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Psychiatr Serv. Posttraumatic stress disorder. Safe, effective management in the primary care setting. Postgrad Med. Alcoholism in Vietnam and Korea veterans: a long term follow-up. Alcohol Clin Exp Res. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity.

Davidson JR. Such experiences have previously been reported to be capable of overwhelming a firefighter's normal ability to cope [51] , [54]. Critical incident stress management originated in the United States in the s as a peer support intervention for emergency service workers [6]. CID is a peer counseling group procedure with psychoeducational aspects which aims to deliver information on stress reactions after exposure to critical incident s [54].

Ideally, the CID is held between 72 hours and 14 days after incident [6] and aims to prevent psychological damage [56].

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The concept is generally credited to the work of Jeffrey Mitchell [54] and thereafter Mitchell and Everly [57] and is led by one mental health professional, supported by trained sector peers [57]. The seven-step approach [6] , [57] aims to teach the recipients about their stress reaction:. It also aims to enable individuals and groups to have their needs assessed and receive practical support to reduce psychological distress post exposure [58]. Sessions last for 1. The session is brought to a close with psychoeducational input.

While in widespread use, CID has its critics. These quote variables significantly affect the outcomes, examples being a lack of clarity on which disorders CID is intended to improve; a lack of evidence on the level of disorders which requires large-scale interventions; and a lack of evidence that correlates intervention with outcomes [62] , [63] , [64]. Hytten and Hasle [49] found that there was no difference between those formally debriefed and those who received social support by chatting to colleagues.

Regel and Joseph [6] refute the critics of CID on the basis that only two studies may have had any such relevance, and in both cases, the participants were not of the groups that the interventions were intended for i. They also refer to flaws in methodologies used for those studies. They instead argue that a number of studies exist which do demonstrate positive outcomes from CID. Regel and Joseph [6] explained a concept of how individuals sometimes deal with their exposure to traumatic events.

This literature review has examined the concept of PTSD and the various factors that may lead to the condition arising. It has also offered detail on why some people appear to be more at risk of succumbing to PTSD than others and why some are able to cope more effectively in the aftermath of a traumatic event. Importantly, this review has also provided insight into protective factors, support mechanisms, and the arguments that continue to exist on the benefits and limitations of each.

It allows for an academic approach to be adopted and enables a comprehensive study into the risk posed to LFRS and the suitability of current arrangements that are in place to manage PTSD risk. The first step was to conduct secondary research on PTSD which was carried out through the university search engine known as Scopus and through various internationally based organizations, such as the World Health Organization, etc. This was to collect various standpoints, opinions, and hypotheses that could be explored. A level of knowledge and understanding was then reached by the researcher whereby opinions and perspectives could be discussed and either substantiated or rebuffed by virtue of the case studies, reports, and texts that were available.

This enabled the researcher to remain objective throughout the study to differentiate fact from supposition or opinion. It should be noted that although a number of different measures of PTSD exist, no single measure can definitely determine whether or not an individual has PTSD; instead, multiple measures should be administered [66]. Therefore, the adopted methodology was to settle on the use of two recognized clinical questionnaires. While a number of historic USA-derived screening tools were available, the development of culturally sensitive psychological tests and symptom checklists for assessing anxiety and depression is promoted [67].

The GHQ [68] is used to indicate psychological well-being and detect possible cases of psychiatric disorders psychiatric morbidity [69]. The reason for using this questionnaire was to identify aspects of poor physical health [70] and problems in intimate and family relationships [71] which are frequently associated with PTSD. The GHQ is commonly used as a community-screening tool and for the detection of nonspecific psychiatric disorders among individuals in primary care settings [65].

It has been recommended in previous studies for screening trauma victims [8] , and although developed in the United Kingdom, it has been widely employed in other countries translated into c. A number of different scoring systems can be applied, but for the purposes of this study, the preferred Likert scale was applied [72] to the descriptive answers. This produces a maximum score of 84 across the 28 questions.

Under DSM, PTSD is diagnosed if at least one reexperiencing, three avoidance, and two arousal symptoms are revealed at a rating of 2 or 3. The exposure had to have taken place more than one month before. As per the GHQ, these questions are answered using the Likert scale with the maximum score across the 17 questions being 51, representing the total severity score [1].

This allows the PSS to be used as either a categorical or dimensional measure. This was to make interpretation and analysis of the results more consistent. Although the application of the PSS for emergency service workers has been limited in other studies, it is frequently referred to as being used for circumstances such as rape victims; for this reason access to psychometric data for such samples was also very limited; nonetheless, the questionnaire draws some correlations with aspects considered under the GHQ A modified version of this scale exists which includes both frequency and intensity ratings.

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This allows assessment of symptoms related to multiple traumatic events [66] , and perhaps, this assessment type could also be a useful alternative to the PSS. Operational staff were approached during the late and early and asked to provide consent to participate. To ensure anonymity, completed questionnaires were return mailed in a self-addressed envelope to the authors. From this point, the completed returns were kept securely stored and not shared with third parties.

The aim was to collect responses representing Once the data were collated, statistical analysis using a combination of thematic and graphical analysis was then completed. In addition, appropriate for our case study was to use descriptive and summary statistics such as the mean and standard deviation to indicate what the average numbers and variations for different phenomena were, so as to determine if relationships existed.

On completion of the analysis, the findings were then compared with observations from other literature sources to determine how our results fitted with their findings. The outcomes of this analysis are discussed in the remainder of this article along with the conclusions that were drawn. Within the range of 0—84, a score of 23 or 24 is deemed to be the threshold for the presence of distress [73]. For this study, a total score of 23 or above has been taken as being the baseline.

The GHQ results are divided into four sections based on the subject headings within the questionnaire:. Generally, categories 0 and 1 are positive responses i. In summary, most responses were of a positive nature when compared with the other sections of the GHQ Owing to the serious nature of the questions, this is expected. In summary, the vast majority of responses within this section were of positive nature. As previously discussed, the PSS questionnaire's questions can be divided into three sections: reexperiencing, arousal, and avoidance.

The first five questions summarize the questions relating to reexperiencing from the PSS. This was similar to that seen for the reexperiencing questions. These results will be discussed further in the following sections. From looking at the results of the GHQ, it was decided to divide the findings into three sections corresponding to physical symptoms, positive emotions, and negative emotions.

This was to determine how the most significant symptoms manifest in the most significant emotions. Standard deviation was then applied to determine which variables were significant. Any variables that were higher than one standard deviation above the average were considered a warning sign and therefore significant. For Section C, no variables were found to be significant.


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  • In Section D, just one variable was found to be more than one standard deviation above the average. This variable was over two standard deviations above the mean and was, therefore, seen as being very significant. All these four people surprisingly did not score significantly in the GHQ as expected with scores ranging from 9— The PSS questionnaire is divided into three sections: reexperiencing, avoidance, and arousal. Based on the findings from the literature and results, this analysis aims to see how the different sections of the PSS manifest in people's everyday lives.

    From the results section, counts were also made on each of the variables that were identified as interfering with aspects of everyday life after exposure to a traumatic event. However, it is seen that sex and education seem to have the lowest count and may suggest that there may be some strategies used to deal with matters of distress. On completing this research, some interesting observations have been made. If this number was multiplied to represent the number of LFRS employees, approximately operational members of staff could hypothetically be suffering from distress.

    This was to determine whether general health affected PTSD. The results were inconclusive as of the four people who showed symptoms of PTSD, only two people were identified as high risk from the GHQ scoring As a result, it was not possible to establish whether general health did influence the development of PTSD symptoms.

    The analysis of the results produced some interesting findings. From the GHQ, it was determined that emotions affect physical symptoms, supporting the theory that comorbid mental health issues could potentially bring about the development of PTSD. Interestingly, from a productivity perspective, some of the evidence suggests that the coping strategies used by firefighters are actually more important than their levels of personal motivation, as motivation itself may be directly affected by an individual's ability to cope with the trauma that they witness.

    Certainly, this survey of LFRS staff highlighted that some will throw themselves into distraction activities such as sex or education. The cultural appetite for engaging in this process is presently limited, and a number of variables exist which may determine the effectiveness of CID such as the timing of the debrief, the duration, or the qualifications, expertise, and training of the facilitator. The literature review highlighted that CID supporters claim some highly positive outcomes, yet their findings tend not to appear within professional journals.

    Conversely, several of the less positive studies referred to earlier within this text, which cast doubt over the success of CID, are visible throughout a number of professional medicine and psychology journals. Equally, if no baseline assessment has been undertaken, the outcomes may not be valid, given that the subject may have had existing conditions such as a premorbid personality.

    Current practices within the LFRS are carried out on an optional basis on the part of employees. There is a nonmandatory CID process which employees can take part in if they wish. There is also voluntary counseling service that is available if required and generally, staff is expected to keep an eye on anyone who has recently experienced a traumatic event within the organization. The primary research shows that a PTSD problem does exist within LFRS but at a level which is lower than that found in other similar studies and indeed lower than the quoted lifetime prevalence levels of c.

    Secondary research has shown that incidents involving children are the most commonly cited factor for the development of PTSD within FRS personnel. Evidence from Haslam and Mallon [15] suggests that this difficulty in dealing with child victims is borne mainly from a sense of identification between the victims and one's own children. While research suggests that PTSD manifests itself in a person's day-to-day life through reexperiencing, avoidance, and arousal, it was clear from the respondents to this study that arousal was the most significant detriment to a person's everyday life.

    This was displayed through the existence of anxiety, depression, addictive behaviors, and insomnia. Based on the primary research undertaken, it is clear that LFRS presently has a number of personnel experiencing adverse psychological and physical reactions, many of which may be going undiagnosed and untreated at the present time. Where incidents are discussed in the social setting i. This article supports the continued development of organizational and leadership practices to assist LFRS in planning for, and mitigating against, the inevitable threat that arises from exposure to traumatic incidents.

    One of the limitations of the study was that the intention was to draw findings from a larger sample size than was achieved; national environmental factors the ongoing industrial dispute within the sector affected the ability to deliver this. It is therefore a recommendation of this article that a wider study be undertaken, perhaps on a north-west regional footprint to obtain both a wider sample and detect variances between FRS and between firefighters working in urban and rural environments.

    With the relevant consents, such a study could also consider the implications of gender, age, ethnicity, position within the organizational structure, and whether whole time or retained duty system. It should also be noted that the sample used was from within a single county. Lancashire is predominantly rural with several large conurbations. It does not face the same level of challenges and perhaps more serious threats and events as may be seen by some larger metropolitan FRS.

    As a result, caution should be applied to the current findings when considered in the context of other FRS areas. To fully appreciate the benefits associated with CID, further research could be undertaken within LFRS or regionally to examine more closely the interactions of participants, the outcomes, and the how CID or the involvement of professionals may deliver better outcomes for staff.

    It is recommended that LFRS commission further works to explore the expected implications of such new work streams and the potential impacts to inform the future needs of the service.

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    The authors are grateful to the Lancashire Fire and Rescue Service for their kind cooperation that enabled them to pursue this research successfully. The following is the supplementary data related to this article:. National Center for Biotechnology Information , U. Journal List Saf Health Work v. Saf Health Work. Published online Nov Graham , Hamid R. Nasriani , Shephard Ndlovu , and Jianqiang Mai. Author information Article notes Copyright and License information Disclaimer.

    Khalid Khan: ku. Associated Data Supplementary Materials mmc1. Methods The overarching purpose of this epidemiological study is to assess the prevalence of post-traumatic stress disorder PTSD amongst operational LFRS personnel and to analyse the effects upon those who may be suffering from it, whether brought about by a single traumatic event or by repeated exposure to traumatic occurrences over a period of time. Introduction 1.

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    Linked to this trauma exposure a number of other common health sequelae, such as alcohol and drug abuse, depression, anxiety, and suicide [5] , [14] , are frequently documented Few empirical studies have systematically examined the cause and effect of work stresses affecting firefighters [5]. Suffering from distressing images and memories reliving. Avoidance of similar situations. Suffering nightmares about the event. Being unable to recall parts of the event.

    Learning that someone close experienced or was threatened by the traumatic event. Suffering flashbacks involving reenactment of the event. Feeling negativity toward self, others, and the world. Being repeatedly exposed to graphic details of traumatic events.


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    • Suffering emotional distress or physical anxiety symptoms if encountering a trigger of the traumatic event. Feeling detached from family and friends and losing interest in activities previously enjoyed. Having an inability to show feelings. Irritability and anger. Dangerous or self-destructive behavior. Open in a separate window. Source: [26] , [27]. Study area Lancashire is a coastal county, bordered to the north by Cumbria, to the south by Merseyside, and to the east by North and West Yorkshire and the metropolitan county of Greater Manchester.

      Whole time Full-time staff working in a rotational shift system of 2 days, 2 nights, and 4 rest days.

      PTSD Warning Signs

      Day crewed Operate as full-time staff during the 3 day shifts of their duty period and respond from home on a 5 minute response to station on the same 3 evenings, followed by 3 rest days and repeated. The study describes mental health approaches to treatment, such as individual, group, and substance abuse counseling. Techniques such as exposure therapy, Eye Movement Desensitization and Reprocessing, and Traumatic Incident Reduction are also discussed as well as drug treatments.

      PTSD and the Individual.