Post-traumatic stress disorder (PTSD) is most commonly associated with members of the military, but it can affect anyone who has survived a traumatic experience. This includes healthcare workers who were overwhelmed by the surge of COVID-19 patients and struggled to allocate scarce resources, all while worrying about their own health and transmitting the virus to loved ones.
PTSD occurs most commonly through direct exposure to traumatic events and secondarily through witnessing a traumatic event experienced by another, often referred to as vicarious traumatization, notes George Vergolias, PsyD, CTM, a forensic psychologist and medical director for R3 Continuum, a company based in Minneapolis that provides behavioral health and security solutions for workplace well-being.
PTSD is not uncommon among healthcare workers in general, Vergolias says. They must face a host of stressful and often competing issues as they navigate treating the ill during the pandemic. Often, these workers do so in far less than ideal circumstances.
Vergolias notes that a recent study showed emergency physicians are five times more likely to experience PTSD than the general population, with 15% of emergency physicians meeting the criteria vs. 3% of the general population. (More about the study is available here.)
“It is important to note that [study] was [conducted] prior to the [COVID-19] pandemic. We are still studying and understanding the impact of the pandemic on healthcare workers in general,” Vergolias says. “Without doubt, it has taken an emotional toll. The question remains to what extent healthcare workers will rebound from the past eight weeks within a reasonable window, or will they show an increased prevalence of sustained PTSD symptoms?”
Emotional Reactions, Avoidance
Vergolias identifies several common symptoms of PTSD:
• Intrusive symptoms. Traumatic memories, recurrent dreams, thoughts or flashbacks of the event(s), and heightened emotional and physical reaction to cues reminding one of the trauma.
• Avoidance symptoms. Excessive efforts to avoid places, people, or other cues that remind one of the trauma; attempts to emotionally numb oneself from intrusion.
• Alterations in cognitions and emotions. Distraction; reduced memory function; and increased difficulty with decision-making, anxiety, and depression.
• Increased physiological arousal and emotional reactivity. These can affect sleep, appetite, and/or physical energy levels. Those symptoms can overlap in manifestation, such as when someone has intrusive thoughts or flashbacks while attempting to avoid thinking about traumatic images, Vergolias says. For healthcare workers who might be affected by their COVID-19 experience, Vergolias advises watching for these signs:
• Pattern of mistakes made on minor procedural steps the physician should know and has demonstrated consistent habitual performance on in the past. These mistakes often are a function of distractibility, intrusive symptoms, and/or changes in mood or cognition. These are the kinds of mistakes the person has not made before. Such errors may occur on tasks or procedures he or she has completed successfully numerous times.
• Attempts to avoid exposure to locations or situations that were perceived as traumatic. For example, an emergency physician who must return to the emergency department or a nurse who must return to an intensive care unit where he or she treated virus patients. They may show increased emotional reactions such as hypervigilance, irritability, or anger reactions that are out of character.
“With physicians, this can manifest as avoidance of going into certain hospital units or even certain patient rooms that have been associated with a traumatic moment,” Vergolias says. “The avoidance may not be so pronounced as avoiding physical space. Instead, the physician may simply emotionally ‘tune out’ and does not seem fully engaged while at work. They are physically there, but not emotionally or cognitively present in the moment.”
• Significant changes in mood. This can manifest as increased emotionality (frustration, anger reactions, temper, anxiety, panic attacks), yet also can manifest as restricted emotions, too (social and emotional withdrawal, depression, self-isolation).
Vergolias offers one point of caution: While increased fatigue and worse personal hygiene can be indicators of difficulty in these situations, remember that most healthcare staff are working extensive hours. This may be the simplest explanation for troubling signs. As such, these two symptoms are not the best indicators to separate stress reactions from the healthcare worker simply feeling tired from an excessive workload, he says.
“The best way to monitor this issue is to monitor overall behavioral performance in general. There can be many reasons a given physician’s performance falters. The first step is to identify that a performance issue exists and be clear on the nature and scope of the negative performance impact,” he says. “Next is the task of determining what is contributing to that performance issue. I recommend starting with an open and supportive discussion with the physician. If approached from a caring and supportive perspective, most physicians who are indeed struggling will be more open to admitting such and seeking needed support.”
Once a problem is detected, Vergolias says there are treatment options for consideration:
- Refer to supportive peer groups or resources.
- Provide psychoeducational materials so the worker can better understand his or her reactions and place them into a proper context.
- Consider referring to mental health counseling if more serious symptoms present or seem entrenched over several weeks.
“In some cases with a repeated performance issue, in which the physician is unable or unwilling to recognize the identified problems, it might be appropriate to consider referral for a psychological fitness for duty evaluation to help assess functional capability and determine next steps to assist in return to pre-morbid functioning,” Vergolias explains.
The best way hospitals can assist healthcare workers through these difficult times is to provide clear and accessible support, and convey that message loud and often, Vergolias says. Support should be in the form of both physical and logistical needs, including adequate personal protective equipment and clear procedural protocols.
Make sure to include emotional support, such as providing support groups, psychoeducational materials, and counseling as needed.
“Lastly, recognizing and acknowledging the herculean effort that physicians and other healthcare workers have made during this time is another very simple yet powerful way that hospitals can show support,” Vergolias adds.
- George Vergolias, PsyD, CTM, Forensic Psychologist and Medical Director, R3 Continuum, Minneapolis. Phone: (888) 736-0911.