Post-traumatic stress disorder (PTSD) is a psychiatric disorder that may be witnessed in people who have a prior history of exposure to graphic, traumatic or gross imagery that may be manifest in potentially life-threatening circumstances such as war, sexual assault, natural disasters, mass fatalities, mass shootings or terrorist attacks. This paper explores the concept of PTSD among various cadres of first responders in emergency situations that warrant their intervention in the alleviation of human suffering with particular emphasis on firefighters as portrayed in the book, ‘In the Line of Fire: Trauma in the Emergency Services’ by Cheryl Regehr and Ted Bober.
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Worth noting is that PTSD may also be witnessed in other cadres of first responders such as paramedics and armed forces personnel when mobilized to save lives, as was the case in America during the 9/11 terrorist attacks. This paper is a product of meticulous qualitative and quantitative research with examples and statistics shared based on interviews and questionnaires that have been specially prepared to query the first-hand experiences of these responders.
Keywords: PTSD, trauma, human suffering
Literature Review: Impact of PTSD on First Responders
Given that emergency work entails always being at the forefront of virtually all tragic events, emergency workers frequently get to interact with human suffering and pain on a daily basis. That puts them at risk of developing PTSD, anxiety, depressive episodes, impaired memory, and a low concentration span. Other issues they face include irritability, loss of detachment, dissociation, recurrent dreams, and physical disturbances even though they undergo rigorous training that is ideally meant to equip them to handle such situations. Researchers agree that in emergency service delivery practice, there is at least a chance to experience a once-in-a-lifetime event that is so gross and beyond the scope of training of emergency workers and difficult for them to contend with (Muhammad, Ahmad, & Baik 2018). Some of those interviewed mentioned the terrorist attacks of September 11, 2001, as being too graphic for them ever to forget.
The typical work of emergency and rescue personnel entails evacuating vulnerable people, such as children and women who are trapped in buildings set on fire, extricating the remains of suicide victims, and averting the wanton destruction of property (Muhammad et al., 2018). It has been established that these events have a profound impact on not just their physical but also mental and psychological well-being, and that of their family members. Thus, it predisposes them to re-experience or relive the tragic once-in-a-lifetime events that they have faced when they encounter similar stimuli (Marmar et al., 2016). This is one of the manifestations of PTSD. Consequently, they are at risk of indulging in drugs and substance abuse, and at worse, even suicide.
Quiet events, far from mass casualties that perpetually make headlines are more likely to trigger emotional responses that ultimately contribute to PTSD in emergency workers. Such events include isolated cases of suicide of individuals who get the going too tough to handle, deaths involving elderly persons, and the gruesome murder of a spouse by a jilted lover (Muhammad et al., 2018). These events are likely to occur much more frequently compared to the once-in-a-lifetime occurrences like train or shipwrecks, bomb blasts, mass shootings, and other natural disasters (Regehr, Hill, & Glancy, 2017). The focus emphasized here is that cases involving mass casualties can more easily invite a lot of scrutiny and research when compared to everyday emergencies, emergency workers deal with. In empirical studies done on emergency responders that link these tragic events to future PTSD development, clinical experiences implicated in causing distress in these population also include the death of a co-worker in the line of duty, physical assaults by members of the public, and witnessing acts of violence.
Several studies reveals the impacts of everyday emergency ultimately contributes to PTSD in emergency workers. “Exposure to critical events” records of three exposure study groups involving 86 paramedics, 164 fire-fighters from Canada and Australia confirms the assertions mentioned above (Regehr et al., 2017). Over 80% of paramedics reported having experienced each of the tragic events about which they were asked. Those events were deaths of children, mass casualties and witnessing the death of patients. Close to 70% of those paramedics were reported to at least have been assaulted at some point, and said they felt their security had been threatened most of the time (Alexander & Klein, 2015). Paramedics were more likely to have been assaulted at 70% of the time, during emergencies (Regehr, Chau, Leslie, & Howe, 2012). About 40% of the fire-fighters in Canada reported having interacted with mass casualties, whereas about 40% from both countries reported having witnessed the demise of an individual who was under their care.
The following statistics serve as a threshold for identifying which emergency responders qualified to have gone through “significant emotional distress” that had psychological implications on their well-being. The percentage of paramedics who witnessed the death of patients in their care was about 30%, and the percentage of emergency volunteer fire-fighters who reported to have had their security threatened in New South Wales was put at about 56% (Marmar et al., 2016). Researchers were also able to establish that the events which caused the greatest distress in these emergency workers are as follows in the order of importance and impact; deaths that involved children, deaths involving co-workers in the line of duty, and deaths involving patients for whom the respondent emergency worker was entrusted with their care (Regehr et al., 2017). Regarding violence meted on children, neglect, and abuse, respondents reported having been so moved by the suffering that they were able to recollect fine details regarding the circumstances pertaining to every unique case they had come across.
Understanding the development of PTSD starts with understanding the theories postulated in helping the body respond to adversity. These theories include the stress theory, occupational stress theory, crisis theory, trauma theory, and the vicarious or secondary trauma theory (Regehr et al., 2017). The stress theory is founded on the idea that there are biological adaptations that the body mounts when faced with acute threats, and these can be thought of as, “flight” or “fight” response. This involves shifting of energy to the large muscles and an elaborate systemic increase in blood pressure and respiration to meet the body’s new demands (Marmar et al., 2016). As a result, a General Adaptation Syndrome theory that describes a three-step model for the body’s responses to stress has since been developed. These steps are mobilization and alarm, resistance, and exhaustion that aims to predict the body’s course of action.
Psychosocial factors which account for recurrent adversity and stress are emphasized in this new model (General Adaptation Syndrome theory). Since they present an allostatic load, which refers to the continuous strain on an individual (Regehr et al., 2017). Social relationships have a buffer action on the wear and tear caused by these stressors, and this is more so in women than men. Lazarus and Falkman (2014) came up with two appraisal systems that major on bio-behavioral aspects of stress, which shifts attention to the cognitive effects caused by these stressors. The incorporation of the cognition process in stress underscores the fact that stress is not just a mere physiologic reaction, but also can alter people’s responses. Primary appraisal involves the perception of an event as benign or stressful, whereas secondary assessment has to do with the estimation of one’s ability to cope using appropriate responses.
The Conservation of Resources (COR) theory postulated by Hobfall reaffirms the critical role of the appraisal theory by emphasizing the value of resources. In this theory, stress is determined by the loss or gain in crucial social or personal resources that have huge meaning to a person. Individuals strive to protect, attain, and defend resources such as self-love and knowledge; and stress arises when these resources are deficient (Regehr et al., 2017). The crisis theory hypothesizes that the exposure of an individual to sudden events that they are not adequately prepared to handle at a given time leaves them psychologically vulnerable to develop feelings of anxiety, helplessness, shock, depression, confusion, and PTSD in the long term (Marmar et al., 2016). These result in feelings of guilt, reduced self-esteem, and emotional distress.
The trauma theory has neuropsychological implications for individuals undergoing post-traumatic stress. It states that there are longstanding alterations in the cellular biology with increased amygdala action, diminished levels of cortisol, hypothalamic alterations, and a marked startle response which fails to habituate (Marmar et al., 2016). This is in contrast to ordinary experiences of fear, where there is a return to normal levels of these neuropsychological changes (Marmar et al., 2016). In this theory, stimulation by traumatic experiences and images lead to a hyper-arousal of the autonomic nervous system that continuously recurs. This is marked by alterations in memory sequence of the events and disorganization that renders these individuals to hyper-vigilance, impulsive and agitated with occasional periods of normalcy.
Studies, however, shows that between 50-80% of respondents from either male or female gender undergo traumatic life events. However, these events do not culminate in post-traumatic stress disorder (PTSD) (Alexander & Klein, 2015). This insinuates that there are people that are more adaptive and resilient, when faced with potentially traumatizing events. The theory of vicarious traumatization states that, by listening to graphical accounts of experiences faced by others, an individual develops alterations in their world perspective, sleep disturbances, altered arousal, phobias, and intrusive imagery experiences (Regehr et al., 2017). It has the effect of resulting in guilt, hopelessness, cynicism, burnout, and pessimism if it continues with time.
The critical incident stress (CIS) theory relates to the direct effects that a stressor event has on the psychological well-being of a person that has the first-hand experience of a tragedy or natural catastrophe. Stressor events can be psychosocial or physical, and they may result in behavioral and cognitive manifestations (Marmar et al., 2016). The occupational stress theory examines the macro aspects of emotional and physical responses that renders a worker incapable of meeting the overwhelming demands of the workplace (Regehr et al., 2017). Models that have been brought forward to explain this theory include the social role theory approach, the demand or control or support model, and the effort-reward imbalance model.
The demand or control or support approach correlates psychological implications of work factors, such as overload on an individual worker, whereas the effort-reward imbalance model investigates the rewards and input in work and how much strain it puts to the workers (Regehr et al., 2017). The social-role theory comes into play, where there is ambiguity or conflicting societal expectations between expectations and demands. Workplace related negative psychosocial factors are likely to aggregate into resentment, exhaustion, and diminished productivity.
The ecological framework provides a comprehensive perspective of individuals and their environment and thus, provides a context for the study and analysis of individual reactions to adverse life events. The World Health Organization (WHO) states that life circumstances and workplace dynamics play a role in the health of any given society (Marmar et al., 2016). Interventions aimed at improving public health are focused at primary, secondary, and tertiary approaches. Distress reactions occur when an individual is exposed to life-threatening or tragic events that are beyond the scope of their coping mechanisms.
In this paper, this does not just apply to the victims of these tragic events, but also to the individuals who witnessed the unfolding of events and reported feeling helpless as the events unfolded. Secondary trauma, therefore, is the phenomenon that occurs when an individual is exposed to catastrophic events that befall another person (Lazarus & Folkman 2014). This helplessness, despair, and horror may culminate in PTSD, which is the term that refers to the cluster of symptoms discussed in the Diagnostic and Statistical Manual of The American Psychiatric Association (DSM IV-TR).
There are three distinct clusters of symptoms unique to PTSD namely: re-experiencing symptoms that involve the individual reliving memories of the event usually by way of recurring flashbacks that may be sensory, visual or auditory, avoidance symptoms in which the individual frantically tries to keep off thoughts, places, and people that may trigger memories of the ordeal (Lazarus & Folkman 2014). The arousal symptoms are characterized by agitation, irritability, impulsivity, hyper-vigilance, and hyper-arousal (Lazarus & Folkman 2014). The third symptom, which is the intrusive symptoms, has been reported by some as their worst experience, since such symptoms are bordered on interrupting their sleep cycles via the graphic nightmares that they get.
In studies done on paramedics, fire-fighters, and the police; it was revealed that at a random given moment, about 57.1% had zero to a low-level symptom, about 18.3% qualified as moderate and about 4.2% prove to have high levels symptoms. Those with symptoms that were categorized as severe were about 20.4% (Alexander & Klein, 2015). More studies on ambulance workers, police, and firefighters showed that between 25-30% of those sampled had high or severe levels of stress symptoms. Associated long-term consequences of PTSD were substance abuse and depression. Family members of the affected individuals were also reported to be emotionally distant and disengaged from each other. Arguments were the order of the day in such households and in some cases, family violence was rampant. This manifests to the outer society as increased numbers of suicide cases, and higher divorce rates among these populations.
Emergency respondents and rescue workers are affected by tragic events, just as much as the real victims. They put their lives in harm’s way to save others and might get injured or even have themselves killed, maimed for the rest of their lives or suffer adverse psychological effects in the process. These include PTSD that may predispose them to substance abuse, depressive episodes, anxiety, and even suicidal tendencies. These effects may have consequences not just on their health, but also on those with whom they closely interact with, such as their spouses. Spouses may suffer divorce, since divorce rates are higher among these populations; their children may suffer neglect, in the case where these people (emergency workers) who are breadwinners’ resort to substance abuse and neglect of their parental duties. On the larger scale, the economy might suffer a lack of productivity, due to sub-optimal performance as a result of diminished workplace productivity. There should thus be research-based mechanisms, such as counseling and fostering strong social relationships that can be used in the care of these individuals.
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