This piece was written by one of our contributors; intercalating medical student in urgent and emergency care – Ria Marwaha
What is PTSD?
To truly understand PTSD, it can be helpful to trace back to our ancestors and understand how they lived to gain an insight into the mental health condition.
(Top tip:“Sapiens: A brief history of humankind” is an interesting read to find out more about our ancestors!).
(In the context of a prey and predator)
When there is an extreme threat to our survival you develop a strong sense of fear. The role of fear is to motivate survival. In the situation of the prey sensing a predator, the role is to both escape from the predator and try your hardest to avoid the predator seeing you.
These responses include;
- avoidance
- attentive immobility
- withdrawal
- aggressive defence
- appeasement
- immobility
It is important for these defences to exist as they optimise our chances of survival. Clearly these are essential characteristics for survival; therefore have been conserved over evolutionary time. When exposed to a traumatic event, the defence response is innately activated aiding survival. The defence-based model of PTSD suggests that following being triggered, the system inadequately recalibrates which results in heightened levels of any of these 6 defences mentioned above, in the absence of a fear trigger present (1).
*This model is supported through the strong link between the characteristics of these defence mechanisms and the diagnostic criteria for PTSD.
The “fight or flight” response is a well documented occurrence activated in a number of circumstances, one being the exposure to fear. When exposed to a threat, the sympathetic nervous system is activated resulting in a strengthening heart contraction to increase blood flow to areas of the body that facilitates movement in response to the threat. It is crucial to understand the physiological response to stressful situations to help identify the most effective treatments for disorders related to stress (2).
As little as one traumatic experience can be enough to increase the sensitivity of an individual to one or more of the innate defense mechanisms previously stated. For example, in the case of “attentive mobility”, the individual may be in a persistent state of hypervigilence, even without the presence of a fear trigger. This may present with symptoms of anxiety such as a fast heart rate and the person may constantly feel unsafe in a safe environment. When this heightened state of anxiety extends into normal daily activities, lasting for one month or longer, and is in the context of a previous exposure to a traumatic experience, a diagnosis of PTSD can be made (2).
How does PTSD link to our human anatomy and the brain?
There are 3 areas of the brain believed to be involved in the response to traumatic events and therefore have a role in PTSD
- amygdala
- hippocampus
- the prefrontal cortex (3).
Amygdala:
A study performed MRI scans on 200 military service members. The amygdala was significantly smaller in the group that had a diagnosis of PTSD than those that did not. Additionally, functional MRI scans have shown that individuals with PTSD have an exaggerated response in the amygdala to emotional stimuli (4). The amygdala has a central role in the emotional response and recognition of fear.
It functions to identify whether a stimuli represents a danger or not, and initiates the fight or flight response as a response to recognised danger. Amongst the many functions it has, it contributes to the identification of whether the person needs to respond to a stressful event and sends out danger signals and initiates fight or flight response. Features of traumatic events such as sights, smells and sounds, are stored by the amygdala. This is an extremely beneficial survival benefit as if the person is exposed to any of these stimuli again, the body would remember the previous exposure and respond more quickly to the identified danger.
However, in the case of PTSD, this is dysregulated meaning the body is falsely activated into a state of defence, and frequently thinks it is under threat, even in safe situations (3, 5).
Hippocampus:
The hippocampus has a central role in the formation and storage of memories. This area is believed to be overactive in individuals with PTSD, resulting in nightmares and flashbacks of the traumatic event (3).
Prefrontal cortex:
This area of the brain lies directly behind the forehead. It has a central role in controlling behaviours, emotions and impulses. Following a traumatic event it suppresses the response of the amygdala when danger is no longer present.
However, it may be underactive in individuals with PTSD. Therefore this negative reinforcement is lost, resulting in continuous activation of the amygdala (3).
What is the history of PTSD?
The condition was first recognised in war veterans. Exposure to the horror of war and death is psychologically damaging. Different names were given to the group of symptoms such as “shell shock” and “soldier’s heart”. In World War 1, men experiencing symptoms of what we now know as PTSD, were shot resulting in high numbers of execution. Soldiers developed extreme fear of this fate leading to men developing extreme nervous system diseases such as paralysis. This was then put down to the high use of artillery machinery, which gave rise to the term “shell shock”. As the field of psychiatry progressed, identification of war related psychiatric symptoms were becoming better understood. Screening tests were used to select soldiers that may be less psychologically vulnerable to the stress and trauma of war (6).
How is PTSD diagnosed?
Following a traumatic event, it is normal to experience a range of emotions and maybe not quite feel yourself. However, if these symptoms are particularly worrying or last more than 4 weeks, it is important to see your GP. This may lead to a medical appointment with a mental health specialist for further assessments. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is frequently updated and outlines the range of symptoms often experienced in PTSD. The symptoms can be largely divided into 3 main categories:
- Flashbacks and nightmares: these are intrusive symptoms that are often easily triggered. The experience can be extremely realistic with physical sensations felt from the traumatic event, such as sounds and pain.
- Being hypervigilant: Your body is unable to distinguish between ordinary life and danger. Feeling irritable is common.
- Avoidance and numbing: You avoid anything that may be linked to the traumatic event. Altered mood such as persistent negative emotions such as fear, horror and guilt may be experienced, as well as the inability to experience positive emotions (7-9).
How common is PTSD?
Individuals working as; soldiers, healthcare professionals, fire brigade workers, and police officers are among those at highest risk of having to deal with distressing and potentially traumatic events, and therefore are at greatest risk of developing PTSD (7).
The Emergency Department (ED) is an environment of high intensity and stress for all staff members. Healthcare professionals are required to work extremely quickly and maintain a very small margin of error. This can result in heightened levels of anxiety and fear within the department. Additionally, there is a high volume of exposure to traumatic events such death of a child, severe burns, violent individuals, large amounts of bleeding, the list goes on. Prevalence of PTSD amongst physicians has been found to be approximately double that in the general population. Worryingly, these figures are presumed to be lower than realistic/underreported due to a) the difficulty diagnosing the condition, b) failure of healthcare professionals to seek medical care due to the stigma surrounding PTSD (10).
A sample of Emergency ambulance professionals were studied, revealing that of those that responded, there was a 22% rate of PTSD (11). These statistics are shocking. It is critical that we start looking after healthcare professionals to allow them to continue to provide the best healthcare to the public.
Additionally, obstetricians often experience traumatic events, combined with the high level of pressure to ensure a successful delivery with a healthy mother and baby. A national survey was sent to 6,300 doctors on the Royal College of Obstetricians and Gynecologists database. There were 1095 responses and 43 in depth interviews with trauma-exposed individuals were completed and analysed. 91% of participants felt that specific support for traumatic events should be provided such as; being able to discuss the event relatively soon after it had happened and an option to take time off. Suggestions included the implementation of mandatory training around trauma and the need to change the culture around work related events to supporting one another and drawing away from a blame culture, as well as destigmatising access to psychological support.
2/3 reported exposure to traumatic work-related events and of these, 18% reported clinically significant PTSD. This is alarming and emphasises the need for urgent action to be taken to improve work place environments, to ensure the physical and psychological wellbeing of our doctors, and subsequently the delivery of the optimal and safest quality of care offered to women and their babies (12).
The emotional challenges of working in Paediatric Intensive care units across the UK are becoming increasingly recognised with contributing factors including cases being negatively dissected on social media and in the courts and increasing admissions due to the growing population. The total number of respondents was 1,656 and one of the findings included that just over a third of participants provided comments and suggestions for future work. A frequent comment was that actually completing the questionnaire raised issues of stigma within the department. A suggestion was that the impact of challenging relationships with families, withdrawal of treatment and child death, on psychological well being of healthcare professionals should be explored (13).
“A report on the welfare, morale and experiences of Anesthetists in training: the need to listen”, was conducted by the Royal College of Anesthetists between December 2017 and January 2017 through a survey. The number of respondents with 2312, representing 58% of anesthetists training in the UK. This is highly valuable data that strongly reflects the experience and welfare of anesthetists in training in the UK. Two examples where the physical and mental health of anesthetists has been show to be directly at risk:
- (mental health) 61% of respondents felt their job negatively affected their mental health and 21% reported that this occurred frequently,
- (physical health) 57% of respondents have had an accident or a near miss during their commute to and from work (14).
The results from these studies warrant significant change within healthcare departments. Systemic problems must be addressed, including; low staffing levels, shift patterns and low pay for nurses, as these are some of the many contributing factors (13), as well as measures put in place to protect the mental health of staff.
What’s being done?
The Royal London Hospital in Whitechapel has recognised the need to support staff. Being one of the four major Trauma Centres in the UK and situated in one of the most violent areas of London, the department perform more emergency operations within 24 hours than anywhere else in the UK. This means that healthcare professionals often have to respond to traumatic cases back-to-back with little or no time in between to be debriefed and process their emotions (15).
In 2018, the “Theatre Wellbeing Project” was set up at the Royal London Hospital. Approximately 200 healthcare professionals attended the morning event including 3 wellbeing workshops. One of these sessions involved individuals exposing their personal vulnerabilities through sharing their experiences of traumatic experiences.
This was chaired by critical care clinical psychologist who was able to give expert advice to those who attended. Feedback forms following the event revealed an average score of 4.7/5, which is clear evidence of the benefit of wellbeing sessions. The department now holds fortnightly sessions of informal peer support (15), with the intention of continuing to improve staff wellbeing, an idea which could be adopted by organisations such as the NHS, should it continue to show benefit.
Schwartz rounds have been an independent charity since 2013. It is an open forum that helps to improve feelings of stress and isolation amongst healthcare professionals by providing a forum for close conversation about the social and emotional aspects of working in healthcare. Their mission is to “humanise healthcare” (16).
What can you do in your department?
Communicate: it seems simple and is a fundamental human need, however throughout the literature and feedback from healthcare professionals it is clear that there is a lack of conversation between healthcare professionals regarding looking after one another. Simply asking “are you ok” in a genuine and non judgmental way, can go a long way (14).
Fatigue educational resources: should be frequently distributed to encourage healthcare professionals to maintain their own wellbeing (see more here: http://www.aagbi.org/professionals/wellbeing/fatigue) (14).
Treatments
There is a lack of research to identify interventions to prevent individuals from developing PTSD following trauma (17).
Randomised control trials have been conducted to analyse the effectiveness of a variety of psychological therapies for PTSD. However there are a number of factors that will influence how effective different therapies are for you, a few being; age, gender, the type of trauma you experienced, the number of sessions you had and many more. There are a vast variety of different interventions and it is important to seek out help and guidance as well as trying a variety to identify which are most beneficial to you, such as; different types of Cognitive Behavioural Therapy (CBT), cognitive restructuring, stress management, eye movement desensitisation reprogramming (EMDR), family therapy, hypnotherapy and supportive counseling (18).
The National Collaborating Centre for Mental Health (a collaboration between Royal College of Psychiatrists and the Centre for Outcomes Research and effectiveness at University College London) recommend trauma-based psychological treatments, aimed at personally addressing the traumatic event (19)
- Trauma focused CBT: involves repeated exposure of the traumatic memory,
- EMDR: aim is to encourage engaging in tasks such as eye movements and hand tapping whilst focusing on the negative trauma related memory. This should result in more positive trauma related memories to emerge (18).
The impact of Covid-19
Covid-19 has impacted the world in unprecedented ways and has negatively affected people’s physical, mental and social well-being. The COVID-19 pandemic has affected a wide variety of individuals including survivors, family members, those providing healthcare and the general public (20). However, healthcare professionals have suffered massively due to the high number of patients admitted and lack of resources available. This has caused high burnout rates and potential PTSD new cases in healthcare professionals. It is important that we analyse the effects of the pandemic on everyone and provide appropriate mental health support as soon as possible to prevent further deterioration (21).
References
(1)Cantor C. Post-traumatic stress disorder: evolutionary perspectives. Aust N Z J Psychiatry. 2009;43(11):1038-48.
(2) Baldwin DV. Primitive mechanisms of trauma response: an evolutionary perspective on trauma-related disorders. Neurosci Biobehav Rev. 2013;37(8):1549-66.
(3) The Anatomy of PTSD. BrainLine.
(4) Morey RA, Gold AL, LaBar KS, Beall SK, Brown VM, Haswell CC, et al. Amygdala volume changes in posttraumatic stress disorder in a large case-controlled veterans group. Arch Gen Psychiatry. 2012;69(11):1169-78.
(5) Rasia-Filho AA, Londero RG, Achaval M. Functional activities of the amygdala: an overview. J Psychiatry Neurosci. 2000;25(1):14-23.
(6) Corvalan JC, Klein D. PTSD: diagnosis, evolution, and treatment of combat-related psychological/psychiatric injury. Mo Med. 2011;108(4):296-303.
(7) Psychiatrists RCo. Post Traumatic Stress Disorder (PTSD) [Available from: https://www.rcpsych.ac.uk/mental-health/problems-disorders/post-traumatic-stress-disorder.
(8) (US) CfSAT. Trauma-Informed Care in Behavioral Health Services. 2014.
(9) England N. Overview: Post Traumatic Stress Disorder (PTSD) [Available from: https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/.
(10) Vanyo L, Sorge R, Chen A, Lakoff D. Posttraumatic Stress Disorder in Emergency Medicine Residents. Ann Emerg Med. 2017;70(6):898-903.
(11) Bennett P, Williams Y, Page N, Hood K, Woollard M. Levels of mental health problems among UK emergency ambulance workers. Emerg Med J. 2004;21(2):235-6.
(12) Slade P, Balling K, Sheen K, Goodfellow L, Rymer J, Spiby H, et al. Work-related post-traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO a mixed methods study with a cross-sectional survey and in-depth interviews. BJOG. 2020.
(13) Jones GAL, Colville GA, Ramnarayan P, Woolfall K, Heward Y, Morrison R, et al. Psychological impact of working in paediatric intensive care. A UK-wide prevalence study. Arch Dis Child. 2019.
(14) Anaesthetists RCo. A report on the welfare, morale and experiences of anaesthetist in training: the need to listen. 2017.
(15) S A, T A, J-A S. The Theatre Wellbeing Project at The Royal London Hospital. Anaesthesia News. December 2019.
16. Foundation TPoC. About Schwartz Rounds [Available from: https://www.pointofcarefoundation.org.uk/our-work/schwartz-rounds/.
17. Kearns MC, Ressler KJ, Zatzick D, Rothbaum BO. Early interventions for PTSD: a review. Depress Anxiety. 2012;29(10):833-42.
(18) Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety. 2009;26(12):1086-109.
(19) (UK) NCCfMH. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. 2005.
(20) Xiao S, Luo D, Xiao Y. Survivors of COVID-19 are at high risk of posttraumatic stress disorder. Glob Health Res Policy. 2020;5:29.21. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. J Am Coll Radiol. 2020;17(7):921-6.
