Work-related post-traumatic stress disorder.

BACKGROUND: Work-related post-traumatic stress disorder (PTSD) is an important condition encountered by many occupational health practitioners. AIMS: To carry out an in-depth review of the research on occupational groups that are at particular risk of developing work-related PTSD. METHODS: A literature search was conducted in the databases OVID MEDLINE, OVID Embase, Ovid PsycINFO, ISI Web of Science and CSA Health and Safety Science Abstracts. RESULTS: Professionals such as police officers, firefighters and ambulance personnel often experience incidents that satisfy the stressor criterion for the PTSD diagnosis. Other professional groups such as health care professionals, train drivers, divers, journalists, sailors and employees in bank, post offices or in stores may also be subjected to work-related traumatic events. Work-related PTSD usually diminishes with time. CONCLUSIONS: Mental health problems prior to the traumatic event and weak social support increase the risk of PTSD. Prevention of work-related PTSD includes a sound organizational and psychosocial work environment, systematic training of employees, social support from colleagues and managers and a proper follow-up of employees after a critical event.

Use of and satisfaction with support received among survivors from three Scandinavian countries after the 2004 Southeast Asian tsunami.

INTRODUCTION: There is limited guidance regarding effective preventions for post-disaster mental health problems and what kind of support is preferred by disaster survivors. AIM: To describe the use of and satisfaction with support in three Scandinavian countries after the tsunami and analyzing the association between support and posttraumatic stress reactions. METHOD: The sample comprises 6772 responders who returned to Scandinavia from the tsunami-struck countries of Southeast Asia in 2004. RESULTS: Most were satisfied with informal support on site. Support from embassies/consulates was not received well, leaving about 64% of the Danes/Norwegians and 73% of the Swedes dissatisfied. After returning home, support from close relatives rendered highest degree of satisfaction. Consultation with general practitioner (GP) was reported by 63% of Norwegians, 40% of Danes, and 16% of Swedes. Most responders (60-77%) were satisfied with their GP, although Norwegians were least satisfied. Using support was associated with higher levels of posttraumatic stress symptoms. CONCLUSIONS: Informal support was used to a high degree and rendered considerable satisfaction in all three countries, while the use of and satisfaction with formal support varied more. Lack of satisfaction with embassies and consulates may indicate deficiencies in the authorities' preparedness in assisting disaster stricken citizens abroad.

The effects of group psychological debriefing on acute stress reactions following a traffic accident: a quasi-experimental approach.

The purpose of this study was to evaluate the effects of a Group Psychological Debriefing (GPD) on acute stress reactions and perceptions following a traumatic situation. A group of military personnel (N = 9) and a group of voluntary civilian firefighters (N = 9) were exposed to severe stress during rescue work in a tunnel following a fatal traffic accident. Both groups participated in an operational debriefing and received brief stress management counseling after the incident. In addition the military personnel also participated in a structured 2.5 hour GPD after the accident. Two weeks later both groups completed the Coping Style Questionnaire (CSQ-30), the Impact of Event Scale (IES), the Post Traumatic Symptom Scale (PTSS-10), the General Health Questionnaire (GHQ-30) and questions about stress and coping after the incident. Lower frequency of symptoms were found in the GPD compared to the non-debriefed group measured by the PTSS-10. Single item analyzes of the scale revealed lower levels of symptoms related to emotional arousal in the GPD participants. Furthermore, the GPD participants revealed more positive personal outcomes than the non-debriefed group after the accident. The total PTSS-10 score and mental preparedness were the two variables that were best able to classify participants as belonging to the two groups, thus indicating significant clinical differences between the debriefed and non-debriefed group and the potential usefulness of PTSS-10 scale as a brief screening inventory after traumatic events.

Acute posttraumatic stress: nonacceptance of early intervention.

Psychological resistance may be of considerable importance in the posttraumatic stress disorder (PTSD) population, considering that researchers in the field of traumatic stress are frequently unsuccessful in achieving high response rates, that many subjects suffering from PTSD never seek help, and that dropouts from therapy are frequent. This article presents data on the main complaints reported in the acute aftermath of an industrial disaster by 246 employees who had been exposed to the disaster. The dominant concerns were symptomatic complaints related to posttraumatic stress reactions rather than external problems. Sleep disturbance, anxiety/fear responses, and physical symptoms were reported by individuals with complaints in the acute phase as most problematic, while irritability and depressive symptoms appeared very infrequently among the reported main complaints. A high specificity and sensitivity were achieved in predicting later PTSD (as defined by DSM-III criteria) by applying early response variables: thus, there were few false-positives and false-negatives. There was a considerable overlap between the PTSD predictors and the main symptom complaints. From a prevention point of view, this should be advantageous, since it would bring the right people to seek help. However, in a significant proportion of the acutely distressed, the reluctance to seek help was motivated by the very symptoms that predicted PTSD. Even a relatively high rate of subjects agreeing to be screened (82.8%) would have lost 42% of those who qualified for a diagnosis of PTSD, and more than half of the subjects with severe outcomes would not have been included. For primary and secondary prevention, the findings suggest that early screening and outreach should be very active.

[Psychosocial aspects in presymptomatic testing for genetic diseases. Experiences after 2 years of counseling in Huntington disease]. / Psykososiale aspekter ved presymptomatisk testing for genetisk sykdom. Erfaringer etter to års veiledning ved Huntingtons sykdom.

The authors describe their experience from the psychiatric assessment and psychosocial counselling of 28 persons who sought presymptomatic testing for Huntington's chorea. Half of the persons had lived with a disease-affected parent during childhood and early adolescence. Nine of these persons had suffered from a psychiatric disorder at least once. Of the whole sample, 32% had a psychiatric disorder at the time of the assessment. Most persons experienced major emotional distress in relation to the testing but severe psychiatric responses were not observed. Suicidal ideation in relation to the testing was most often reported by persons who had had extremely negative experiences during childhood with their own affected parent. In some persons who were found to be free of risk, the main problem was guilt owing to survival. The psychosocial and psychiatric aspects of the possibilities of gene technology in the future must be addressed more seriously.

[From war psychiatry to disaster and crisis psychiatry]. / Fra krigs- til katastrofe- og krisepsykiatri.

Psychiatry has derived much benefit from the combat experience of military medicine. The Allies' military psychiatry during the Second World War established cardinal modes of treatment, such as group therapy, the therapeutic community, and crisis intervention. The principles of field psychiatry consist in that the treatment be administered near the scene of the injury, in an early phase, be of short duration, be focused here and now, and be characterised by prognostic optimism; moreover the victim must retain his group identity. Many of these intervention techniques are now successfully used at disaster and crises in peacetime, e.g. at the recent ferry disaster on the Scandinavian Star.

Suicide among soldiers and young men in the Nordic countries 1977-1984.

A comparison of suicide rates among soldiers and civilians in the Nordic countries during the 8-year period 1977-1984 revealed that suicides among soldiers were more frequent in Norway than in Sweden and Finland. An in-depth study of the suicides of Norwegian soldiers during the same time period points to selection procedures and distance from home to the soldier's duty camp as possible causal factors. The suicides were frequently precipitated by an acute crisis. Preventive measures are discussed.

A research method for the study of psychological and psychiatric aspects of disaster.

This paper attempts to draw together some of the current questions related to the methodology of exploring the psychological and psychiatric aspects of human response to disaster. It sets out some of the key areas in which research questions might be mounted. A range of relevant instruments are suggested. The value of a structured interview which can explore issues of relevance to disaster victims is demonstrated. Early screening measures and proposals regarding these, as well as the particular instruments for longer term follow-up and assessment of outcome, are discussed in considerable detail. The article concludes with an overview of the principal issues to be addressed in methodology research, and emphasises the need for a collaborative approach using core items so that studies embracing different disasters and different countries can have some comparative basis.

Disaster psychiatry and traumatic stress studies in Norway. History, current status and future.

The breakthrough of Norwegian disaster psychiatry and traumatic stress studies came when the "Board of Norwegian Doctors of 1957" carried out exceptionally thorough and comprehensive studies of former concentration camp prisoners. These studies convincingly demonstrated that chronic mental illnesses could develop in persons who had a harmonious childhood but who had been subject to extreme physical and psychological stress. During the seventies Norway became the first country in the world to have a University chair of disaster psychiatry. The scope of the field was broadened by the initiation of several studies on traumatic neurosis, industrial disaster and injuries. The support from the Joint Norwegian Armed Forces Medical Services, the University of Oslo, the Norwegian Research Council for Science and the Humanities, and later the Royal Norwegian Council for Scientific and Technical Research, was crucial for this development. Currently stress and disaster psychiatry has become an integrated part of the care of victims who have suffered individual or collective disaster. Disaster psychiatry is taught in medical schools and is part of the obligatory training for residents in psychiatry.

A study of behavioural responses to an industrial disaster.

Based upon 7 response variables we categorized the impact behaviour of 123 industrial employees who had been exposed to a disastrous factory explosion and had survived without suffering severe injuries. The subjects were personally examined and the data controlled by cross-interviews shortly after the disaster. In the analysis the subjects were divided into a high stress (n = 64) and a medium stress exposure group (n = 59) based upon their closeness to the explosion centre. The 7 variables were cognitive function, inadequate behaviour, help received, leadership, cooperative activity, absolute and relative rescue efforts. While about 50% of the total number reported some disturbance in their cognitive control, and 34% of the high stress exposure group experienced a near total loss of cognitive control, severe inadequate behaviour did not occur. Modelling and corrective social interactions may have played an important role in this. Still, 20% of the high stress exposure group had some behavioural response that increased the risk to their life or that of others. The 7 scores were added to an index and cut-off points established to separate 3 different groups of behavioural responses: 29% of the high stress group displayed Maladaptive Disaster Behaviour; inhibited behaviour and uncontrolled flight behaviour dominated in this group. Adaptive Disaster Behaviour was rated in 34% and Optimal Disaster Behaviour in 37%. The following background variables correlated strongly to Optimal Disaster Behaviour: high level of disaster training/experience, male sex, age above 40, maritime occupational background, above average intellectual ability, a life history without mental health problems. A discriminant analysis with 8 variables predicted correctly whether the response would be Optimal or less than that in 84% of the 121 subjects tested in the analysis. A high level of disaster training/experience yielded an overall correct prediction rate of 63.6%, and a sensitivity of 81%, specificity of 85.9% and positive predictive power of 70.7% in predicting Optimal Disaster Behaviour.

Importance of high response rates in traumatic stress research.

Non-response and psychological resistance, i.e. degree of unwillingness to undergo the primary examination (screening), and its implications for estimation of PTSD prevalences was measured in a longitudinal study of 246 employees exposed to an industrial disaster (explosion/fire). Resistance including refusal, was measured by counting the number of contacts needed in the calling-in procedure to secure cooperation. Resistance to the primary examination related to severity of exposure (24.2% in the high exposure versus 6.8% in the medium exposure and 4.2% in the low exposure group). If those who initially resisted had been lost to the 7 month follow-up the total response rate would have been 82.8%, with an estimated frequency of high PTSS scores of 15. By increasing the response rate to 100%, the true prevalence of high PTSS scores increase to 22.4%. The initial resistance related strongly (P less than 0.001) to the severity of outcome at 7 months. The potential loss to the follow-up would have included 42% of the PTSD cases, and 64% of the severe PTSD cases would have fallen out, resulting in distorted prevalence rates of PTSD. The high potential loss to follow-up in the high exposure category would reduce the predictor value of belonging to that exposure group. The initial resistance in many who later developed PTSD was found to relate to the psychological defences such as avoidance against the re-experiences in the acute post-traumatic stress syndrome. For traumatic stress studies on the after-effects of shock traumas the implication of findings is that response rates need to be high. For primary and secondary prevention the implication may be that early outreach must be very active.

The stressors and the post-traumatic stress syndrome after an industrial disaster.

Acute and subacute post-traumatic stress reactions are reported among 246 employees of an industrial factory which was severely damaged by an explosion and fire. Sixty-six A-subjects had narrow escape experiences (high stress exposure group), while 59 B-subjects were less severely exposed (medium stress exposure group). The 121 C-subjects were not present at work when the explosion occurred (low stress exposure group). A response rate of 97.6% was achieved at the primary examination, and a 100% response at the 7 months follow-up. The frequency and intensity of post-traumatic stress reactions were linked to the severity (A,B,C) of the stress exposure; specific post-traumatic anxiety reactions reported by more than 80% of A-subjects. The reactions appeared immediately or within hours, only 5% of A had delays of a few weeks. While 24.3% of A had State Anxiety Inventory scores 1 week post-disaster higher than 60, 8.5% of B and 2.5% of C had similar scores. Depressive reactions, social withdrawal, guilt, shame and irritability were less frequent, and appeared nearly always concomitant with anxiety symptoms. While the anxiety symptoms made up a tight knit syndrome, the less frequent non-anxiety symptoms were linked to the post-traumatic anxiety syndrome. The subjects' fears reflected the trauma, they feared inanimate objects, and there were hardly any paranoid ideations. The disaster exposure of the A and B but not of the C group members constituted a stressor which fulfilled the PTSD stressor criterion of the DSM III R. A minority of the C group developed a post-traumatic stress syndrome. After 7 months, all 30 post-traumatic stress reactions were more frequent and severe in the A than B group which again differed from the C group. Irritability was the only post-traumatic stress reaction that increased in frequency and intensity during the 7 months observation period. The findings represent evidence that supports the face validity, descriptive and construct validity of the PTSD diagnosis.

The stress upon rescuers involved in an oil rig disaster. "Alexander L. Kielland" 1980.

Nine months post-disaster, 134 rescuers involved in an off-shore oil rig disaster were investigated by using a structured self report questionnaire to chart their experience of coping with disaster impact stressors and their mental and physical health 9 months after the disaster. Of the 134 rescuers, 24 were categorized as professional rescuers, 101 as non-professionals and 9 could not be classified. Of the 212 victims, all oil rig workers, 89 (42%) were rescued. Seventy-six percent of the rescuers reported they had been exposed to danger during the rescue operation, and 62% found the experience to be the worst ever. Eighty to ninety percent felt they had coped fairly well with the task, and severely disturbed coping was reported to be below 10% for decision-making, ability to judge risk, capacity to function as leader, and finally ability to cooperate and act efficiently. For the non-professionals, severe disturbance in ability to plan before acting was reported by 10% and moderate disturbance was reported by 38%. The frequency of emotional stress reactions during the rescue work can be assessed from the fact that 64% to 52% reported discouragement, restlessness, uncertainty, anxiety and irritation. The stressors inherent in this type of disaster seem to satisfy the DSM III stressor criterion for post-traumatic stress disorder. Nine months after the disaster 24% reported their mental health to be poor due to the disaster impact, and only the most experienced rescuers had a low health risk compared to the others.

Torture of a Norwegian ship's crew. The torture, stress reactions and psychiatric after-effects.

During the summer of 1984, 14 seamen, the entire crew of a Norwegian ship, were seized upon arrival in Libya. They were kept under arrest for 67 days and subjected to psychological and physical torture because they were suspected of being enemies of the Libyan state. Within the first few days of imprisonment one seaman had been murdered, another had been abducted and was believed to be dead, and a third had been severely physically maltreated. The immediate reactions to the extreme stress were fear, depression and rage. Not a single seaman gave in to the torture. Shortly after their release, all the seamen underwent thorough medical examinations. Six of them suffered from clear-cut post-traumatic stress disorder (PTSD) and one more seaman developed the disorder two months later. In spite of comprehensive treatment, the same seven sailors, or 54% of the crew, still suffered from post-traumatic stress disorder six months after their release. Used in conjunction with clinical interview, general mental status rating scales (GHQ 20, STAI, State Anxiety Inventory), and specific post-traumatic rating scales (Amnesty Score, IES intrusion subscale, PTSS-10) had a high sensitivity and specificity in discriminating between cases and non-cases.

Short-term dynamic psychotherapy. I. The Oslo group's form to score outcome, the reliability testing of this form and observer characteristics.

The aim of short-term dynamic psychotherapy is, through working with a central conflict and transference reactions, to obtain lasting changes based on cognitive and emotional understanding of the main dynamics of the central conflict, called insight. The aim of the present study was to construct a follow-up form that was easy to handle, could score different outcome of short-term dynamic psychotherapy, as for instance symptom relief, change in social functioning and better insight, and was reliable. Sufficient reliability was established with a reliability coefficient between 0.756 and 0.564 for eight result variables. Percentage agreement was estimated in addition. As a total only 10% of the scores differed more than +/- 1 from a consensus score on a scale from zero, no change, to 7, recovered. The therapist was a reliable observer of his/her own patients. The sex of the observer did not influence percentage agreement. High-formal training in psychotherapy tended to give higher percentage of agreement compared to low-formal training.

Short-term dynamic psychotherapy. II. Prognostic value of characteristics of patients studied by a 2-year follow-up of 39 neurotic patients.

39 out-patients, 19 men and 20 women with a neurotic personality structure, evaluated by at least 2 therapists, were treated with short-term dynamic psychotherapy. 33 patients were followed up 2 years after the end of treatment with a semi-structured, problem-oriented interview, scored by 3 therapists according to a follow-up form developed for the study. Sufficient reliability was demonstrated for the follow-up form. 11 of 36 patients (31%), followed up 2 years after the end of treatment, obtained a high score on the dynamic result variable, and 24 (67%) on symptom relief. It could be established that these changes were mostly due to the therapy given. Variables pertaining patients' ability to relate to another person correlated with outcome. This is consistent with what Malan found in his two studies.