The trauma experienced as a paramedic can have a devastating psychological impact on both professionals and students in training, and increases the risk of developing post-traumatic stress disorder (PTSD). Paramedics are often placed in high-risk situations involving multiple or sustained trauma and also experience high levels of occupational stress, which can produce adverse psychological and physiological responses. Despite these risks, understanding trauma and its various manifestations in paramedicine has not been well documented.
This narrative review describes the history and changes in diagnostic criteria, and contrasts the methods of measuring PTSD symptomology with the current criteria.
PTSD was first defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) in 1980, however the diagnostic criteria and associated measurement tools failed to reflect the repeated and vicarious traumatic events experienced by paramedics.Currently, the majority of the measurement tools used to assess post-traumatic stress are still aligned with superseded diagnostic criteria and many only classify the symptoms of PTSD as present or absent with little consideration given to symptom severity. Consequently, these existing measurements of PTSD are out dated and inefficient in their ability to identify and measure PTSD using the revised criteria.
The development of a more specific measurement tool, which reflects the DSM-5 diagnostic criteria of trauma-related stressors within this population, will allow for a more comprehensive measurement of symptoms. Future research undertaken in this specific field will also help to inform education and training programs to assist with the negative impacts of trauma and aid in management and treatment of PTSD in paramedics.
Skeffington PM, Rees CS, Mazzucchelli T. Trauma exposure and post-traumatic stress disorder within fire and emergency services in Western Australia. Aust J Psychol 2017;69:20-8. doi:10.1111/ajpy.12120
Fjeldheim CB, Nothling J, Pretorius K, et al. Trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees. BMC Emerg Med 2014;14:11. doi:10.1186/1471-227x-14-11
Wild J, Smith KV, Thompson E, et al. A prospective study of pre-trauma risk factors for post-traumatic stress disorder and depression. Psychol Med 2016;46:2571-82. doi:10.1017/s0033291716000532
Fullerton CS, Ursano RJ, Wang L. Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry 2004;161:1370-6. doi:10.1176/appi.ajp.161.8.1370
Haugen PT, Evces M, Weiss DS. Treating posttraumatic stress disorder in first responders: a systematic review. Clin Psychol Rev 2012;32:370-80. doi:10.1016/j.cpr.2012.04.001
Lowery K, Stokes MA. Role of peer support and emotional expression on posttraumatic stress disorder in student paramedics. J Trauma Stress 2005;18:171-9. doi:10.1002/jts.20016
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Arlington VA: Author; 2013.
Blake DD, Weathers FW, Nagy LM, et al. The development of a clinician-administered PTSD scale. J Trauma Stress 1995;8:75-90. doi:10.1002/jts.2490080106
Australian Bureau of Statistics. 2071.0 – Census of Population and Housing: Reflecting Australia – stories from the census, 2016, 2018.
Boyle M, Koritsas S, Coles J, Stanley J. A pilot study of workplace violence towards paramedics. Emerg Med J 2007;24:760-3. doi:10.1136/emj.2007.046789
Adams RE, Boscarino JA, Figley CR. Compassion fatigue and psychological distress among social workers: a validation study. Am J Orthopsychiatry 2006;76:103-8. doi:10.1037/0002-9418.104.22.168
Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy, and trauma in ambulance paramedics. ibid. 2002;72:505-13.
Rothbaum BO, Davis M. Applying learning principles to the treatment of post-trauma reactions. Ann N Y Acad Sci 2003;1008:112-21.
Briere J. Psychological assessment of adult posttraumatic states: phenomenology, diagnosis, and measurement. Washington DC: American Psychological Association; 2004.
Price M, van Stolk-Cooke K. Examination of the interrelations between the factors of PTSD, major depression, and generalized anxiety disorder in a heterogeneous trauma-exposed sample using DSM 5 criteria. J Affect Disord 2015;186:149-55. doi:10.1016/j.jad.2015.06.012
Phoenix Australia. Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne Australia: Australian Centre for Posttraumatic Mental Health; 2013. Available at: http://phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines.pdf [Accessed 1 September 2018].
LeBlanc VR, Regehr C, Birze A, et al. The association between posttraumatic stress, coping, and acute stress responses in paramedics. Traumatology 2011;17:10-6. doi:10.1177/1534765611429078
Maunder RG, Halpern J, Schwartz B, Gurevich M. Symptoms and responses to critical incidents in paramedics who have experienced childhood abuse and neglect. Emerg Med J 2012;29:222-7. doi:10.1136/emj.2010.099838
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617-27. doi:10.1001/archpsyc.62.6.617
Donnelly E, Siebert D. Occupational risk factors in the emergency medical services. Prehosp Dis Med 2009;24:422-9.
Berger W, Coutinho ESF, Figueira I, et al. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Soc Psychiatry Psychiatr Epidemiol 2012;47:1001-11. doi:10.1007/s00127-011-0408-2
McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:957-67. doi:10.3109/00048674.2011.624083
Black Dog Institute. Expert guidelines: diagnosis and treatment of post-traumatic stress disorder in emergency service workers 2015. Available at: https://blackdoginstitute.org.au/docs/default-source/research/expert-guidelines---diagnosis-and-treatment-of-post-traumatic-stress-disorder-in-emergency-service-workers.pdf [Accessed 1 September 2018].
Berger W, Figueira I, Maurat AM, et al. Partial and full PTSD in Brazilian ambulance workers: prevalence and impact on health and on quality of life. J Trauma Stress 2007;20:637-42. doi:10.1002/jts.20242
Magruder KM, Yeager DE. The prevalence of PTSD across war eras and the effect of deployment on PTSD: a systematic review and meta-analysis. Psychiatr Ann 2009;39:778-88. doi:10.3928/00485713-20090728-04
Dworkin ER, Menon SV, Bystrynski J, Allen NE. Sexual assault victimization and psychopathology: a review and meta-analysis. Clin Psychol Rev 2017;56:65-81. doi:10.1016/j.cpr.2017.06.002
Liebschutz J, Saitz R, Brower V, et al. PTSD in urban primary care: high prevalence and low physician recognition. J Gen Intern Med 2007;22:719-26. doi:10.1007/s11606-007-0161-0
Galatzer-Levy IR, Bryant RA. 636,120 ways to have posttraumatic stress disorder. Perspect Psychol Sci 2013;8:651-62. doi:10.1177/1745691613504115
Halpern J, Gurevich M, Schwartz B, Brazeau P. Interventions for critical incident stress in emergency medical services: a qualitative study. Stress Health 2009;25:139-49. doi:10.1002/smi.1230
Middleton K, Craig CD. A systematic literature review of PTSD among female veterans from 1990 to 2010. Soc Work Ment Health 2012;10:233-52. doi:10.1080/15332985.2011.639929
Maia DB, Marmar CR, Metzler T, et al. Post-traumatic stress symptoms in an elite unit of Brazilian police officers: prevalence and impact on psychosocial functioning and on physical and mental health. J Affect Disord 2007;97:241-5. doi:10.1016/j.jad.2006.06.004
Creamer M, Burgess P, McFarlane AC. Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychol Med 2001;31:1237-47.
Sijbrandij MRJB, Roberts NP, Engelhard IM, Olff M, Sonneveld LP. Self-report screening instruments for post-traumatic stress disorder (PTSD) in survivors of traumatic experiences. Cochrane Database Syst Rev 2013;6. doi:10.1002/14651858.CD01057
Elwood LS, Mott J, Lohr JM, Galovski TE. Secondary trauma symptoms in clinicians: a critical review of the construct, specificity, and implications for trauma-focused treatment. Clin Psychol Rev 2011;31:25-36. doi:10.1016/j.cpr.2010.09.004
Davidson JR, Book SW, Colket JT, et al. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med 1997;27:153-60.
Davidson JR, Colket JT. The eight-item treatment-outcome post-traumatic stress disorder scale: a brief measure to assess treatment outcome in post-traumatic stress disorder. Int Clin Psychopharmacol 1997;12:41-5.
Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD checklist (PCL): reliability, validity, and diagnostic utility. Annual Meeting of the International Society for Traumatic Stress Studies; San Antonio TX1993.
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 2015;28:489-98. doi:10.1002/jts.22059
Hogan N, Costello S, Boyle M, Williams B. Measuring workplace trauma response in Australian paramedics: an investigation into the psychometric properties of the impact of event scale. Psychol Res Behav Manag 2015;8:287-94. doi:10.2147/prbm.S96647
Norris FH, Hamblen JL. Standardized self‐report measures of civilian trauma and PTSD. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York NY: Guilford Press; 2004. p. 63-102.
Brewin CR. Systematic review of screening instruments for adults at risk of PTSD. J Trauma Stress 2005;18:53-62. doi:10.1002/jts.20007
Del Vecchio N, Elwy AR, Smith E, Bottonari KA, Eisen SV. Enhancing self-report assessment of PTSD: development of an item bank. ibid. 2011;24:191-9. doi:10.1002/jts.20611
Bryant RA. Assessing individuals for compensation. In: Carson D, Bull R, editors. Handbook of psychology in legal settings. Oxford UK: Oxford University Press; 2003.
Bostock Matusko D, Kemp RI, Paterson HM, Bryant RA. The assessment of Post-traumatic Stress Disorder for workers' compensation in emergency service personnel. Aust Psychol 2013;48:420-7. doi:10.1111/ap.12009
Keane TM, Buckley TC, Miller MW. Forensic psychological assessment in PTSD. In: Simon R, editor. Posttraumatic stress disoder in litigation: guidelines for forensic assessment. 2 edn. Washington DC: American Psychiatric Publishing Inc; 2003. p. 119-40.
Watson CG. Psychometric posttraumatic stress disorder measurement techniques: a review. Psychol Assess 1990;2:460-9. doi:10.1037/1040-3522.214.171.1240
Keane TM, Caddell JM, Taylor KL. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. J Consult Clin Psychol 1988;56:85-90.
Weathers FW, Litz BT, Keane TM, et al. The PTSD checklist for DSM-5 (PCL-5): The National Center for PTSD; 2013. Available at: www.ptsd.va.gov [Accessed 1 September 2018].
Costello AB, Osbourne J. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Practical Assessment Research & Evaluation 2005;10:1-9.
Wortmann JH, Jordan AH, Weathers FW, et al. Psychometric analysis of the PTSD checklist-5 (PCL-5) among treatment-seeking military service members. Psychol Assess 2016;28:1392-403. doi:10.1037/pas0000260
Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (PCL-5) in veterans. ibid. 2016;28:1379-91. doi:10.1037/pas0000254.