PTSD in Nurses

About

Introduction

Post-Traumatic Stress Disorder (PTSD) gained recognition from its association with Military Veterans in the Vietnam War emotional strain from the events they witnessed after returning home from war. Names like “shell shocked” or “combat fatigue” were used to describe the Veterans upon their return. In 1980, the Diagnostic and Statistical Manual of Mental Health Disorders, developed by the American Psychiatric Association, officially identified this condition as a psychological disorder (4).  

Although anyone can experience PTSD, healthcare professionals have an increased risk of presenting with this disorder. Year 2020 has most likely been the most s most stressful year for many people. Many have lost their income, family, homes, and sense of well-being. Emergency personnel, rescue workers, physicians, and nurses have all voiced how COVID-19 has had a terrible impact on everyone. The increase in hospitalization and deaths has caused a major increase in Post-Traumatic Stress Disorder Diagnosis (PTSD) among the general population and healthcare professionals. In this course, we will discuss strategies that healthcare professionals can utilize to promote successful identification and coping mechanisms for PTSD. 

Healthcare professionals practice in an environment that is extremely high stressed, demanding, and unpredictable. Nurses, physicians, and other healthcare professionals are continuously exposed to physical, psychological, and mental hazards for upward of 12-16 hours a day. Each person reacts and responds to extreme stress and trauma in various ways. Since there are so many variables to consider, it has been difficult to diagnose PTSD in healthcare professionals.  

It is natural for individuals to experience fear, heightened senses, and avoidance after experiencing a traumatic event. Healthcare professionals are aware of the “fight or flight” response – our body’s natural defense to our sense of danger or fear. Everyone has an individual definition of trauma. For some people losing a loved one is considered a traumatic event. For others, the definition of a traumatic event may be coming in contact with an immediate threat on their personal life or witnessing a dangerous situation. When does it turn into PTSD? To understand that question we must first define PTSD. 

Case Study

Laura is a 26-year-old new nurse of five years that has decided to take a job doing traveling nursing to help with the overwhelming demand of taking care of COVID-19 patients. She is offered a wonderful opportunity to make a difference. The travel agency offers her a staff nurse position taking care of two patients in the critical care unit. She will work 13 weeks at 36 hours weekly on nights. Her pay is 5,000 per week plus a non-tax stipend for her lodging and meals. She accepts the position and takes leave from her full-time position. She leaves behind her pet dog as she prepares to go to California from Tennessee to begin working at the hospital. The agency contacts her to tell her they will also provide transportation to and from her residence to the hospital at no charge.  

Laura arrives in California and reports to the hospital department where she will work. After speaking with the nurse manager, Laura is told that her assignments have changed, and she will still work in the critical care unit but will care for at least seven patients who have COVID-19 because they are so short-staffed. Laura is confused and does not really know if she can say no to the assignments because of her contract. She tries to contact her agency, but no one can take her call. She leaves a message in hopes that someone will return her call. Laura is expected to start work that same evening. She is a little hesitant but reports to duty as scheduled. 

Laura's first night is horrific. She must care for seven patients who have COVID-19. The patients are all on ventilators and no one is available as a resource for her to ask questions. The entire environment is overwhelming. Patients are lined against the wall, people are crying, a code red is called every 10 to 15 minutes, and most of the time the patient dies. The morgue is overflowing and some of the deceased patients are placed in body bags and lined against the wall. After three shifts Laura decides she cannot fulfill this contract because she has no support. Lately, she is experiencing nightmares, feels very agitated and anxious, and cries all the time.  

Laura reaches out to her agency and informs them of her decision, but she is informed that if she breaks the contract, she will be reported to the board of nursing for job abandonment. Laura decides to stay to fulfill the contract. Laura also notices some of her co-workers are manifesting a change in behavior. They have become increasingly sad, detached from others, and anxious. They are also displaying anger toward other staff members. Laura feels the environment is toxic and wishes she were anywhere but there. 

Refer to this case study to answer some questions throughout the course. 

Definition 

Post-traumatic stress disorder is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event (1). 

The DSM-5 diagnostic criteria for PTSD include: 

A. Stressor (one required):  

• Personally experiencing trauma or watching someone endure it. 
• Learning that a traumatic event(s) may have occurred to a close family member or friend. 
• In cases of life-threatening instances, or the death of a family member/friend, the event(s) must have been violent or accidental.  
• Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. nurses working in critical care units, caring for COVID-19 patients, etc.) (2). 

B. Intrusion symptom (one or more required):  

• Recurrent and distressing memories or dreams of the trauma experienced. 
• A dissociative reaction in which the person is completely unaware of their surroundings.  
• Intense, prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
• Distinct physiological reactions of internal or external reminders that may represent any aspect of the traumatic event (2). 

C. Avoidance (one or both required): Avoiding any memories, thoughts, or feelings related to the traumatic event on a continuous basis.  

• Avoidance or efforts to avoid instances or items that resemble or remind the person of the traumatic event. Examples include (2): 
• People 
• Places 
• Activities 
• Conversations 
• Familial objects 

D. Negative alteration in cognition and mood (two required):  

• Inability to remember specifics of the traumatic event due to dissociative symptoms.  
• Persistent and over-exaggerated negative belief about oneself, others, or the world (e.g. “the world is completely dangerous” or “my whole nervous system is shot”).  
• Persistent negative emotional state (e.g. fear, anger, guilt, or shame).  
• Persistent distorted perception about the cause of the traumatic event leads an individual to blame themselves. 
• Distinctive or diminished interest or participation in any significant activities. Feelings of detachment from others. Continuous inability to experience positive emotions (2). 

E. Alterations in arousal and reactivity (two or more): 

• Angry outbursts and irritable behavior without provocation, leading to physical aggression toward people or objects.  
• Self-destructive reckless behavior. 
• Hypervigilance. 
• Exaggerated startle response. 
• Problems with concentrating. 
• Sleep disturbance (2). 

F. Duration of the disturbance (criteria B, C, D, and E required):  

• More than a month. 

G. Functional Significance (required): 

• Clinically significant distress caused by the traumatic event(s) or impairment in social, occupational, or other areas of functioning.  
• The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2). 

Case Study 

Post-Traumatic Stress Disorder (PTSD) is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape (1). PTSD also can occur in people who have been threatened with death, experienced sexual violence, sustained a serious injury, continuously works in a highly stressful environment (such as a hospital), or feel helpless in assisting those that have been placed in their care (1). 

The DSM-5 diagnostic criteria for PTSD includes the following. 

Stressor: (one required) 

• Experiencing trauma 
• Watching some type of trauma as it occurs to others 
• Learning that the traumatic event(s) may have occurred to a close family member or close friend.  
• Actual or threatened death of a family member or friend (the event or events must have been violent or accidental).  
• Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. healthcare professionals working in critical care units, nurses, physicians, paramedics caring for COVID-19 patients) (2). 

Intrusion Symptom: (one or more required) 

• Recurrent and distressing memories of the trauma experienced 
• Recurrent and distressing dreams related to the traumatic event.  
• Dissociative reaction in which the person is completely unaware of their surroundings. 
• Intense prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
• Distinct physiological reactions of internal or external reminder that may represent any aspect of the traumatic event (2). 

Avoidance: (one or both required) 

• Avoiding any memories, thoughts, or feelings related to the traumatic event.  
• Avoidance or efforts to avoid people, places, activities, conversation, or familial objects that may be a reminder of the traumatic event (2). 

Negative Alteration in Cognition and Mood (two required) 

• Inability to remember any aspect of the traumatic event due to dissociative symptoms.  

• Persistent overexaggerated negative belief about oneself, others or the world (e.g. such as the world is completely dangerous or my whole nervous system is shot).  
• Persistent negative emotional state (e.g. fear, anger, guilt or shame).  
• Persistent distorted perception about the cause of the traumatic event that leads an individual to blame themselves.  
• Distinctive or diminished interest or participation in any significant activities.  
• Feelings of detachment from others.  
• Continuous inability to experience positive emotions (2). 

Alterations in Arousal and Reactivity (two or more) 

• Angry outbursts and irritable behavior without provocation, leading to physical aggression towards people or objects.  
• Self-destructive reckless behavior.  
• Hyper vigilance.  
• Exaggerated startle response.  
• Problems with concentrating.  
• Sleep disturbance (2). 

Duration of the Disturbance (Criteria B, C, D, and E required) 

More than a month 

Functional Significance (required) 

• Clinically significant distress caused by the traumatic events or impairment in social, occupational, or other areas of functioning. The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2) 

Sign and Symptoms 

There are many signs and symptoms of PTSD. Symptoms may develop immediately or within three months of the traumatic event(s). On some occasions, a person can suppress their feelings for up to a year before remembering a traumatic event. These signs and symptoms are grouped into four categories: intrusive memories, avoidance, negative changes in mood and thinking, and negative changes in physical and emotional reactions (3).  

Intrusive Memories 

Intrusive memories include recurrent distressing memories of the traumatic event, flashbacks, nightmares, severe emotional distress, or a physical reaction to something that reminds you of the traumatic event (3) 

Avoidance  

Avoidance includes cognitively trying to avoid thinking about the traumatic event and avoiding places, activities, conversations, tangible items, and people that reminds you of the traumatic event (3) 

Negative Changes in Mood and Thinking 

Negative changes in mood and thinking include feelings of hopelessness about the future, memory problems including not remembering certain aspects of the traumatic event, difficulty in maintaining close relationships, feeling of detachment, lack of interest in activities once enjoyed, difficulty experiencing positive emotions, feeling emotionally numb, alcohol abuse, drug abuse, having negative thoughts about yourself or other people around you or the world in general (3).   

Changes in Physical and Emotional Reactions 

Changes in physical and emotional reactions include being easily startled or frightened, always being on guard for danger, insomnia, trouble concentrating, overwhelming feelings of guilt or shame, increased irritability, aggressive behavior, angry outburst with no provocation, chronic illnesses, gastrointestinal problems, angina, self-destructive behavior, sweating/shaking, heightened “fight or flight” syndrome, pain, depression, hallucinations, anxiety, and feelings of constant sorrow (3). 

Types of PTSD 

Since we know that the American Psychiatric Association describes PTSD as an anxiety disorder, we know there are different types and severity of PTSD. The types of PTSD are categorized according to the severity of the symptoms to help with the diagnosis. There are five types of PTSD which include: Normal stress response, Acute Stress disorder, Uncomplicated PTSD, Complex PTSD, and Comorbid PTSD (5). 

Normal Stress Response 

The normal stress response, the “fight or flight” syndrome is the precursor to PTSD, and it does not always lead to full blown PTSD. Any event that causes the natural stress response (such as surgery, an injury, or pending thoughts of danger), initiates a normal stress response. The problem occurs when this response is not alleviated within a short amount of time. 

Acute Stress Disorder 

A life-threatening event such as job loss, illness, natural disaster, or death of loved one can initiate this early form of PTSD. While the individual may experience this type of disorder, the individual will usually overcome the initial stressor. If it becomes prolonged and untreated, it can lead to full blown PTSD. 

Uncomplicated PTSD 

This type of PTSD is associated with one major event which makes it the easiest form of PTSD to treat. The individual will want to avoid anything that may remind them of the event. 

Complex PTSD 

Complex PTSD is just as the name implies. This type of PTSD is associated with multiple traumatic events and is usually associated with various types of abuse, violence, war, and traumatic losses. The unfortunate problem with diagnosing this type of PTSD is that some health care professionals confuse it with borderline or antisocial personality disorder or dissociative disorders (5). 

Comorbid PTSD 

This type of PTSD is associated with a person that has more than one mental health concern along with substance or narcotic misuse issues at the same time. This condition is extremely common because most people have more than one problem. What makes this type of PTSD more complicated to treat is the fact that individuals try to self-medicate because they are in denial, but this only leads to self-loathing and self-destructive behaviors (5). 

Phases of PTSD in Nurses 

There are four phases of PTSD identified by Pyramid Health. The phases are the impact phase (emergency), rescue phase, the intermediate recovery phase and the long-term reconstruction phase (6). 

Impact Phase (Emergency) 

The impact phase consists of the initial reaction such as anxiety, helplessness, guilt, shock, or fear. This is the first phase which occurs immediately after the individual experiences the traumatic event. The length of time the individuals stays in this phase depends on the severity of the traumatic event (6). 

Rescue Phase 

The rescue phase involves the affected person being able to come to terms with what has happened. This phase is closely related to the acceptance phase in grieving. The individual may experience flashbacks, confusion, anxiety, denial, or feelings of despair. 

Intermediate Recovery Phase 

The intermediate recovery phase is associated with the individual making the adjustment to return to normal everyday life. In this phase, the individual can begin to look at other issues within their life. While they are addressing new issues, they may have the feeling of altruism in which they feel the love and support from others which gives them the sense that they can also help others. They may also develop the feeling of disillusionment in which they feel overwhelmed because they are not receiving the love and support they think they should, or when the love and support ends, they realize they are on their own. This phase is also closely related to the acceptance phase in grieving. As with the grieving phase the individual may go back and forth between phases. 

Long-term Reconstruction Phase 

The long-term reconstruction phase is characterized by the individual being able to rebuild while dealing with the trauma's aftermath. Their main concern is about their future and how they can maintain healing. 

Causes of PTSD 

Defining the causes of PTSD can be quite difficult because physicians have not been able to determine why some individuals may have a different response to the same traumatic event.  Most adults have experienced some stressful experiences that did not cause PTSD. Some causes of and risk factors for PTSD could include inherited mental health risk, an individual's temperament, and even the way our brain regulates chemicals and hormones which release stress in our bodies. 

Considerable evidence links the hippocampus to the representation of contexts by the brain suggesting that the hippocampus has a central role in solving the equivalence problems with respect to content. Tracking moment-to-moment change in input and detecting change sufficient to require altering behavior is crucial to survival. This perspective highlights the critical role of the hippocampus in both spatial cognition, episodic memory tracking change, and detecting boundaries separating context or episode from another. This is very important in people that suffer with PTSD (14).  

The hippocampus is a component of the brain, a part of the lymphatic system that plays a role in the consolidation of information from short-term memory to long-term memory, linking memories to sensations and in spatial memory that enables navigation (9, 14). The hippocampus is located under the cerebral cortex in the allocortex and there are two hippocampi, one on each side of the brain. Post-traumatic stress disorder is associated with abnormal hippocampal activity (9, 14). It has been noted that PTSD is mainly associated with functional and structural changes in the amygdala, medial prefrontal cortex, and the hippocampus (9, 14).  

The two hippocampi have very distinct roles. The posterior hippocampus' main role is in memory retrieval and spatial cognition. The anterior hippocampus role is mainly associated with the amygdala, the hypothalamic-pituitary-adrenal (HPA) axis, and the limbic prefrontal circuitry (9, 14). The anterior hippocampal-amygdala connections are thought to underlie atypical memory processes in PTSD, including flashbacks, intrusive thoughts, and nightmares (9, 14). There are current theories of PTSD that identify hippocampal dysfunction as a key contributor to hallmark symptoms of PTSD (9, 14). 

One common denominator for causes of PTSD is the actual stress an individual goes through when they experience or learn about a life-threatening event, serious injury, sexual assault, childhood physical abuse, being threatened with a weapon, an accident, being exposed repetitively to death, violence, or sickness.  

The outbreak of COVID-19 has caused a rise in PTSD in healthcare professionals. Working tirelessly to care for patients experiencing new health issues caused by COVID-19 has put so much pressure on healthcare professionals trying to save their lives.  

Unfortunately, because there is no cure for COVID-19 and the public does not always follow the guidelines to prevent the spread of COVID-19, paramedics, doctors, nurses, and other healthcare professionals are continuously putting their own and their families’ lives at risk to try and save lives. This amount of pressure has increasingly led to a spike in PTSD among healthcare workers. 

Healthcare workers in critical care, trauma, and the emergency room continuously witness death while operating in a crowded setting and working with an uninterrupted circadian rhythm due to being short staffed. The healthcare workers’ age, years of work experience, family support, marital status, and coping styles along with prior psychiatric history all play a role in the time they may experience PTSD and what type they will experience. The feelings of helplessness that the healthcare worker experiences when trying to care for the patient who has COVID-19 is a major precursor to the development of full-blown PTSD because they may feel conflicted. They want to help their patients get better, but instead they witness them die alone upwards to every five minutes depending on the department in which they are working. 

Prevalence of PTSD Among Healthcare Workers

Based on the current U.S. population, around 7 or 10 of every 100 (7% - 8% people) will have experienced some traumatic event in their lifetime and this equates to approximately 223.4 million people. Of that amount, currently 20% (44.7 million people) suffer from PTSD. About every 10 out of every 100 (10%) women develop PTSD sometimes in their life compared to about four of every 100 (4%) men. This makes women twice as likely to develop PTSD (11). 

Nurses at the forefront during the pandemic are likely to have experienced major trauma. Such traumas included increased (nearly impossible) workloads, poor patient outcomes, and virtually no support system availability. These traumas led to depression. anxiety and increased cases of PTSD (10). 

Healthcare professionals are trained to take care of the needs of their patients and leave their personal feelings at the door. When the shift starts, the healthcare professional suppresses their emotions so they can get through their shift. The problem arises when the shift is over and the healthcare professional may experience a rush of feelings such as anger, guilt, confusion, sadness, sorrow, and grief. Sometimes in extreme cases, they may experience suicidal or homicidal ideations. To mask their emotions, they may turn to drinking, drugs, or destructive behaviors to cope with the day-to-day trauma. 

A 2021 study in Occupational Health and Safety revealed that during the outbreaks of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome coronavirus (MERS-CoV) and COVID- 19, the development of PTSD ranged between 11% and 73.4% with 51.5% of healthcare professionals and nurses scoring above the Event Scale -Revised (IES-R) threshold for PTSD diagnosis. It was also found that healthcare professionals and nurses during the COVID-19 pandemic have had a higher rate of PTSD symptoms (71.5% - 73%) when compared to rates during the SARS outbreak, which were at only 5% (10). 

One study predicted that approximately 10% - 40% of nurses will have a manifestation of PTSD between one and three years after a pandemic. Poor working conditions and the possibility of COVID-19 exposure had a clear negative impact on nurses' mental health, thus increasing the rate of PTSD (12). 

Young female workers, much of the nursing workforce, who lacked social support due to social distancing restrictions were at a higher risk of developing PTSD. In addition to the social distancing protocols, nurses may have experienced further stress due to self-imposed isolation practices to keep their families from exposure to COVID. This contributed to an even greater percentage of nurses being affected by PTSD (13). 

The nurses that experienced PTSD were in leadership roles, possessed a negative perception of patient care, lacked supportive relationships to work and at home, experienced longterm patient suffering and internalized patient suffering, experienced lack of staffing frequently and lack of organizational support (15). Post-traumatic stress disorder is highly prevalent among healthcare professionals during and after a pandemic, disaster, or tragic event.  

Global Impact

The current outbreak of the COVID-19 infection and the surgency of new mutant strains from the original strand has spread around the world and caused great concern for global and mental health. This current virus, like others before it, has caused an increase in anxiety, stress, economic decline, anger, and most of all fear. This virus has likely touched everyone in the world in some form or fashion due to the isolation that had become the norm.  

While reportedly 92,026,654 people have recovered from the virus, there are long-lasting effects they now must live with whether physical or mental (16). The sheer numbers can cause panic in healthcare professionals. 

In 2003, the SARS-CoV outbreak in Singapore caused a rise of PTSD by 27%. After the 2015 MERS Korean outbreak, the Ebola outbreak in Sierra Leone in 2014 and the Ebola outbreak in 2015 in the Democratic Republic of the Congo, the cases of PTSD in healthcare workers increased significantly because they were on the front lines and had heighten symptoms (17).  

A multinational study that included 906 healthcare workers across the globe taking care of patients who had COVID-19 concluded that the healthcare workers that participated screened positive for moderate to severe depression (5.3%) and moderate to extremely severe stress (3.8%). The prevalence of physical and psychological symptoms such as stress, depression, anxiety leading to PTSD were increased in the healthcare workers (18). 

A study conducted in China revealed that the prevalence of depression, anxiety, and PTSD was estimated at 15.0%, 27.1%, and 9.8%, respectively due to the fear of contracting the virus themselves and death (19). Numerous studies are available that have shown how PTSD is currently on the rise due to COVID-19. There are other traumatic events occurring, but COVID-19 has caused a drastic increase in PTSD symptoms, especially in healthcare professionals. Having to care for patients with COVID-19 while trying to protect your own health and the health of your loved ones can evoke increased stress, anxiety, fear, and feelings of hopelessness in the daily work environment and at home. Some healthcare professionals have had to walk away from the profession they genuinely love.  

For those who have decided to stay in the profession, the need for treatment is the main priority. Before a healthcare professional can help their patients, they must first care for themselves because without proper treatment, they may cause a cascade of tragic events to occur. There may be an increase in medication errors, possible patient abuse, neglect, or procedural mishaps. 

Current Therapy

Post-Traumatic Stress Disorder (PTSD) will get worse without treatment. The Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) in 2017 each establish treatment guidelines for PTSD, which are recommended for treatment of PTSD (20). Current treatment strategies for control of trauma associated symptoms of PTSD have recently been updated by the Veterans Affairs (VA) and the Department of Defense (DoD) after over a decade of dedicated research (21). Both guidelines recommend the use of Prolong Exposure (PE), Cognitive Processing Therapy (CPT) and trauma focused Cognitive Behavioral Therapy (CBT).

The reason why there is strong support for these therapies is because these treatments are evidence-based and trauma-focused. This means they directly address the individual’s memories, feelings, and thoughts related to the traumatic event. These therapies are currently the gold standard for treatment. Eye Movement Desensitization and Reprocessing (EMDR) therapy is also trauma-focused therapy (20, 21). Non-trauma-focused treatments include medication and relaxation therapy.

Prolong Exposure

Prolonged exposure (PE) is strongly recommended by both the APA and VA/DoD as successful treatment for PTSD. Prolonged exposure is based on emotional processing theory which states that traumatic events are not processed emotionally at the time of the event. Theory goes on to suggest that fear is represented in the memory as a cognitive structure that includes representation of the feared stimuli, the meaning associated with the stimuli, and the responses to the stimuli. Prolonged exposure therapy consists of a patient being instructed by a therapist to confront traumatic memories and expose themselves continuously to fearful stimuli with the goal of reaching habituation or extinction.

Some therapists believe that prolonged exposure tends to activate higher rates of fear in individuals suffering with PTSD (21). Psychoeducation about PTSD and the various reactions to trauma, breathing retraining, and vivo and imaginal exposure (two types of exposure) are the main components of prolonged exposure therapy (20). In vivo exposure helps the patient with approaching situations, people, and places they have been avoiding because of the fear response that comes from the traumatic event. This is repeated until the distress decreases.

Imaginal exposure helps the patient to approach the memories, emotions, and thoughts surrounding the traumatic event that they have been avoiding. The patient recounts a narrative of the event in the present tense repeatedly while tape recording themselves as part of homework therapy. Then, the therapist and patient will process the information revealed during the imaginal exposure. This will allow the patient to activate their fear structure and incorporate new information. This process usually takes 8 to 15 sessions (20).

Cognitive Processing Therapy

Cognitive processing therapy (CPT) utilizes social cognition theory and the informed emotional processing theory. Following a traumatic event, usually a survivor attempts to make sense of what has happened and oftentimes it leads to distorted cognitions regarding themselves, the world, and others. According to CPT, people tend to integrate the traumatic event with prior schemas they often assimilate accommodate or over accommodate (20, 21). The main goal of CPT is to shift a person’s belief toward accommodation which is a result of altering their beliefs enough to accommodate a new learning (20, 21). Sessions usually take 12 weeks, and incorporate psychoeducation about the cognitive model and exploration of the patient’s conceptualization of the traumatic event (20, 21).

Cognitive Behavioral Therapy

Trauma -focused CBT is based on behavioral and cognitive models that draw from cognitive behavior theories which include Prolonged Exposure and CPT. The aim of this type of therapy is to modify negative appraisals, correct the auto biographical memory, and remove problematic behaviors and cognitive strategies. It is believed that guilt-associated appraisals tend to evoke negative effects and are usually paired with images and thoughts of the trauma. This causes repeated reconditioned memory of the trauma-producing distress leading to tendencies to suppress or avoid the trauma related stimuli (20, 21). The techniques associated with CBT include exposure and cognitive restructuring.

The exposure technique for a traumatic memory utilizes imaginal exposure, writing about the trauma. and reading the traumatic memory out loud. Treatment for a traumatic-related stimulus usually involves in vivo exposure or instructing patients to identify various triggers of re-experiencing (20). Patients are also taught to practice discrimination of “then verses now “(20). The most important part of cognitive restructuring is teaching patients to identify the various dysfunctional thoughts and erroneous thinking and replace them with rational alternative thoughts and reconsider beliefs about themselves, the trauma, and the world (20).

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Eye Movement Desensitization and Reprocessing (EMDR) is a type of traumatic exposure therapy in which healthcare professionals help the individual make their eyes move back and forth while they imagine the trauma. The EMDR therapy allows for the individual to reprocess the memory while addressing the past, present, and future aspects of the traumatic memory. EMDR can be used to help reduce anxiety and depression associated with PTSD. Therapists have indicated individuals who participated in therapy sessions twice daily (prolonged exposure session in the morning and an EMDR in the evening) were found to have higher satisfaction rates and reduced PTSD symptoms. EMDR has been shown to reduce fear and leave patients feeling relieved and satisfied (21).

Medication Therapy

The current medication therapy recommended by the American Psychological Association for PTSD treatment are paroxetine (Paxil), fluoxetine (Prozac) and venlafaxine (Effexor). Based on the most relevant and recent research, these medications have shown the most benefit as monotherapy in treatment of post-traumatic stress disorder symptomology (21). The relative benefit of using selective serotonin reuptake inhibitors (SSRI) or selective norepinephrine reuptake inhibitors (SNRI) is side effects profiles are generally well tolerated (21). All medications must be customized for everyone because people react differently to medications and their dosages.

Medications that help with PTSD symptoms may be in conjunction with antidepressants. These include:

Clonidine and Guanfacine, Risperidone for agitation

Clonidine, Prazosin and Trazodone for trauma related nightmares

Some beta-blockers (such as Propanol) to decrease hyperarousal symptoms, but it has not been approved by the FDA (21, 22).

Another medication therapy that has grown attention for treatment of PTSD is the Stellate Ganglion Block (SGB) injection. While SGB treatment has been around for a while to treat patients suffering with chronic pain and some neurological problems, it is now being used in the treatment of PTSD. Positive results include improving PTSD symptoms and reducing or eliminating suicidal ideations (23). The procedure is performed under local anesthetics placing the medication at the C6-C7 level guided by ultrasound or x-ray imaging. The injection resets the sympathetic nervous system to its pre-trauma state. The effects can be felt as early as 30 min after injection and can last for years. Research has shown that the overall success rate has averaged 85% - 90% range (23).

Relaxation Therapy

Relaxation therapy is a form of psychotherapy that utilizes breathing techniques, progressive muscle techniques, and meditation and to illicit a voluntary relaxation response of the individual. Sometimes the use of guided imagery is used to help the individual focus on positive mental images. This technique helps lower blood pressure, relieve muscle tension, and lower stress.

Progressive Muscle Relaxation has been used to help reduce fatigue in nurses and relieve PTSD symptoms. This technique involves sequential tensing of major muscles in the body which reduces feelings of tension and lowers perceived stress. Progressive muscle relaxation can be performed anywhere at any time. This technique can decrease the pulse rate, increase the individual’s oxygen saturation, and is sometimes used in conjunction with other forms of psychotherapy (24, 25).

Coping Mechanisms 

For general individuals experiencing PTSD, it is sometimes difficult to cope with the mountain of symptoms that they may experience. For healthcare individuals experiencing PTSD it is critical that they seek treatment and develop coping mechanisms to deal with their symptoms because if they do not, their actions can become detrimental to their patients and themselves. 

There are negative and positive coping mechanisms. Negative coping mechanisms include avoidance, becoming defensive and confrontational, displacement of feelings, suppression, self-isolation, and destructive behavior (25). There are three broad categories of coping responses. They include voluntarily seeking or receiving social support, voluntary strategies of gathering information and rehearsing responses to danger, and involuntary deployment of an unconscious homeostatic mechanism that reduces the disorganizing effects of sudden stresses (25, 26). 

Healthcare professionals have resources available to help them cope with PTSD. Some workplaces have elicited the help of a psychiatrist or psychologist to provide drop-in services at the work site. Various positive coping mechanisms include: 

• Spiritual guidance in prayer 
• A strong support system to lean on such as a sponsor that the individual can call when feeling overwhelmed 
• Including family in the healing process 
• Performing mindful meditation (one of the newest forms of coping mechanisms for PTSD which encompasses a form of meditation in which the individual focuses on current sensations and feelings without applying any thoughts to them. This results in mental clarity and reduction of stress.  

Moral resilience describes when an individual can confront distressful and uncertain situations with courage and confidence while relying on a strong system of values and beliefs. Moral resilience helps keep the individual “in check,” which allows their mind to conceptualize the situation, knowing when events are out of their own control. Moral resilience must be gradually built and developed by an individual and requires persistence and experience (26). Nurses should focus on developing moral resistance when caring for patients.  

Other positive coping mechanisms include yoga, relaxation techniques, guided imagery to focus on positive thoughts when the stressors resurface, prescription medication for PTSD, peer support at work, professional counseling, group therapy, tai chi, and developing a hobby.

Conclusion

Post-traumatic stress disorder can be a very debilitating condition. PTSD affects millions of people a year during non-pandemic crises. This condition nearly doubles during pandemic crises, especially for healthcare professionals. Healthcare professionals are the first line of help for the public. In order for them to do their jobs effectively, mental health must be a top priority. COVID-19 has caused an increased level of PTSD in healthcare professionals. As we watch colleagues, strangers, and loved ones battle with or succumb to COVID-19, we may find ourselves feeling hopeless and wanting to leave the profession we love. 

Health care professionals develop a bond with their patients as well as their colleagues. It is that bond that gives some people more purpose than others and helps them to get through PTSD. Healthcare workers must receive the help that they need so that they can continue to help their patients.  

Many organizations now offer counseling, time off, peer support, and incentives for healthcare professionals who engage in self-care. Proper treatment can alleviate or control PTSD in healthcare workers. Our goal in the future is to continue to make the physical health, spiritual health, and mental health of all healthcare workers top priority so we can continue to give the best care to everyone who comes to us for help. 

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