Note: This article includes references to suicidal behavior. If you or someone close to you is having suicidal thoughts, call 988 for the Suicide and Crisis Lifeline.

At a birthday party, kids yelp with joy in a bouncy house. It’s a nice day; no imminent threat is present. But for someone with PTSD, the screams of children may slick the body with sweat and quicken the heart.

That’s what happened to Travis Howze, 44, a veteran, former firefighter and police officer who lives in Charleston, S.C. The screaming heightened; it rattled his brain, and before he knew it he was shouting at a room full of stunned adults.

Post traumatic stress disorder can emerge after a person experiences a traumatic event, such as a death, a car accident or a sexual assault. PTSD leads to hypervigilance, aggressive behavior, dissociation, memory lapses and nightmares. Being triggered by something specific such as a song, a smell, the location the trauma took place or, in Howze’s case, screaming children, can launch a person with PTSD into an episode: Their cortisol or stress levels jump up; they can start to sweat; their heart races.

Six out of 10 men and 5 out of 10 women will experience some trauma in their lives, and 6% of the population will develop PTSD, according to the U.S. Department of Veterans Affairs National Center for PTSD. Twelve million Americans have the disease in any given year.

Paramedics, law enforcement workers, firefighters, active military personnel and veterans are particularly at risk.

“We deal with people on their worst days,” said Donald A. Brucker, chief deputy fire marshal at the Allegheny County fire marshal’s office. Many police officers and people serving in the military frequently see graphic violence, and that culture heralds being “tough” and burying emotions, while displaying emotion like sadness or pain is seen as weak.

PTSD plagues veterans: About 11% to 20% of those who served in Iraq and Afghanistan have PTSD in a given year, 12% for Gulf War vets, and 30% for Vietnam vets in their lifetime. People in the military need not be on duty to get PTSD. The National Center for PTSD also reports that among veterans, more than half of all women and 38% of all men have experienced sexual harassment, and only 23% of those women have reported a sexual assault while in the military.

Greg J. Siegle, a professor of psychiatry, psychology and translational science at the University of Pittsburgh, has worked with the veteran population for years through clinical trials. “When people experience trauma, the brain learns very quickly,” he explained. This can manifest as hypervigilance or dissociation, disconnecting from one’s thoughts, feelings, memories or sense of identity.

When a person dissociates, the part of the brain behind the forehead called the prefrontal cortex “slams the brakes,” he said. It shuts things down to prevent the person from experiencing the full gamut of that trauma. People who dissociate say they feel like they’re floating, hovering above their body or not really there. Because of this disconnect, Siegle said, those with PTSD who dissociate can often be the coolest under pressure.

PTSD can also trigger other regions of the brain, including the amygdala, commonly called the fear center, and the hippocampus, which is involved in memory storage. These two areas are strongly linked — emotional memories are remembered more than neutral ones. When PTSD impairs function between these regions and ramps up activity in the amygdala, people can feel as though they’re under threat even when they’re not, and many report intrusive thoughts and nightmares.

Opening up about PTSD

The COVID-19 pandemic exposed many flaws in the U.S. health care system, including how mental health is treated. But in some respects, conversations about mental health are more socially acceptable now than in the past. Justin Schreiber, a UPMC pediatrician and child psychiatrist, said he’s seen kids open up now about what they need more than before the pandemic began. And Howze, the former firefighter, marine and police officer-turned author and motivational speaker, is using his own PTSD experience to help other veterans and emergency medical services personnel.

Howze was exposed to violence and death early: When he was 10 years old, a friend on his baseball team was shot by his own father and survived the gunshot wound. At 15, Howze got his first ride in a fire truck, but dread quickly replaced his excitement when he realized the team was responding to a fatal car accident of another firefighter. After high school, he joined the Marine Corps infantry and served for four years. Then at 22, on his first day working as a firefighter, his first call was for a head-on collision, and he had to drag the bodies out of their mangled vehicles.

On June 18, 2007, he had been working as a firefighter in Charleston, S.C., when he responded to a rescue call around 8 pm. A warehouse had caught fire and trapped his crew members in a deadly inferno. Nine of his friends died that night, and he spent all night identifying them and pulling their bodies out of the wreckage.

After that call, he wasn’t the same — PTSD had set in. He began to lash out at his loved ones. He showed up to work drunk and stopped caring about his appearance when he used to spend time shining his boots and shaving his face. Eventually he retired, and after years of physical altercations, verbal attacks and one suicide attempt, he vowed to get his mind right. He published a book in 2020 called “Create Your Own Light” about his experiences and gives speeches around the world raising awareness about PTSD in EMS workers.

During one speech at Ross Municipal Center Park in Ross on Sept. 29, sponsored by the Mindful Nation Foundation, the Penguins, Awaken Pittsburgh and the Village Center for Holistic Therapy, he asked a group of 160 people — mostly law enforcement workers and firefighters — for a show of hands if mental wellness was not even a consideration when they started the job. Everyone raised their hands.

“Who here has received training on how to call for help when you have a gun in your mouth?” he continued. No hands went up. “How many people in this room have tried to take their own life?” Eight hands.

“EMS is losing more people to suicide than to line-of-duty deaths,” Howze said. “We are more of a threat to ourselves than this job is.”

A change in culture

What’s the solution to thousands of traumatized EMS workers, police officers and veterans? Many agree that, largely, it’s communication and breaking down what Howze calls the “false tough guy culture.”

“The toughest people I’ve met are compassionate,” Howze said in an interview. “Vulnerability makes them stronger.” Howze wants to show that being open about his own struggles will illustrate to others that it’s OK for them to do the same.

“Dialogue promotes longevity in this career,” he said.

In 2016, he asked a group of law enforcement and EMS workers during one of his speeches how many of them could relate to his feelings of trauma, hopelessness and suicidal ideation. None of them raised a hand; he was the lone hand-raiser on the stage. Six years later, when most people in the audience raised their hands, he saw that as progress.

Brucker, the deputy fire marshal, said taking the day off to attend Howze’s talk was “definitely worth it.” In other similar workshops, people might use their own employees as teachers, Brucker said. “People don’t wanna learn from people they work with ... [Howze] was so knowledgeable about this topic that he normalizes it, and I think that’s the key to its success.”

Brucker also participated in a pilot program with Awaken Pittsburgh, a nonprofit focusing on mindfulness, and the health center Village Center for Holistic Therapy. The aim of the pilot was to see if mindfulness techniques like breathing exercises, visualization, sensory awareness and mindful walking could help treat anxiety, depression and PTSD in law enforcement, EMS and veteran populations.

Kristy Weidner, a licensed clinical social worker and co-owner of Village Center, and Stephanie Romero, founder and executive director at Awaken, who has a doctorate in education, saw a shared mission, and they worked together to create the pilot. The program has run three times and is still accepting participants, free of charge for two years thanks to a $145,000 grant from the Mary Hillman Jennings Foundation.

“It’s important for people to show up for themselves so they can show up for other people,” said Weidner. “As a reason for not seeking treatment, people often say ‘it’s not that bad.’ Why wait for it to get that bad?"