Beyond the broad concept of stress and its relationship to general health issues, there has been little attention to the role of psychiatric diagnosis in the prevention and treatment of the mental health consequences of work-related injuries. Most of the work on job stress has been concerned with the effects of exposure to stressful conditions over time, rather than to problems associated with a specific event such as a traumatic or life-threatening injury or the witnessing of an industrial accident or act of violence. At the same time, Post-traumatic Stress Disorder (PTSD), a condition which has received considerable credibility and interest since the mid-1980s, is being more widely applied in contexts outside of cases involving war trauma and victims of crime. With respect to the workplace, PTSD has begun to appear as the medical diagnosis in cases of occupational injury and as the emotional outcome of exposure to traumatic situations occurring in the workplace. It is often the subject of controversy and some confusion with respect to its relationship to work conditions and the responsibility of the employer when claims of psychological injury are made. The occupational health practitioner is called upon increasingly to advise on company policy in the handling of these exposures and injury claims, and to render medical opinions with respect to the diagnosis, treatment and ultimate job status of these employees. Familiarity with PTSD and its related conditions is therefore increasingly important for the occupational health practitioner.
The following topics will be reviewed in this article:
- differential diagnosis of PTSD with other conditions such as primary depression and anxiety disorders
- relationship of PTSD to stress-related somatic complaints
- prevention of post-traumatic stress reactions in survivors and witnesses of psychologically traumatic events occurring in the workplace
- prevention and treatment of complications of work injury related to post-traumatic stress.
Post-traumatic Stress Disorder affects people who have been exposed to traumatizing events or conditions. It is characterized by symptoms of numbing, psychological and social withdrawal, difficulties controlling emotion, especially anger, and intrusive recollection and reliving of experiences of the traumatic event. By definition, a traumatizing event is one that is outside the normal range of everyday life events and is experienced as overwhelming by the individual. A traumatic event usually involves a threat to one’s own life or to someone close, or the witnessing of an actual death or serious injury, especially when this occurs suddenly or violently.
The psychiatric antecedents of our current concept of PTSD go back to the descriptions of “battle fatigue” and “shell shock” during and after the World Wars. However, the causes, symptoms, course and effective treatment of this often debilitating condition were still poorly understood when tens of thousands of Vietnam-era combat veterans began to appear in the US Veterans Administration Hospitals, offices of family doctors, jails and homeless shelters in the 1970s. Due in large part to the organized effort of veterans’ groups, in collaboration with the American Psychiatric Association, PTSD was first identified and described in 1980 in the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) (American Psychiatric Association 1980). The condition is now known to affect a wide range of trauma victims, including survivors of civilian disasters, victims of crime, torture and terrorism, and survivors of childhood and domestic abuse. Although changes in the classification of the disorder are reflected in the current diagnostic manual (DSM IV), the diagnostic criteria and symptoms remain essentially unchanged (American Psychiatric Association 1994).
Diagnostic Criteria for Post-TraumaticStress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
- The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
- The person’s response involved intense fear, helplessness or horror.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
- Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.
- Recurrent distressing dreams of the event.
- Acting or feeling as if the traumatic event were recurring.
- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
- Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
- Efforts to avoid thoughts, feelings or conversations associated with the trauma.
- Efforts to avoid activities, places or people that arouse recollections of the trauma.
- Inability to recall an important aspect of the trauma.
- Markedly diminished interest or participation in significant activities.
- Feeling of detachment or estrangement from others.
- Restricted range of affect (e.g., unable to have loving feelings).
- Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
- Difficulty falling or staying asleep.
- Irritability or outbursts of anger.
- Difficulty concentrating.
- Exaggerated startle response.
E. Duration of the disturbance (symptoms in criteria B, C and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more.
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.
Psychological stress has achieved increasing recognition as an outcome of work-related hazards. The link between work hazards and post-traumatic stress was first established in the 1970s with the discovery of high incident rates of PTSD in workers in law enforcement, emergency medical, rescue and firefighting. Specific interventions have been developed to prevent PTSD in workers exposed to job-related traumatic stressors such as mutilating injury, death and use of deadly force. These interventions emphasize providing exposed workers with education about normal traumatic stress reactions, and the opportunity to actively surface their feelings and reactions with their peers. These techniques have become well established in these occupations in the United States, Australia and many European nations. Job-related traumatic stress, however, is not limited to workers in these high-risk industries. Many of the principles of preventive intervention developed for these occupations can be applied to programmes to reduce or prevent traumatic stress reactions in the general workforce.
Issues in Diagnosis and Treatment
The key to the differential diagnosis of PTSD and traumatic-stress-related conditions is the presence of a traumatic stressor. Although the stressor event must conform to criterion A—that is, be an event or situation that is outside of the normal range of experience—individuals respond in various ways to similar events. An event that precipitates a clinical stress reaction in one person may not affect another significantly. Therefore, the absence of symptoms in other similarly exposed workers should not cause the practitioner to discount the possibility of a true post-trauma reaction in a particular worker. Individual vulnerability to PTSD has as much to do with the emotional and cognitive impact of an experience on the victim as it does to the intensity of the stressor itself. A prime vulnerability factor is a history of psychological trauma due to a previous traumatic exposure or significant personal loss of some kind. When a symptom picture suggestive of PTSD is presented, it is important to establish whether an event that may satisfy the criterion for a trauma has occurred. This is particularly important because the victim himself may not make the connection between his symptoms and the traumatic event. This failure to connect the symptom with the cause follows the common “numbing” reaction, which may cause forgetting or dissociation of the event, and because it is not unusual for symptom appearance to be delayed for weeks or months. Chronic and often severe depression, anxiety and somatic conditions are often the result of a failure to diagnose and treat. Thus, early diagnosis is particularly important because of the often hidden nature of the condition, even to the sufferer him- or herself, and because of the implications for treatment.
Although the depression and anxiety symptoms of PTSD may respond to usual therapies such as pharmacology, effective treatment is different from those usually recommended for these conditions. PTSD may be the most preventable of all psychiatric conditions and, in the occupational health sphere, perhaps the most preventable of all work-related injuries. Because its occurrence is linked so directly to a specific stressor event, treatment can focus on prevention. If proper preventive education and counselling are provided soon after the traumatic exposure, subsequent stress reactions can be minimized or prevented altogether. Whether the intervention is preventive or therapeutic depends largely on timing, but the methodology is essentially similar. The first step in successful treatment or preventive intervention is allowing the victim to establish the connection between the stressor and his or her symptoms. This identification and “normalization” of what are typically frightening and confusing reactions is very important for reduction or prevention of symptoms. Once the normalization of the stress response has been accomplished, treatment addresses the controlled processing of the emotional and cognitive impact of the experience.
PTSD or conditions related to traumatic stress result from the sealing off of unacceptable or unacceptably intense emotional and cognitive reactions to traumatic stressors. It is generally considered that the stress syndrome can be prevented by providing the opportunity for controlled processing of the reactions to the trauma before the sealing off of the trauma occurs. Thus, prevention through timely and skilled intervention is the keystone for the treatment of PTSD. These treatment principles may depart from the traditional psychiatric approach to many conditions. Therefore, it is important that employees at risk of post-traumatic stress reactions be treated by mental health professionals with specialized training and experience in treating trauma-related conditions. The length of treatment is variable. It will depend on the timing of the intervention, the severity of the stressor, symptom severity and the possibility that a traumatic exposure may precipitate an emotional crisis linked to earlier or related experiences. A further issue in treatment concerns the importance of group treatment modalities. Victims of trauma can achieve enormous benefit from the support of others who have shared the same or similar traumatic stress experience. This is of particular importance in the workplace context, when groups of co-workers or entire work organizations are affected by a tragic accident, act of violence or traumatic loss.
Prevention of Post-Traumatic Stress Reactionsafter Incidents of Workplace Trauma
A range of events or situations occurring in the workplace may put workers at risk of post-traumatic stress reactions. These include violence or threat of violence, including suicide, inter-employee violence and crime, such as armed robbery; fatal or severe injury; and sudden death or medical crisis, such as heart attack. Unless properly managed, these situations can cause a range of negative outcomes, including post-traumatic stress reactions that may reach clinical levels, and other stress-related effects that will affect health and work performance, including avoidance of the workplace, concentration difficulties, mood disturbances, social withdrawal, substance abuse and family problems. These problems can affect not only line employees but management staff as well. Managers are at particular risk because of conflicts between their operational responsibilities, their feelings of personal responsibility for the employees in their charge and their own sense of shock and grief. In the absence of clear company policies and prompt assistance from health personnel to deal with the aftermath of the trauma, managers at all levels may suffer from feelings of helplessness that compound their own traumatic stress reactions.
Traumatic events in the workplace require a definite response from upper management in close collaboration with health, safety, security, communications and other functions. A crisis response plan fulfils three primary goals:
- prevention of post-traumatic stress reactions by reaching affected individuals and groups before they have a chance to seal over
- communication of crisis-related information in order to contain fears and control rumours
- fostering of confidence that management is in control of the crisis and demonstrating concern for employees’ welfare.
The methodology for the implementation of such a plan has been fully described elsewhere (Braverman 1992a,b; 1993b). It emphasizes adequate communication between management and employees, assembling of groups of affected employees and prompt preventive counselling of those at highest risk for post-traumatic stress because of their levels of exposure or individual vulnerability factors.
Managers and company health personnel must function as a team to be sensitive for signs of continued or delayed trauma-related stress in the weeks and months after the traumatic event. These can be difficult to identify for manager and health professional alike, because post-traumatic stress reactions are often delayed, and they can masquerade as other problems. For a supervisor or for the nurse or counsellor who becomes involved, any signs of emotional stress, such as irritability, withdrawal or a drop in productivity, may signal a reaction to a traumatic stressor. Any change in behaviour, including increased absenteeism, or even a marked increase in work hours (“workaholism”) can be a signal. Indications of drug or alcohol abuse or change in moods should be explored as possibly linked to post-traumatic stress. A crisis response plan should include training for managers and health professionals to be alert for these signs so that intervention can be rendered at the earliest possible point.
Stress-related Complications of Occupational Injury
It has been our experience reviewing workers’ compensation claims up to five years post-injury that post-traumatic stress syndromes are a common outcome of occupational injury involving life-threatening or disfiguring injury, or assault and other exposures to crime. The condition typically remains undiagnosed for years, its origins unsuspected by medical professionals, claims administrators and human resource managers, and even the employee him- or herself. When unrecognized, it can slow or even prevent recovery from physical injury.
Disabilities and injuries linked to psychological stress are among the most costly and difficult to manage of all work-related injuries. In the “stress claim”, an employee maintains he or she has been emotionally damaged by an event or conditions at work. Costly and hard to fight, stress claims usually result in litigation and in the separation of the employee. There exists, however, a vastly more frequent but seldom recognized source of stress-related claims. In these cases, serious injury or exposure to life-threatening situations results in undiagnosed and untreated psychological stress conditions that significantly affect the outcome of work-related injuries.
On the basis of our work with traumatic worksite injuries and violent episodes over a wide range of worksites, we estimate that at least half of disputed workers’ compensation claims involve unrecognized and untreated post-traumatic stress conditions or other psychosocial components. In the push to resolve medical problems and determine the employee’s employment status, and because of many systems’ fear and mistrust of mental health intervention, emotional stress and psychosocial issues take a back seat. When no one deals with it, stress can take the form of a number of medical conditions, unrecognized by the employer, the risk manager, the health care provider and the employee him- or herself. Trauma-related stress also typically leads to avoidance of the workplace, which increases the risk of conflicts and disputes regarding return to work and claims of disability.
Many employers and insurance carriers believe that contact with a mental health professional leads directly to an expensive and unmanageable claim. Unfortunately, this is often the case. Statistics bear out that claims for mental stress are more expensive than claims for other kinds of injuries. Furthermore, they are increasing faster than any other kind of injury claim. In the typical “physical-mental” claim scenario, the psychiatrist or psychologist appears only at the point—typically months or even years after the event—when there is a need for expert assessment in a dispute. By this time, the psychological damage has been done. The trauma-related stress reaction may have prevented the employee from returning to the workplace, even though he or she appeared visibly healed. Over time, the untreated stress reaction to the original injury has resulted in a chronic anxiety or depression, a somatic illness or a substance abuse disorder. Indeed, it is rare that mental health intervention is rendered at the point when it can prevent the trauma-related stress reaction and thus help the employee fully recover from the trauma of a serious injury or assault.
With a small measure of planning and proper timing, the costs and suffering associated with injury-related stress are among the most preventable of all injuries. The following are the components of an effective post-injury plan (Braverman 1993a):
Companies should require a brief mental health intervention whenever a severe accident, assault or other traumatic event impacts on an employee. This evaluation should be seen as preventive, rather than as tied to the standard claims procedure. It should be provided even if there is no lost time, injury or need for medical treatment. The intervention should emphasize education and prevention, rather than a strictly clinical approach that may cause the employee to feel stigmatized. The employer, perhaps in conjunction with the insurance provider, should take responsibility for the relatively small cost of providing this service. Care should be taken that only professionals with specialized expertise or training in post-traumatic stress conditions be involved.
Return to work
Any counselling or assessment activity should be coordinated with a return-to-work plan. Employees who have undergone a trauma often feel afraid or tentative about returning to the worksite. Combining brief education and counselling with visits to the workplace during the recovery period has been used to great advantage in accomplishing this transition and speeding return to work. Health professionals can work with the supervisor or manager in developing gradual re-entry into job functioning. Even when there is no remaining physical limitation, emotional factors may necessitate accommodations, such as allowing a bank teller who was robbed to work in another area of the bank for part of the day as she gradually becomes comfortable returning to work at the customer window.
Post-traumatic reactions are often delayed. Follow-up at 1- and 6-month intervals with employees who have returned to work is important. Supervisors are also provided with fact sheets on how to spot possible delayed or long-term problems associated with post-traumatic stress.
Summary: The Link between Post-Traumatic Stress Studies and Occupational Health
Perhaps more than any other health science, occupational medicine is concerned with the relationship between human stress and disease. Indeed, much of the research in human stress in this century has taken place within the occupational health field. As the health sciences in general became more involved in prevention, the workplace has become increasingly important as an arena for research into the contribution of the physical and psychosocial environment to disease and other health outcomes, and into methods for the prevention of stress-related conditions. At the same time, since 1980 a revolution in the study of post-traumatic stress has brought important progress to the understanding of the human stress response. The occupational health practitioner is at the intersection of these increasingly important fields of study.
As the landscape of work undergoes revolutionary transformation, and as we learn more about productivity, coping and the stressful impact of continued change, the line between chronic stress and acute or traumatic stress has begun to blur. The clinical theory of traumatic stress has much to tell us about how to prevent and treat work-related psychological stress. As in all health sciences, knowledge of the causes of a syndrome can help in prevention. In the area of traumatic stress, the workplace has shown itself to be an excellent place to promote health and healing. By being well acquainted with the symptoms and causes of post-traumatic stress reactions, occupational health practitioners can increase their effectiveness as agents of prevention.