By Michael Rallo, Rutgers University ’17

Exposure to trauma is an integral part of the human experience. Through the years, such reactions to traumatic events have been termed “soldiers’ nostalgia,” “irritable heart,” “shell shock,” “battle fatigue,” “post-Vietnam syndrome,” and “gross stress reaction.” Many different names for symptoms – sleep disturbances, flashbacks, anxiety, and fear – are now recognized as one psychological condition: post-traumatic stress disorder (PTSD).1 Healthcare providers can quickly name the populations most at risk for developing PTSD: members of the armed forces, victims of violence, and those afflicted by overwhelming disaster. However, the general population often fails to realize that we, the healthcare community, also bear the stress and trauma that can manifest itself in PTSD.

People encounter stress every day. While most can often overcome stressors such as a difficult exam or challenging day at work, some incidents – witnessing patients’ deaths, coworkers committing suicide – cannot be handled alone. Burnout and PTSD in healthcare workers are becoming a greater problem. Future healthcare workers must learn to recognize the signs of these conditions themselves and take steps toward alleviating them. They can only promote the health of their patients by maintaining their own.   

Physiologists have long been interested in understanding how the body responds to and copes with stressors. Homeostasis describes the tendency of biological systems to maintain a stable equilibrium. Biological and psychological stressors disrupt this equilibrium and initiate a cascade of physiological mechanisms to restore it, a reaction known as the stress response. Dr. Hans Selye, an Austrian-Canadian endocrinologist, pioneered the first work in establishing the stress response.2 He found that organisms undergo three distinct stages in response to “noxious stimuli,” which he termed general adaptation syndrome. The first stage, known as the alarm reaction, is the body’s immediate reaction to a stressor in which it prepares itself for physical activity. We often term this “fight or flight.” During this period, the sympathetic nervous system is activated, leading to increased blood pressure and heart rate, dilated pupils, sweating, etc. Stress hormones such as adrenaline, cortisol, and norepinephrine are maintained at high levels to continue these effects for the duration of the stress. This reaction mechanism is quite beneficial; it primes our circulatory system, large muscle groups, and brain for a period of extreme exertion such as evading or confronting a stressor. The second stage is resistance; the body’s adaptation to the continued stress and its efforts to reduce the impact of the stressor. Hormone levels decrease, but are still elevated, maintaining the body in a constant state of threat.2 Finally, if the stressor is not removed, the third stage, exhaustion, ensues. Hormones like cortisol, while essential to the stress response, have damaging side effects, which can deplete the immune system. The body is no longer capable of sustaining the stress and will develop a pathological state.3 Conditions such as heart attacks, strokes, and immunodeficiencies are all associated with chronic stress. It is essential to understand this stress response because future healthcare providers will continue to experience it throughout our lives. The average man or woman must take action to relieve stress and burdens so that they can lead healthy, balanced lives.  

Sudden traumatic events, such as those experienced in combat or by victims of violence, trigger the stress response described above. In most cases, the reaction subsides naturally once the stressor is removed. Sometimes an individual may experience problems that last long after the situation is over, and they may be diagnosed with PTSD. PTSD is defined as “a disorder that develops in some people who have experienced a shocking, scary, or dangerous event” and is characterized by symptoms such as flashbacks, avoidance of feelings associated with the trauma, feeling “on edge”, and intense changes in mood.4 To be diagnosed with PTSD, one must meet the criteria set forth by the American Psychological Association in the Diagnosis and Statistical Manual of Mental Disorders (DSM). Current criteria include re-experiencing, avoidance, negative cognitions and mood, and heightened arousal. The impact of these symptoms on one’s work and relationships is also considered in the diagnosis.4 It is estimated that 7-8 out of every 100 people will be diagnosed with PTSD at some point in their lives.3 Studies done on nurses, paramedics, hospital emergency personnel, and physicians have revealed a higher prevalence of PTSD in these populations; in one study, nurses were shown to have a 35% prevalence of nightmares related to their job. The recurrence of such nightmares and other PTSD-related symptoms were often associated with end-of-life care and traumatic events.6,7,8

Major strides have been taken in identifying the underlying neurophysiological causes of PTSD. The era in which PTSD was viewed as a “weakness” with no physical cause is coming to an end. A variety of physiological factors are altered in patients with PTSD including endocrine hormones, neurochemicals, and brain circuitry or “wiring.”9 Interestingly, altered hormone cortisol levels are shown in individuals diagnosed with PTSD. However, the direction of the alteration (increased or decreased) remains inconsistent across several studies.10 Many researchers believe that an “imbalance” in brain chemicals (i.e. neurotransmitters) is the cause of several psychological disorders. While it is hard to describe what an “imbalance” in the brain looks like, altered levels of catecholamines (e.g. dopamine and norepinephrine) and serotonin have been found in patients suffering from PTSD.9 When altered, these neurotransmitters, which are responsible for normal communication between neurons in the brain, may negatively impact behavior, mood, and emotions. Finally, heightened activation of the amygdala, a brain structure that processes the emotions associated with memories, especially fear, has been found upon presentation of stressful stimuli to PTSD patients.11 While this is just a brief overview of the physical correlates, it demonstrates the strides that have been taken to understand PTSD. Further research will bring us closer to identifying therapeutic targets for treating victims.

The most difficult question comes now: how do we take care of those who have built their lives on caring for others? Healthcare workers and combat veterans – two populations at high risk for PTSD – pride themselves on their strength and ability. The stigma that PTSD is a fault or a weakness makes it difficult for these individuals to admit that they need help. For this reason, both military and civilian organizations have established campaigns to eliminate the stigma of PTSD and encourage victims to seek help. For example, the Cleveland Clinic has implemented a “Code Lavender” program through which its staff can call a “Code Lavender” to receive mental rehabilitation during difficult shifts in which they have lost one or more patients or witnessed devastating trauma. The program inspires a sense of community and supports the emotional needs of physicians and nurses.12 Similarly, “The Code Green Campaign” was initiated in 2014 to raise awareness of the high rates of PTSD and suicide in first responders and to reduce the stigma of getting help.13 Through television programs and social media campaigns, such as “Humans of New York,” PTSD has worked its way into the public eye. Aside from raising awareness, research through the Department of Veterans Affairs is working to understand, treat, and possibly prevent PTSD. This research has demonstrated the efficacy of prompt mental health care, prolonged exposure therapy, and deep brain stimulation in treating PTSD.14 No individual should ever feel ashamed of admitting that they have PTSD. In fact, the earlier one seeks help, the easier it will be to get treatment and recover.

Stress and trauma are two elements experienced by nearly every person in every walk of life. Fortunately, our bodies are well prepared to deal with these physical ailments or psychological stressors. Some stressors are so prolonged that they overwhelm the body’s capabilities, and lead to sickness or fatigue. These bodily symptoms emphasize the importance of recognizing and handling the stress of everyday life. Other stressors, such as intense psychological trauma, induce severe reactions and result in long-term conditions such as PTSD. In these cases, it is essential for an individual to seek early therapy and work towards overcoming the trauma. Future healthcare providers will be subjected to a stressful work environment plagued with illness, death, and trauma. When events may become too difficult to handle alone, programs and strategies that acknowledge the risks for stress conditions will serve as crucial support mechanisms for providers.
References:

  1. Friedman, Matthew J. “PTSD: National Center for PTSD.” History of PTSD in Veterans: Civil War to DSM-5. Veterans Administration, n.d. Web. 20 Oct. 2016.
  2. Everly, G.S., and J.M. Lating. “Chapter 2: The Anatomy and Physiology of the Human Stress Response.” A Clinical Guide to the Treatment of the Human Stress Response. 3rd ed. New York: Springer, 2013. 17-51. Print.
  3. Charmandari, Evangelia, Constantine Tsigos, and George Chrousos. “Endocrinology of the Stress Response.” Annual Review of Physiology 67 (n.d.): 259-84. Web.
  4. “Post- Traumatic Stress Disorder.” Mental Health Information. National Institute of Mental Health, 1 Feb. 2016. Web.
  5. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association, 2013. Print.
  6. Mealer, Meredith, Ellen L. Burnham, Colleen J. Goode, Barbara Rothbaum, and Marc Moss. “The Prevalence and Impact of Post Traumatic Stress Disorder and Burnout Syndrome in Nurses.” Depression and Anxiety 26.12 (2009): 1118-126. Web.
  7. Iranmanesh, Sedigheh. “Post-traumatic Stress Disorder among Paramedic and Hospital Emergency Personnel in South-east Iran.” World J Emerg Med World Journal of Emergency Medicine 4.1 (2013): 26. Web.
  8. Laposa, J.M., and L.E. Alden. “Posttraumatic Stress Disorder in the Emergency Room: Exploration of a Cognitive Model.” Behaviour Research and Therapy 41.1 (2003): 49-65. Web.
  9. Sherin, Jonathan E., and Charles B. Nemeroff. “Post-traumatic Stress Disorder: The Neurobiological Impact of Psychological Trauma.” Dialogues in Clinical Neuroscience 13.3 (2011): 263-78. Web.
  10. Delaney, Eileen. “The Relationship between Traumatic Stress, PTSD and Cortisol.” Naval Center for Combat & Operational Stress Control (n.d.): n. pag. Web.
  11. Shin, L. M. “Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD.” Annals of the New York Academy of Sciences 1071.1 (2006): 67-79. Web.
  12. “The Amazing Way This Hospital Is Fighting Physician Burnout.” The Huffington Post, 2 Dec. 2013. Web.
  13. “The Code Green Campaign.” The Code Green Campaign, n.d. Web.
  14. “VA Research on Posttraumatic Stress Disorder (PTSD).” Office of Research and Development. U.S. Department of Veteran Affairs, n.d. Web. 20 Oct. 2016.

 

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