Commentary, Exclusives, Resiliency

Toward a Better Understanding of Post-Traumatic Stress Disorder (PTSD)

Above, National Highway Traffic Safety Administration photo.

Post-Traumatic Stress Disorder (PTSD) has become a prevailing topic of conversation in EMS and first responder circles. It has been described as a clear and present danger for emergency services personnel who are often exposed to human events that are stressful. But, how many people truly understand PTSD and has the condition been properly diagnosed? Is it as common in EMS as many people think? If present, what is the treatment?

The history of PTSD, when compared to other psychiatric conditions, is somewhat different. PTSD as a disease was not identified until after the Vietnam War. Mental health professionals felt that some veterans of that long and controversial war had a unique psychiatric profile that was different than other psychiatric conditions previously described. It was not until 1980 that the American Psychiatric Association (APA) listed this disorder in the Diagnostic and Statistical Manual of Mental Diseases, Third Edition (DSM-III). However, the disorder had been previously described in persons who were subjected to catastrophic stressors (e.g., Holocaust survivors, sexual assault survivors, soldiers).

However, the condition had been reported for years prior. It had actually been described in the Civil War where physicians reported the development of a rapid heart rate, anxiety, and trouble breathing in certain soldiers. Because of the physical signs and symptoms, the condition was referred to as “Soldier’s Heart”. Later, in World War I, it was referred to as “Shell Shock”. In World War II, it was called “Battle Fatigue” or “Combat Stress Reaction (CSR)”. In 1952 the APA called the condition “Gross Stress Reaction.” When the diagnosis of PTSD was first formally recognized, it was controversial in that PTSD occurred due to conditions outside of the individual (stressors) rather than typical psychiatric conditions that can occur without outside causes (inherent illnesses). Today, the diagnosis is widely accepted although treatment remains controversial.1

What is PTSD?

The diagnostic features of PTSD have been determined and refined by the APA and detailed in the Diagnostic and Statistical Manual of Mental Diseases, Fifth Edition (DSM-5).2 It is described as a trauma-and stressor-related disorder. In order to be diagnosed with PTSD, according to the DSM-5, the person must meet the following criteria:

  • Criterion A. The person was exposed to actual or threatened death, actual or threatened serious injury or threatened sexual violation. In addition, these events were experienced in one or more of the following ways:
    1. Directly experiencing the traumatic event(s).
    2. Witnessing, in person, the event(s) as it occurred to others.
    3. Learning that the traumatic event(s) occurred to a close relative or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
    4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). (Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related).
  • Criterion B. The presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
    1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
    2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
    3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
    4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
    5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Criterion C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
    1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
    2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Criterion D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
    1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs).
    2. Persistent and exaggerated negative beliefs or expectations about oneself, others or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
    3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
    4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
    5. Markedly diminished interest or participation in significant activities.
    6. Feelings of detachment or estrangement from others.
    7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
  • Criterion E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
    1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
    2. Reckless or self-destructive behavior.
    3. Hypervigilance.
    4. Exaggerated startle response.
    5. Problems with concentration.
    6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
  • Criterion F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
  • Criterion G. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
  • Criterion H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Certainly the diagnosis of PTSD is complex and the condition is actually fairly uncommon. It is important to point out that persons with PTSD must have all of the diagnostic criteria discussed in this comprehensive list. Also, it is important to note that the disturbance must be present for at least one month before the diagnosis can be made. Furthermore, the disturbance must significantly distress or impair the person’s day-to-day functioning. Most important, the diagnosis cannot be made when the patient is suffering from other medical conditions and/or using medication and/or alcohol.

What is the Incidence of PTSD in the United States?

Despite what has been widely reported, PTSD is fairly uncommon. It has been estimated that approximately 50% of women and approximately 60% of men have experienced some type of traumatic event. Despite this, most of these individuals will never develop PTSD. The overall lifetime prevalence of PTSD in adults in the United States is roughly 6.8%. It is somewhat higher in women (9.7%) than in men (3.6%). These data were based on DSM-4 criteria.3 Prevalence incidence using the updated DSM-5 criteria is slightly lower.4

What is the Incidence of PTSD in Emergency Services Personnel?

Interestingly, for the most part, we really don’t know the incidence of PTSD in EMS personnel in the United States. An Australian systematic review/meta-analysis of the scientific literature found 13 studies that met inclusion criteria relating to PTSD and EMS (ambulance personnel). Overall they found the incidence of PTSD in EMS personnel to be 11%.5 They found that PTSD was not the most common mental health condition seen in ambulance personnel. Depression and anxiety were more commonly encountered. An earlier systematic review found the incidence of PTSD in first responders to be 10.2%.6 A study of PTSD in first responders who responded to the World Trade Center in New York on September 11, 2001 to be 12.4%.7

What is the Treatment for PTSD?

The treatment for PTSD is neither straightforward or easy. There are several considerations in regard to PTSD and EMS personnel. First, it takes months or years for PTSD to develop. It is generally recommended that no treatment be provided within the first three months of the traumatic event. There is no evidence that popular EMS practices such as Critical Incident Stress Management (CISM) in any way mitigate stress or PTSD. There is some evidence that it does reduce alcohol use immediately following the stressful event.8 There is limited evidence that Psychological First Aid (PFA), which is not an intervention, may be of benefit to some. Initially, CISM/D was promoted as a strategy to mitigate EMS stress and PTSD. After several studies showed that CISM had no significant beneficial effect, and some papers that showed evidence of harm, that statement was removed from CISM literature.9 Recently, other first responder groups have taken a critical stance on CISM.10

Second, the diagnosis must be correct. A proper diagnosis is required to begin treatment. Treating a patient for PTSD when they actually have depression, acute stress disorder, or another condition can actually worsen the situation. Furthermore, the diagnosis cannot be made if the affected person is using alcohol or medications. The affected person must be evaluated by the appropriate mental health professional (e.g., psychiatrist, clinical psychologist) before the diagnosis of PTSD is given to an individual.

PTSD treatment must be provided by licensed mental health personnel with experience in this condition. Principal strategies include Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). CBT is a type of psychotherapy that helps patients understand the thoughts and feelings that influence behaviors. EMDR is a type of psychotherapy where the person being treated is asked to recall distressing images. The therapist then directs the client in one type of bilateral sensory input such as side-to-side eye movements or hand tapping. It is unclear how it works and it is not without controversy. There is some evidence that selected medications may be of limited benefit. These include the antidepressants fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), venlafaxine (Effexor) and the antipsychotic quetiapine (Seroquel). 11

Recovery from PTSD is possible but difficult. Many persons who develop PTSD have other issues going on in their lives (e.g., family problems, divorce, work problems, financial problems, substance abuse) that can inhibit or delay recovery. Unless these associated problems are also addressed in treatment, recovery may be difficult.

Summary

EMS personnel are at an increased risk of developing PTSD but the incidence does not appear to be as high as is often touted. Certainly, significant work-related stressors can lead to the development of the condition. But, other pre-existing stressors (substance abuse, personal problems, financial problems, work problems) can worsen the illness. Surveillance of personnel for several months after a major stressful event by mental health personnel is prudent. Those not recovering should be screened for PTSD and other disorders (depression, acute anxiety disorder, substance abuse) and referred to the proper mental health personnel for treatment.  

References

1. Turnbull GJ. A review of post-traumatic stress disorder. Part I: Historical development and classification. Injury. 1998;29(2):87-91.

2. American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: 2013.

3. Kessler RC, Berglund P, Delmer O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 2005;62(6): 593-602.

4. Goldstein ED, Smith SM, Chou SP, et al. The Epidemiology pf DSM-5 Postraumatic Stress Disorder in the United States: Results from the National Epidemiologic Survey of Alcohol Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol. 2016;51(8):1208-1215.

5. Petrie K, Milligan-Saville J, Gayed A, et al. Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):897-909.

6. Berger W, Coutinho ES, Figueira I, et al. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):1001-11

7. Perrin MA, Digrande L, Wheeler K, Thorpe L, Farfel M, Brackbill R. Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. Am J Psychiatry. 2007;164(9):1385-94.

8. Tuckey MR, Scott JE. Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety Stress Coping. 2014;27(1):38-54.

9. Bledsoe BE. Critical incident stress management (CISM): benefit or risk for emergency services? Prehosp Emerg Care. 2003;7(2):272-9.

10. The American Society of Evidence-Based Policing. The harmful effects of Critical Incident Stress Debriefing (CISD): Why police departments should stay up to date on evidence-based practices. Available at: https://www.americansebp.org/the-harmful-effects-of-critical-incident-stress-debriefing-cisd-why-police-departments-should-stay-up-to-date-on-evidence-based-practices/. Accessed July 13, 2019.

11. International Society for Traumatic Stress Studies: Posttraumatic Stress Disorder Prevention and Treatment Guidelines Methodology and Recommendations. Available at: http://www.istss.org/getattachment/Treating-Trauma/New-ISTSS-Prevention-and-Treatment-Guidelines/ISTSS_PreventionTreatmentGuidelines_FNL-March-19-2019.pdf.aspx. Accessed July 13, 2019.