Confusion, nightmares, uncertainty, hyper-vigilance, suspiciousness, intrusive images, blaming, poor problem solving, impaired abstract thinking, difficulty with numbers, poor concentration, memory problems, disorientation, difficulty identifying objects or people, heightened or diminished alertness, higher or lower awareness of surroundings.
Fear, guilt, grief, panic, denial, anxiety, agitation, irritability, depression, apprehension, emotional shock, emotional outbursts, loss of emotional control, thoughts of suicide or homicide, inappropriate emotional responses.
Withdrawal, anti-social acts, inability to rest, intensified pacing, erratic movement, change in social activity, change in speech pattern, loss or increase of appetite, hyper-sensitivity to environment, increased alcohol consumption, change in normal communications.
Source: CISM International, Sherry Cardinal, LCSW
Those first on the scene of tragedies like this week's shooting at an Amish school are getting more help than in past generations, when police, rescuers and firefighters simply were expected to be tough, experts say.
"It always was a myth, because human beings are human beings," said Sherry Cardinal of Richmond, Texas, a licensed clinical social worker in crisis stress management for 16 years.
"First responders have notoriously high incidents of suicide and alcoholism and family problems," Cardinal said.
Support services are evolving nationwide and -- especially since the Sept. 11, 2001 terrorist attacks, the December 2004 tsunami and Hurricane Katrina -- public safety agencies are giving more help to first responders coping with traumatic stress.
"It's not looked upon as negatively as maybe it was before, that you just dealt with it and went home," said Delaware State Police spokeswoman Sgt. Melissa Zebley.
A key issue is exposure to human remains, whether from disaster or crime, according to the Homeland Defense Journal, which began national training workshops on the topic last year.
First responders' stress "may take a couple of months for it to really hit people," said Journal spokeswoman Laura Johnson.
And it's not just mass killing.
"For example, a child-involved crash can prove to be very traumatic," Zebley said.
The Critical Incident Stress Management Team helps more than police, Zebley said. "They would gather together EMS [emergency medical services], troopers, any emergency personnel or dispatchers," she said.
The team is trained in counseling and referral for help dealing with depression, said team coordinator Capt. John A. Yeomans, commander of Troop 7 in Lewes.
"Originally, the intent was to provide the service for state police officers and our civilians," he said, "but when we got this up and running, we started broadening to other agencies, police, municipalities."
The New Castle County Police Department also has a critical stress incident team of in-house experts, said spokesman Cpl. Trinidad Navarro.
Because police investigate all deaths outside hospitals, they develop coping abilities, he said, "but you can never prepare yourself for something like what happened out in Lancaster County."
The commander of police in the Amish shooting announced they all are undergoing counseling before returning to work, a point expert Cardinal said will boost the awareness that first responders need help.