate samples of diverse college students (n ₁ = 391; n ₂ = 391) who reported exposure to at least one traumatic event and at least occasional functional impairment. After reducing the original 50 items in the item pool to 20 items, confirmatory factor analyses supported two highly correlated second‐order factors—PTSD and disturbances in self‐organization (DSO)—with PTSD (i.e., reexperiencing, avoidance, sense of threat) and DSO (i.e., affect dysregulation, negative self‐concept, and disturbances in relationships), each loading on three of the six ICD‐11‐consistent first‐order factors, root mean square error of approximation (RMSEA) = .056, 95% confidence interval (CI) [.048, .064], comparative fit index (CFI) = .956, Tucker‐Lewis index (TLI) = .948, standardized root mean square residual (SRMR) = .043, Bayesian information criterion (BIC) = 641.55, χ²(163) = 361.02, p < .001. Internal consistencies for PTSD and DSO were good to excellent (Cronbach's αs = .89 to .92). Supplementary analyses supported the gender invariance of the CFA model, as well as convergent and discriminant validity of the CTI. The validity of the CTI supports the distinction between CPTSD and PTSD. Moreover, the CTI will assist clinicians with diagnosis, symptom tracking, treatment planning, and assessing outcomes.     

A Dyadic Analysis of the Influence of Trauma Exposure and Posttraumatic Stress Disorder Severity on Intimate Partner Aggression

This study used structural equation modeling to evaluate a mediation model of the relationship between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and perpetration of intimate partner physical and psychological aggression in trauma‐exposed veterans and their cohabitating spouses (n = 286 couples; 88% male veteran and female spouse, 80.8% White, non‐Hispanic). Dyadic data analyses were used to simultaneously evaluate actor and partner effects using the actor–partner interdependence model (Kashy & Kenny, 2000). The primary hypothesis was that PTSD would mediate the association between trauma exposure and intimate partner physical and psychological aggression with these effects evident both within and across members of a couple (i.e., actor and partner effects). The best‐fitting model included (a) equivalent actor and partner direct effects of trauma on veterans’ acts of psychological aggression (β = .17 to .20, p = .001), and (b) equivalent actor and partner indirect effects via PTSD on veterans’ acts of physical aggression (β = .08 to .10, p < .001). There were no direct or indirect effects predicting the spouses’ aggression. Results suggest it is important to consider the trauma histories and possible presence of PTSD in both partners as this may be a point of intervention when treating distressed couples.     

Negative Cognitions Prior to Trauma Predict Acute Posttraumatic Stress Disorder Symptomatology

Based on emotional processing theory, preexisting negative cognitions may contribute to the development of posttraumatic stress disorder (PTSD) symptoms. The present study prospectively examined the association between preexisting PTSD‐related cognitions and subsequent acute PTSD symptoms, and the potential mediators of this association. We also compared the effect of preexisting depressive cognitions and preexisting PTSD‐related cognitions on PTSD symptoms. In the current study, 810 Taiwanese undergraduates completed a baseline survey (T1), of which 73.1% (n = 592) participated in a second survey two months later (T2). Of those who completed both surveys, 97 experienced a trauma at least one week before T2; this group comprised the final sample. Hierarchical regression showed that preexisting PTSD‐related cognitions (β = .38, p < .001, sr² = .117), but not preexisting depressive cognitions (β = .11, p = .315, sr² = .011), were a significant and substantial predictor of acute PTSD symptoms after we controlled for established pretrauma risk factors (i.e., gender, prior trauma, and prior psychological problems). Multiple mediation analysis revealed that negative appraisal of symptoms (a₁b₁ = 0.90, 95% CI [0.16, 2.18], P_M = .251) and trauma‐related rumination (a₃b₃ = 1.23, 95% CI [0.23, 2.86], P_M = .341), but not trauma memory disorganization (a₂b₂ = 0.65, 95% CI [?0.17, 1.92], P_M = .182), significantly mediated between preexisting PTSD‐related cognitions and acute PTSD symptoms. Our findings highlight the role of preexisting negative cognitions in acute PTSD symptomatology. The development of PTSD symptoms is likely determined by the interaction of risk factors before and after trauma.     

Preliminary Findings of the Relationship of Lower Heart Rate Variability with Military Sexual Trauma and Presumed Posttraumatic Stress Disorder

Decreased heart rate variability (HRV) occurs with physical and psychological disorders and is a predictor of cardiac and all‐cause mortality. This study was the first of which we are aware to examine and report the relationship between military sexual trauma (MST) and HRV measures. In a historical cohort study of female veterans with (n = 27) and without (n = 99) MST who received Holter and electrocardiogram evaluation at a Veteran Affairs medical center during 2007–2010, we examined the relationship between MST and the standard deviation of all R‐R intervals (SDNN) and the square root of the mean of the sum of the squares of differences between adjacent R‐R intervals (RMSSD). Female veterans with MST were younger, p = .002, frequently had a probable posttraumatic stress disorder diagnosis, 80% versus 15%, p = < .0001, and had lower SDNN, p = .0001, and RMSSD, p = .001, than those without MST. The SDNN and RMSSD of a 25‐year‐old female veteran with MST were comparable to that of female veterans aged 69 to 81 years without MST. Further research is needed to evaluate relationships between MST and HRV measures.     

Posttraumatic Stress Disorder Symptom Clusters,Alcohol Misuse,and Women's Use of Intimate Partner Violence

Exploring how PTSD and alcohol misuse relate to women's use of intimate partner violence (IPV) is vital to develop our understanding of why some women may engage in IPV, which can serve to maximize intervention efforts for women. This study examined the extent to which posttraumatic stress disorder (PTSD) symptom clusters are directly and indirectly related to women's use of IPV through pathways involving alcohol misuse while controlling for severity of women's IPV victimization. The sample was comprised of substance‐using, low socioeconomic status community women (N = 143) currently experiencing IPV victimization. The majority of the sample was African American (n = 115, 80.42%). This sample had an average annual household income of $14,368.68 (SD = $12,800.68) and the equivalent of a high school education (11.94 years, SD = 1.32). Path analyses indicated that the strongest statistical relationship emerged between women's use of IPV and women's IPV victimization. PTSD reexperiencing and numbing symptom severity was related to women's use of psychological, minor physical, and severe physical IPV; however, these relationships were indirect through alcohol misuse. Findings lend preliminary support for the application of the self‐medication hypothesis to the study of PTSD, alcohol misuse, and IPV among women.     

A Test of Adolescent Internalizing and Externalizing Symptoms as Prospective Predictors of Type of Trauma Exposure and Posttraumatic Stress Disorder

The present study utilized longitudinal data from a high‐risk community sample (N = 377; 166 trauma‐exposed; 202 males; 175 females; 73% non‐Hispanic Caucasian) to test pretrauma measures of adolescent internalizing and externalizing symptoms as unique prospective predictors of type of trauma exposure and PTSD over and above the influence of correlated family adversity (a composite of family conflict, stress, and parental psychopathology). Data were analyzed with logistic and multinomial logistic regressions. Results indicated that females, but not males, with higher levels of internalizing (OR = 2.91) and externalizing (OR = 2.37) symptoms during adolescence were significantly more likely to be exposed to assaultive violence (over and above family adversity). In fact, males with higher levels of internalizing symptoms were significantly less likely to be exposed to assaultive violence (OR = 0.54). Neither internalizing nor externalizing symptoms uniquely predicted exposure to traumatic events that did not involve assaultive violence. Among trauma‐exposed participants, the unique association between internalizing symptoms and later PTSD yielded an odds ratio of 1.79 (p = .07) over and above the influences of family adversity, type of trauma exposure, and gender. Assaultive violence exposure fully mediated the association between females’ externalizing symptoms and future PTSD. Findings may help inform the prevention of both assaultive violence exposure and PTSD.     

The Relationship Between Posttraumatic Stress Disorder, Childhood Trauma and Alexithymia in an Outpatient Sample

One aim of this study was to examine the strength of association between posttraumatic stress disorder (PTSD) and alexithymia relative to other psychiatric disorders in a sample of 252 treatment-seeking psychiatric patients. The other aim of this study was to explore which type of childhood trauma was associated with a greater level of adult alexithymia. The study found that PTSD and borderline personality disorder (BPD) were the two disorders among selected psychiatric disorders to contribute independently to a higher degree of alexithymia. Another finding was that a greater severity of emotional neglect and physical neglect, rather than abuse, was significantly related to higher levels of alexithymia. In addition, the study found that among these variables, BPD had the strongest relationship to alexithymia.     

Outcomes of Prolonged Exposure Therapy for Veterans With Posttraumatic Stress Disorder

Prolonged Exposure (PE) is an evidenced‐based psychotherapy for posttraumatic stress disorder (PTSD) that is being disseminated nationally within the U.S. Department of Veterans Affairs (VA) with promising initial results. Empirical evidence, however, regarding the effectiveness of PE for treatment of PTSD in military veterans is limited. Building on previous treatment outcome research, the current study investigated the effectiveness of PE in a diverse veteran sample. One‐hundred fifteen veterans were enrolled in PE at an urban VA medical center and its surrounding outpatient clinics. PTSD and depression symptoms as well as quality of life were measured before and after treatment. Several baseline patient characteristics were examined as predictors of treatment response. Eighty‐four participants completed treatment. Participants experienced a 42% reduction in PTSD symptoms, a 31% reduction in depression symptoms, and an increase in quality of life following PE. Veterans not prescribed psychotropic medication reported greater PTSD symptom reduction than veterans prescribed such medication. The implications of these results for treatment programs targeting PTSD in veterans are discussed.     

Childhood Trauma Exposure Exacerbates the Impact of Concurrent Exposure to Intimate Partner Violence on Women's Posttraumatic Symptoms

Although it is well established that intimate partner violence (IPV) is detrimental to women's mental health, it remains unclear to what extent symptoms can be attributed to the proximal effects of IPV exposure itself as opposed to more stable scarring effects or co-occurring risk factors. Heterogeneity in the magnitude of IPV effects further suggests that IPV-exposed individuals are differentially susceptible to disorder, and an investigation of moderating factors that may make women more vulnerable is warranted. We used a prospective longitudinal study of low-income mothers followed from 3 to 18 months postpartum to distinguish the concurrent mental health effects of IPV exposure from overall person-level IPV-mental health associations, as well as to test the moderating role of prior relational traumatic experiences in the form of childhood maltreatment. Multilevel modeling results demonstrated a unique concurrent association between increasing IPV and women's posttraumatic symptoms over time, even after controlling for an overall association between mean IPV and symptom levels. The effects of concurrent IPV were heightened in women who reported a history of childhood maltreatment. Model effects were medium to large, R² = .27–.35. The implications of these findings for the identification of and intervention with women at the highest risk for relational trauma-related mental health difficulties are discussed.     

Place and Posttraumatic Stress Disorder

Research on traumatic stress has focused largely on individual risk factors. A more thorough understanding of risk factors may require investigation of the contribution of neighborhood context, such as the associations between perceived neighbourhood disorder and social cohesion with reported trauma exposure (yes/no) and posttraumatic stress disorder (PTSD) diagnostic status (past‐year PTSD, remitted). To examine these associations, we used a cross‐sectional analysis of an epidemiological catchment area survey (N = 2,433). Visible cues, indicating a lack of order and social control in the community (neighbourhood disorder), were associated with increased trauma exposure (adjusted odds ratio [AOR] = 1.21, 95% confidence interval [CI] [1.12, 1.31]). For trauma‐exposed individuals, neighbourhood disorder was associated with greater odds of lifetime PTSD (AOR = 1.38, 95% CI [1.10, 1.75]), and the willingness of residents who realize common values to intervene for the common good (social cohesion), was associated with lower likelihood of past‐year PTSD (AOR = 0.64, 95% CI [0.42, 0.97]). For participants with a lifetime diagnosis of PTSD (including past‐year), increased social cohesion was associated with higher odds of remission (AOR = 2.59, 95% CI [1.55, 4.30]). Environmental contexts play a role in the development and progression of PTSD. As such, traumatic stress outcomes may be better understood through a perspective that integrates individual and contextual risk factors.     

Duty‐Related Trauma Exposure and Posttraumatic Stress Symptoms in Professional Firefighters

Firefighters commonly encounter traumatic events during duty hours. The purpose of this study was to investigate the characteristics of duty‐related trauma as risk factors for posttraumatic stress disorder in professional firefighters. A sample of 212 firefighters participated in the study and completed self‐reported questionnaires. Potentially traumatic events (PTE) were assessed using a list of 17 traumatic event types. The posttraumatic stress symptoms (PTSS) were measured by the Impact of Event Scale‐Revised (Lim et al., 2009; Weiss, 2007). A higher score for the composite index, which reflects both multiple PTE and peritraumatic suffering, increased the odds for significant PTSS after adjusting for age, sex, marital status, education, numbers of years worked, childhood trauma, and depressive symptoms (adjusted odds ratio [AOR ] = 2.26, p = .001, Cohen's d = 0.20). Furthermore, indirect (AOR = 1.93, p = .009, Cohen's d = .16) and colleague‐related PTE (AOR = 1.97, p = .037, Cohen's d = .16) showed significant associations with PTSS. It is noteworthy that the combination of multiple PTE and peritraumatic suffering was more predictive of PTSS than either factor alone. Our findings also suggest that daily work exposure to indirect PTE may contribute to the occurrence of PTSS among professional firefighters.