PTSD in healthcare

Post-traumatic stress disorder in health care. What is it? How do we go about it?
And what impact can it have on everybody else?
It's Yuen.
And Mike, welcome to The Imperfect Clinician.
Post-traumatic stress disorder, PTSD. Today we're talking about PTSD, specifically in health care.
Before we start, I think it's important to understand what trauma is. Tell me more.
Trauma is, I mean, the definition is probably very long, but to be as brief as we can,
is essentially classified as witnessing events beyond a typical stressor.
So that's something that is much more pronounced in intensity or also in length when it comes to generating stress in said person.
Is it only in witnessing events? What's about experiencing it yourself?
Experiencing events, by all means. I mean, trauma can affect a lot of, not only profession, but people in general.
It could all be witness of crime, killing, something that can leave a strong impact on us,
and that trauma can potentially lead further on down the line into post-traumatic stress disorder.
I think it's worth to mention that PTSD does not affect everybody.
It doesn't affect everybody who experiences trauma, but if it does, it can leave a significant mark on the individual.
And it's important to acknowledge that there is help available.
Okay. And what are the professions that have high risk of PTSD?
Essentially, we hear most about PTSD in context of military, because that's where it's most obvious and most pronounced.
And you can see there is a lot of charities and specialists that deal with handling trauma in ex-soldiers or veterans in general.
And I think because it's also in films and movies, so people perhaps have more awareness of it.
Yeah, I think that this came to prominence, I mean, that was called in many different terms over the years.
In the past, during the First World War, it was called shell-shocked.
Then you have got combat fatigue as well.
I think in American literature, you can describe it as,
but then as the years went on and we started to understand a little bit more about it,
it doesn't necessarily have to do that much with combat in general.
It can be preceded by trauma of some kind, not necessarily military-related.
It also affects other uniform service people, such as police officers, firefighters, ambulance crews,
also journalists, people who are war correspondents, for example.
Also, which is not really that commonly mentioned, teachers as well,
because you have to understand that the stressing agent can be present in their life over a longer period of time.
And that can lead further down the line to PTSD.
That also may affect rescue workers.
So it includes, for example, volunteers that provide help or support after natural disasters, wars,
tsunamis, wildfires or earthquakes, shootings very often as well.
I think it's important also not to forget victims of slavery, human trafficking,
perhaps refugee asylum seekers, hostages and abuse.
Or victims of rape, for example.
Yeah, so any level of abuse that we're talking about here, whether it's sexual abuse, physical, emotional,
including any bullying and harassment.
And we want everybody to understand that, of course, we understand that the majority of PTSD research
and PTSD treatment is directed to the military personnel or people in uniforms in general.
But I think it's worth recognizing that there were some research studies done on healthcare workers.
And for example, here in the UK, PTSD is twice the rate of the general public.
And that was presented in the Lancet Psychiatry.
So I wonder why we are talking about specifically in healthcare today.
We decided to talk about people in healthcare because they are closest to our hearts.
And I think that knowledge about PTSD in healthcare and outside of the so-called emergency people
who are involved directly in dealing with this immediate trauma, I think it's a little bit undiscovered.
And I think there is a potential for exploring it.
And I believe that the more we're going to discuss it, the more support there's going to be available.
Because if we are already noticing that there is a certain level of trauma,
and we notice that there is a lot of effort done to support the well-being of, for example, clinicians
or people working in healthcare, whereas there is probably not enough systemic changes
that would create the environment that's going to minimize that risk of exposure to trauma.
And the support can be discussed on a wider scale.
There is something else that prompted us to have a little discussion about PTSD in healthcare.
And it is the fact that very often people who are affected by traumatic events are still active professionally.
They still work as doctors, paramedics, nurses, pharmacists in stressful environments.
And they still make decisions about their patients, people who they care for.
And those decisions can be impacted by the traumatic experience.
So in that context, the effect, as dramatic as it is for people in military, for example, and others,
it may not necessarily be only limited to the individual or their family or family and friends.
There is a real impact on people who need help, who are those most vulnerable,
and people who are experiencing trauma themselves.
So the support is essential for people who dedicate their lives to helping others.
Yeah, and I think especially with COVID-19, the stress prior to COVID-19 was already high and significant,
but COVID-19 added multiple layers of complexity to it
and perhaps magnified the impact of trauma in the profession or in healthcare in general.
And also, it brought a lot of professions together.
I mean, there was all of a sudden need for retired doctors to go back into practice,
to get people who weren't directly involved in patient care to provide advice or be on the front line.
So that sort of accelerated the multidisciplinary approach to patient care in general
and exposed a lot more people to direct contact with the patient in a much more stressful environment.
Okay, so then what can it lead to? Can it lead to clinicians perhaps leaving the profession?
So that, in my opinion, can lead to burnout, can lead to leaving the profession,
and can lead to personal mental health issues and that obviously impacts the families and everybody around them.
So when you have highly trained people to deliver complex care that are under prolonged stress
when they leave the profession because of certain traumatic events,
that leaves the gap that is much harder to fulfil and that puts pressure on others to step up.
So that generates more stress as a consequence.
Okay, so what are the risk factors for PTSD?
Like we mentioned before, not everybody who experiences trauma is going to take them into post-traumatic stress disorder
or to experience those prolonged effects, but the risk factors may include,
well, whether we witness or directly involved in intense or prolonged trauma,
also early trauma such as childhood physical, emotional or sexual abuse, bullying, that's another thing,
or any other form of harassment that can lead us more vulnerable and more prone to PTSD.
Later on in life.
Okay, so then if that's the case, if you have early trauma, then perhaps existing mental health problems
such as depression, anxiety, perhaps eating disorders.
It could be, yeah. That's the thing with having an early impact on children that it sort of stays and sits
and that can later on develop into a long-term problem for the individual and people around them.
And perhaps it makes them more susceptible.
It makes people more susceptible, more prone and, you know, another thing is, for example, substance misuse.
If you are either misusing any drug or alcohol, for example, that can make you more prone to PTSD,
but also as a result, PTSD can magnify the problem and also lead to alcoholism or drug addiction.
So that's...
To increase the risk, essentially.
That just increases the risk, yeah.
Also...
In both ways, sorry, I should say, substance misuse increased the risk of getting PTSD,
but also having PTSD that increased the risk that it will lead to the person needing any alcohol or drugs
as a form of substance misuse in order to cope.
Yeah, as a coping mechanism, yeah, later on.
Also, poor support network.
That's something that is around us that can potentially lead to us dealing with trauma,
not skilfully enough and not mindfully enough to prevent PTSD in the future.
There are also other things that with many mental health conditions like a family history of,
you know, for example, mental health disorders,
but that sort of not always is directly translatable on our mental health issues.
Let's focus on PTSD itself.
So what symptoms could be associated with it?
So I would imagine it would be having the feeling of overwhelming guilt,
overwhelming shame and perhaps betrayal, avoidance.
I can imagine that I don't want to talk, I don't want to deal with it.
Perhaps avoiding places or people that reminds you of the trauma that you've experienced
and for you to have PTSD from it, you don't really want to go there.
I've seen patients showing signs of intrusive memory,
so I presume this will be the same when you experience PTSD in healthcare
and changes in sleep and appetite,
so whether you just can't sleep because your sleep can be very disrupted
and you either under-eat or over-eat as a way of coping.
I would also add to it, for example, aggressive outbursts
because that could be one of the symptoms that may affect others as well directly.
Yeah, and sometimes it doesn't have to be aggressive.
It can be outbursts in general, so I would say irritability,
so they're more irritable.
Easier, the threshold is a bit lower for outbursts.
Also difficulty experiencing positive emotions,
that's one thing that may potentially lead further down to break up in relationships
and potentially problems with sexual dysfunction as well.
Yeah, because I presume their libido will be affected as well from that.
So what are potential interventions?
So BMJ in 2022 suggested intervention strategies
such as trauma-related knowledge in general, awareness of it,
emotion regulation and relaxation as a skill training,
also psychological support from peers and psychologists
where three core intervention components were present.
Okay, and I think before all of that can be implemented effectively,
it's important for you to know, to seek help, to be aware of it
and to be brave enough to ask for help.
Yeah, it is important because very often people who have experienced trauma
are trying not to mention it, trying to sweep it under the carpet,
not to relive it again and that is probably one of the biggest problems
with those issues resurfacing again as PTSD in the future.
And sometimes we use comparative suffering where we go,
oh, but somebody else has got it worse than me, so I really shouldn't complain.
And so by doing that, you are belittling the pain that you're feeling
and which makes it really difficult in acknowledging.
Yeah, so I guess we're addressing it in a not very adequate way.
Yes, counselling I think would help as well, CBT, like cognitive behavioural therapy or CPT,
cognitive processing therapy where you get to speak to a therapist,
perhaps EMDR, eye movement desensitisation and reprocessing treatment might help.
Charities, what are the charities that are available
that will be available to provide sort of like a support group?
I mean, here in the UK, there is PTSD UK
and they deal with all sorts of different trauma and post-traumatic stress disorder,
also with complex PTSD and all the other iteration of trauma and post-traumatic disorders.
There is Trauma Treatment International.
We're mentioning mainly organisations that do not necessarily focus only on veterans, okay.
They deal with trauma in general and in a wider context,
not necessarily looking at particular origin in combat conditions, okay.
There is mental health support for refugees and asylum seekers as well
and the most basic and the first thing that usually,
one of the first things that can be recommended by GP or specialists relatively quickly
would be the pharmacological treatment.
So what are the non-pharmacological strategies there are that could help us to, well, be prepared?
I mean, it's hard to be prepared for trauma
but we can in general put ourselves in a better mental state to deal with potential problems.
So I guess the things that I'm going to mention,
it will help more with the awareness and then asking for help
and then after that when you do ask for help, you will get the appropriate support.
So something like mindfulness where you check in with yourself
and see how you're feeling, how you're getting on for the day
by using breathing exercises or journaling any yoga that helps you move
or perhaps using creativity.
So for example, art, music or dance, you mentioned about support network.
So I think that's really important to re-evaluate the support network that you have around you
and make sure you build a strong supportive network.
Yes, PTSD can often take you into loneliness and trying to stay away from people.
Yeah, in the form of isolation, especially when you're dealing with shame.
The first thing that you want to do is to make sure that it's kept in secret.
So breaking that silence might be hard if you are telling somebody.
However, breaking the silence in the form of journaling might be a good way to start
before you feel that you're ready to open up to others.
But I think the ones that I've talked about are more individual-centered.
I think there is so much more that can be done to be more system-focused
where we proactively assess healthcare system to identify any workload and workforce issues
and from then on, we then look at the attraction and retention issues.
Because if we don't, it feels that we are always struggling to catch up with the population
because there is always constant change in the population health due to different factors.
People aging, health inequalities, economic deprivation.
So we need to make sure that we are working with data, working with all different sectors
and with the multidisciplinary approach so that we can plan for the future much better.
So I'm thinking about engaging with higher education, with university.
I'm thinking about liaising with different groups of people, primary care, secondary care, tertiary care
and making sure that we're all thinking in one instead of my sector, like me saying my primary care sector.
Well, it doesn't because people flow within different sectors
and we need to make sure that it's a workforce pool that we're trying to plan for
and making sure that they stay within that pool.
It's very important to retain those clinicians that otherwise may not feel that the stress of the work is adequately managed
and I think that we have to remember that it's not only the cost of treating PTSD later on with CBT
or any other therapy or medications, whatever it is.
It's also the cost of losing a clinician, of losing a teacher, of losing people who really can contribute to the society.
People who do important jobs and whose service can be appreciated by so many.
Yeah, and the things that we perhaps forget to add in the equation is the time to train them
but more importantly the time for them to build relationship with the team and with the patients
and those, if you can factor that in financially, it will make a significant difference.
Most of the time and the cost of gaining experience.
I mean, that's really hard to evaluate what constitutes a good doctor later on,
what constitutes a competent nurse.
The exposition to good quality learning environment and good quality team with a great culture in it,
that allows you to plan for the future and ensure that those gaps are fulfilled
and the bridges are built for the future.
It is our take on PTSD in healthcare.
We wanted to draw your listeners' attention to the issue that very often may not be attributed
to our community of healthcare professionals
but can be quite significant when we consider the prolonged effect on everybody.
And whether you are somebody that is part of the healthcare world or not,
it's useful to start the mindfulness activity, to check in.
Check in with yourself, check in with the people that you care about
because majority of us are exposed to trauma.
And for you to be aware what to look out for, how to keep track and how to ask for help,
it will ensure that you are in a better place than before.
Thank you for listening.
Until next time.
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