Mental Health

Post-traumatic Stress

Post-traumatic stress disorder (PTSD) is a complex response to psychological trauma. The somatic, cognitive, affective and behavioral symptoms of PTSD develop following at least 1 traumatic event. In this regard it is an exposure-related disease. The duration of diagnostic symptoms must be greater than 1 month. If symptoms resolve within 1 month following the inciting event, a diagnosis of acute stress disorder (ASD) may be made. This discussion is restricted to PTSD as diagnostic criteria and disability associated with the 2 conditions are similar except for duration.

PTSD patients vary greatly with regard to the nature and duration of symptoms, the social and occupational dysfunction the condition poses, and their response to treatment. Avoidance of reminders of the inciting trauma is a diagnostic criterion.3 This feature poses particular challenges in diagnosis and treatment of this condition, as patients are often reluctant to reveal or discuss traumatic events.

PTSD may result in extreme alteration of levels of arousal, negative changes in mood and cognition, intrusive thoughts or memories, dissociative events such as flashbacks, nightmares and other sleep disturbances, and distress with recollection of traumatic events. Symptoms may be triggered by workplace experiences that remind the LEO of prior trauma. Dissociative episodes (e.g., flashbacks) may be so severe as to reduce or eliminate situational awareness. Avoidant behavior, and heightened arousal and aggressive behavior in particular, may negatively affect work performance.

Epidemiology

U.S. lifetime prevalence is 8.7%, 12 months prevalence of 3.5%. Rates are lower in Europe and most African, Asian, and Latin American countries. Assuming similar exposure to traumatic events, the likelihood of developing PTSD may also vary across cultural groups. Prevalence and duration of symptoms of PTSD is greater among females than males, but this may be due to greater exposure to traumatic events.

By comparison with non-Latino whites, and after adjustment for demographics and traumatic exposure, rates in the U.S. are higher among Latinos, African Americans, and Native Americans. Rates are lower among Asian Americans. Rates are higher among those with greater exposure to trauma, including veterans, police officers, and firefighters. With the highest rates (33-50%) among: victims of sexual violence; history of military combat and/or captivity; victims of “ethnically or politically motivated internment, or genocide.”3

The diagnosis of PTSD is common among veterans. After hearing loss and tinnitus, PTSD is the third most common reason for Veterans Administration disability awards; 58% of VA awards for mental health disorders are for PTSD. Among veterans of Operation Enduring Freedom/Operation Iraqi Freedom with awards for mental health disorders, 75% are for PTSD.22 This is relevant given the large proportion of veterans among candidates for LEO positions.

PTSD symptoms and their severity may vary over time; 50% of persons diagnosed with PTSD will experience complete recovery within 3 months. However, more than 30% of those diagnosed with PTSD are symptomatic for at least 1 year.23 For some, symptoms last for decades. Symptoms may recur or increase in intensity with reminders of the inciting trauma, new traumatic events, or life stressors.

Comorbidities

Persons with PTSD are 80% more likely to have symptoms meeting diagnostic criteria for another mental health disorder than those without PTSD. Depressive disorders, anxiety disorders, and substance abuse are 2-4 times more prevalent in patients with PTSD; substance abuse is often an attempt to self-medicate.24 There is also a high prevalence of PTSD in persons with history of traumatic brain injury (TBI). In one study returning soldiers with mild TBI, 62% screened positive for PTSD.25 Risk of developing PTSD following trauma is modified by pre-traumatic, peri-traumatic, and post-traumatic factors.

Pre-traumatic:

• Childhood emotional problems by age 6
• Prior mental disorders: panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder.
• Lower socio-economic status, lower education, childhood adversity and trauma, lower intelligence, minority racial/ethnic status, family psychiatric history, female gender, lower age at time of exposure.
• Social support prior to exposure is protective. Self-resilience may be another protective characteristic. In a 2015 cross-sectional study, 112 Korean police officers were tested using the Connor-Davidson Resilience Scale-Korean (CD-RI-K) and found that PTSD symptoms were more likely to be reported by officers with low self-resilience that those with high self-resilience (odds ratio of 3.5 CI: 1.06-19.23).26

Peri-traumatic:

• Severity of the experienced trauma, perceived life threat, personal injury, interpersonal violence (particularly trauma perpetrated by a caregiver, or involving a witnessed threat to caregivers in children), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy, finally, dissociation that occurs during the trauma and persists afterward.

Post-traumatic:

• Upsetting reminders, subsequent adverse life events;
• Negative appraisals, inappropriate coping strategies, development of acute stress disorder;
• Social support is a moderating factor that improves outcomes after trauma.

Treatment

Both psychotherapy and medication have been proven useful in treatment of PTSD, but no randomized trials have compared the two approaches. A systematic review of combined pharmacotherapy and psychological therapies did not find any significant increase in efficacy over either treatment alone.27

Trauma-focused psychotherapeutic approaches to PTSD treatment have been shown to be effective by randomized controlled trials. These include cognitive therapy, trauma-focused cognitive-behavioral therapy (TF-CBT), behavioral therapy (typically exposure therapies), and eye-movement desensitization and reprocessing (EMDR). Evidence suggests that the key component of success with cognitive behavioral therapy and EMDR is exposure to traumatic memories.28

A systematic review of 35 randomized controlled studies found SSRIs effective as first-line agents in PTSD, and are recommended by the American Psychiatric Association practice guidelines for this disorder.29 These agents reduce intrusive thoughts, pathologic avoidance, hyperarousal, depression, vigilance, and impulsivity. Prazosin, an alpha-1-antagonist has been used to treat nightmares and improve overall PTSD symptoms, but studies are conflicting.30,31

Critical incident stress debriefing (CISD) is an intervention often used by police departments and fire departments following traumatic events involving first responders. The technique typically involves group recollection and discussion of a traumatic event. Despite the continued popularity of CISD, meta-analyses of clinical trials have found no evidence of effectiveness in preventing PTSD.32,33