Post-traumatic stress disorder (PTSD) is generally described as a mental disorder characterised by intrusive flashbacks, detachment from the world and disproportionately high arousal, caused by stressful external environmental events (Lasiuk and Hegadoren, 2006; Friedman, 2013). The original articulations of the definition of PTSD can be seen as historically contingent and closely related to historical events.
PTSD was classified as a mental illness in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III) in 1980 (American Psychiatric Association (APA), 1980) and was largely related to the aftermath of the Vietnam War (Shatan, 1973; Horowitz and Solomon, 1975; Young, 1996). Evidence suggests that seemingly relevant symptoms were indeed present in people from earlier times. However, other perhaps more colloquial descriptors would have been used such as shell shock (Meyers, 1915; Miller et al, 1992; Cantor, 2005).
DSM–IV and PTSD diagnosis in paramedics
In 1994, DSM–IV replaced DSM–III, with a major change being the implementation of clinical-significance criterion to almost half of the identified mental disorders, including PTSD (Breslau and Alvarado, 2007; Stein et al, 2010).
While military veterans were the focus of PTSD research during its categorical inception from 1980, studies using DSM–III were able to identify PTSD in other populations exposed to trauma, such as sexually abused children (Wolfe et al, 1989), Holocaust survivors (Kuch and Cox, 1992), clinical staff who were victims of patient violence (Caldwell, 1992) and police officers involved in shooting incidents (Gersons, 1989).
The revision of the definition of PTSD in 1994 in DSM–IV helped to increase and facilitate its diagnosis by lowering the diagnostic threshold (McNally, 2004) and, in turn, PTSD in paramedics received more attention.
The most notable change was to criterion A, regarding the traumatic experience. While DSM–III required this to be outside the usual range of human experience, DSM–IV allowed for stressful experiences that were not necessarily outside the ‘usual range’ as well as exposure to vicarious trauma (Joseph et al, 1997). This could therefore cover bystanders and witnesses of traumatic incidents, rather than only the victims who were directly involved (McNally, 2004).
Research using DSM–IV criteria suggests that PTSD is more prevalent in paramedics than in the general population (Grevin, 1996; Larkin et al, 2000). Studies have explored predictors of PTSD onset in paramedics (Alexander and Klein, 2001), coping strategies (Kirby et al, 2011), underlying causes (Fjeldheim et al, 2014) and support at work (Scully, 2011).
Given that PTSD in DSM–III had been intended to reflect the trauma in soldiers, it may be that its conceptualisation of PTSD in paramedics is closely related to the updates to the criteria of PTSD in DSM–IV.
Conceptual issues of DSM–IV and PTSD in paramedics
Published studies in journals suggest that the increased elasticity of DSM–IV regarding PTSD diagnosis led to it being diagnosed in many more population groups (McNally, 2004; Fink et al, 2018). This increase in inclusion and elasticity was implemented into DSM–IV after researchers in the early 1990s began to notice that people who did not meet the full diagnostic criteria for PTSD in DSM–III displayed significant impairments such as diminished social functioning, suicidal ideation and increased healthcare use (Fink et al, 2019).
Additionally, DSM–IV expanded the definition of traumatic events to include indirect experiences of observing the victims (APA, 1994), increasing the qualifying events of PTSD by 59% (Echterling et al, 2016). This is especially pertinent to paramedics given how their traumatic experiences are largely vicarious (Regehr et al, 2002).
McNally (2004), however, argues that the change to criterion A in DSM–IV has led to an overdiagnosis of PTSD in populations that have not experienced ‘catastrophic events outside the perimeter of everyday experience’ (McNally, 2004: 1). Other researchers note that the vague, inclusive definition of PTSD in DSM–IV means it applies to a wider variety of populations (Spitzer et al, 2007; Andreasen, 2010).
It may be possible that PTSD diagnosis in paramedics became possible only after the ‘conceptual bracket creep in the definition of trauma’ (McNally, 2004; 3) created by DSM–IV.
This may be illustrated in the self-help manual for stress in emergency workers by Hartsough and Myers (1985). Their manual states that common issues after stress-inducing events include anxiety, fatigue, depression and irritability. They advocate that an extreme form of this symptomatology is required for a PTSD diagnosis to be considered. They further argue that, rather than constituting ‘a disorder’, this symptomatology is natural in the circumstances and to be expected in emergency workers: ‘Disaster workers who experience these problems should not be viewed or dealt with as if they suffered from mental illness. They are responding normally to very abnormal situations’ (Hartsough and Myers, 1985: 35).
Arguably, DSM–IV made the diagnostic criteria for PTSD less restrictive. This potentially extended its application to non-military populations, allowing for experiences ‘within the range of usual human experience’ (McNally, 2004: 1) to be included when diagnosing PTSD. This updated criterion could include indirect victims of a traumatic event such as the paramedics who arrive to handle the aftermath of the scene (Regehr et al, 2002; McNally, 2004).
Validity of trauma and PTSD in paramedics
It can be argued that the severity and prevalence of PTSD in paramedics is such that it had the potential to have been diagnosed using the more restrictive DSM–III criteria during the 1980s. A study by Clohessy and Ehlers (1999) found that 21% of the 56 paramedics and technicians from Oxfordshire Ambulance NHS Trust met the criteria for PTSD using DSM–III.
Additionally, recent studies suggest that the rates of PTSD in paramedics are equal to, if not greater than, those in soldiers, with reports of PTSD in around 10% of paramedics (Shepherd and Wild, 2014) and in around 3–5% of UK soldiers (Fear et al, 2010).
Therefore, it is possible that PTSD in paramedics could be diagnosed using the DSM–III between 1980 and 1993. It should, however, be noted that while there are comparisons of rates of PTSD diagnosis between paramedics and soldiers, no studies compare the severity of PTSD between these two populations. Future research should consider this.
It is likely that other factors restricted studies on PTSD in paramedics during this period. One such factor may be that most of the research on PTSD during this time was focused more on the direct rather than indirect victims of traumatic events (McNally, 2004). This may be in part because of the stigmatisation of mental health issues often observed in paramedic workforces. Haugen et al (2017) describe how stigma is a major barrier in receiving mental healthcare for many first responders, and Quaile (2016) discusses how stigma is attached to mental health issues in paramedics, especially regarding PTSD. This stigmatisation may cause an under-reporting of mental health issues, as well as a lack of published research into PTSD in paramedics in the 1980s and early 1990s.
The increase in studies investigating PTSD symptomatology in paramedics after 1994 may be explained by a wider cultural shift in the perception of what mental illness in paramedics is. A meta-analysis on reports of national time trends suggests that mental health literacy and acceptance of professional help for mental health problems has increased in the general public since 1990 (Schomerus et al, 2012).
More specifically to paramedics, programmes such as the Blue Light Programme implemented in 2014 have aimed to help tackle stigma and raise awareness about mental health in the emergency services and has displayed positive impacts in this area (Quaile, 2016; Maguire and Baraki, 2018). For instance, Blue Light champions (volunteers from the emergency services) reported an increase in feeling comfortable in talking about their own and others' mental health, signifying a reduction of stigma alongside an increase in awareness (Maguire and Baraki, 2018).
Hartsough and Myers (1985: 35) said paramedics were responding ‘normally to abnormal situations’ and were therefore not experiencing mental illness. More recently, researchers argue that psychological distress experienced by paramedics because of critical incidents at work is not a ‘normal’ response, and they are in fact victims who need support and treatment (Krupa et al, 2009; Crampton, 2014; Pucci, 2017). The change in approach towards mental illness in paramedics may also explain the increase in research since 1994.
The growth in research on trauma and PTSD in paramedics may have arisen from both cultural shifts towards perceptions of mental illness and the change in PTSD criteria in DSM–IV.
Despite the apparent importance of DSM–IV in paving the way for PTSD research in paramedics, the diagnostic criteria in DSM–IV are not without issues (McNally, 2004; Spitzer et al, 2007; McNally, 2009). These include vagueness and overuse because of ‘conceptual bracket creep’ (McNally, 2004: 3).
Another issue is that DSM–IV was unclear whether its criteria included PTSD symptomatology caused by chronic traumatic experiences. Criterion A(1) states: ‘The person experienced, witnessed, or was confronted with an event, or events, that involved actual or threatened death or serious injury, or a threat to the physical integrity or self or others’ (APA, 1994: 427). The pluralisation of ‘events’ does not provide specific enough confirmation that the criterion includes PTSD symptomatology caused by repeated exposure to traumatic stimuli.
Chronic stress disorders and PTSD in DSM–IV: issues for paramedics
The literature suggests that repeated exposure to traumatic stimuli leads to variations of PTSD. Lanius et al (2010) report that repeated stresses such as long-term childhood abuse and combat trauma can result in a dissociative subtype of PTSD that is more characterised by affective symptomatology.
A standardised classification of PTSD based on repeated interaction with traumatic stimuli is important for paramedics because their profession is possibly more characterised by the accumulation of stressful work events than acute traumatic work incidents (Alexander and Klein, 2001; Regehr et al, 2002; Unison, 2013). The ability to diagnose a dissociative subtype of PTSD in this workforce may help produce effective approaches to alleviate this issue more efficiently.
This form of PTSD will be referred to as ‘negative PTSD’ and the more typical form characterised by acute trauma and hyperarousal symptoms will be referred to as ‘positive PTSD’. This distinction is similar to that used in schizophrenia literature and evaluation (McGlashan and Fenton, 1992).
The effects of chronic stress on mental wellbeing have been investigated. However, research in this area has several issues. There was no official, clear category for such a disorder in DSM–IV (APA, 1994). This has resulted in research on chronic stress disorders using a wide range of non-standardised terminology with non-specified intensity of symptoms. Unlike the unity of acute stress disorders defined by the criteria for PTSD in DSM–III (Blake et al, 1992; Joseph et al, 1997), neither DSM–III nor DSM–IV include criteria for negative PTSD.
Separate bodies of work link paramedics to burnout (Grigsby and Knew, 1988; Nirel et al, 2008), compassion fatigue (Inbar and Ganor, 2003; Figley, 2013) and chronic workplace stress (Halpern and Maunder, 2011). None of these disorders were listed in DSM–IV (APA, 1994), and some form of classification may assist with furthering the understanding of the complete aetiology of PTSD, especially given that paramedics appear to be susceptible to the form of negative PTSD described by Lanius et al (2010).
DSM–5: PTSD diagnosis from repeated exposure to trauma
The criteria for PTSD was further altered in DSM–5 (APA, 2013). Following criticism that DSM–IV had become too inclusive (McNally, 2004; 2009; Spitzer et al, 2007), DSM–5 aimed to have a more conservative, restrictive diagnosis criteria for PTSD (Pai et al, 2017). This is reflected by the change in criterion A, which now requires ‘actual or threatened death, serious injury or sexual violence’ and no longer requires the victim's subjective response of ‘fear, helplessness or horror’ (Joseph et al, 1997; Pai et al, 2017). Therefore, criterion A is now based more on the traumatic event than on the person's response to it.
The updated, more restrictive criterion appears to have made the diagnosis of PTSD less inclusive. Kilpatrick et al (2013) recruited participants from the general population using an online survey and found that 60% of cases that met the DSM–IV criteria for PTSD did not meet the criteria in DSM–5. Diagnosis of PTSD in paramedics may be changed little by DSM–5, given that the nature of their profession means that they are often exposed to and witnesses of death and serious injury (APA, 2013; Pucci, 2017).
Nevertheless, studies investigating PTSD in paramedics using DSM–5 need to be conducted to investigate this. So far, no such studies published after 2013 have used the DSM–5 criteria and have mostly used DSM–IV (Fjeldheim et al, 2014; Michael et al, 2016; Oravecz et al, 2018). While these studies were published after 2013, it is likely that most began before DSM–5 was published in 2013 so used the criteria in DSM–IV.
Importantly, DSM–5 has included criteria for the dissociative subtype of PTSD proposed by Lanius et al (2010). First, criterion A has listed a fourth exposure type: ‘Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g. first responders, collecting body parts; professionals repeatedly exposed to details of child abuse)’ (APA, 2013). This addition to the criteria has therefore made it more feasible to diagnose paramedics with PTSD based on their repeated traumatic experiences in their work.
Second, DSM–5 has updated the symptomatology to include affective symptoms associated with negative PTSD (Chu, 2010; Lanius et al, 2010). PTSD is no longer associated entirely with anxiety and is now in a new category of ‘trauma and stress-related disorders’ (APA, 2013; Pucci, 2017) as research has suggested that PTSD does not have to include symptoms of anxiety (Spitzer et al, 2007; Pucci, 2017). DSM–5 has therefore increased the emphasis on affective symptoms with a new criterion (criterion D), which requires at least two affective symptoms.
DSM–5 has expanded the diagnosis criteria for PTSD to include negative PTSD. Therefore, paramedics who in the past may have been labelled with a chronic stress disorder not listed under DSM, such as burnout or work stress, may be more likely to receive a diagnosis of PTSD through the affective symptoms listed under criterion D.
PCL–5 questionnaire to investigate PTSD caused by repetitive exposure
The updated changes to PTSD diagnosis in DSM–5 have the potential to include negative PTSD. This is more characteristic of the stress and trauma found in the paramedic profession (Regehr et al, 2002).
Nevertheless, the ability to diagnose PTSD still often requires assistance from questionnaire-based tools, especially when a structured interview is not possible (Weathers et al, 1993). To help diagnose negative PTSD, questionnaires must facilitate this aspect as well as symptoms of positive PTSD. Before DSM–5, most studies on psychopathology in paramedics used both a PTSD scale and a separate scale for the stress-related mental distress caused by repetitive exposure (Alexander and Klein, 2001; Fjeldheim et al, 2014; Wild et al, 2016). It may, however, be possible for one updated PTSD questionnaire to cover both of these aspects.
The first PTSD questionnaire to be made in response to the changes in DSM–5 was the post-traumatic stress disorder checklist 5, or PCL–5 (Weathers et al, 2013) (Appendix 1). This questionnaire demonstrated good levels of validity in a study on soldiers (Bovin et al, 2016). To date, the PCL–5 has been used only once on paramedics; the study focused on their responses to a single traumatic event (Shrestha, 2015). The questionnaire has not yet been used to measure the effects of repetitive traumatic events in paramedics.
PCL–5: advantages and disadvantages
In PCL–5 a new, fourth addition to criterion A in DSM–5 was made (‘repeated exposure to stressful events as part of one's job’), with paramedics included as an example.
The identification of the worst event at the start of the questionnaire also allows for the option of ‘multiple similar events’: ‘Also it could be a single event (for example, a car crash) or multiple similar events (for example, multiple stressful events in a war-zone or repeated sexual abuse).’ This option appears to expect the participant to group a multitude of stressful experiences into a broad grouped experience, especially given the little room they have to write down their experience or experiences.
Because the questionnaire requires a person to write only one example in the measure, it may not be capable of measuring the often wide-spanning traumatic experiences that paramedics endure. The trauma experienced by paramedics often results from the toll of these collective experiences, rather than a single incident (Lanius et al, 2010; Stassen et al, 2013).
Regehr et al (2002) provide a list of critical events a paramedic may experience, such as the death of a child, being attacked by disorderly patients and multiple casualties. Additionally, qualitative interviews by Clompus (2014) seem to indicate that the paramedic's PTSD symptomatology is often the result of a culmination of different cases as well as isolated incidents. Therefore, paramedics using the PCL–5 may struggle to provide an answer representative of their experiences.
Furthermore, the Likert scale section of PCL–5 contains several questions based on the participant's experience. Examples include ‘Repeated, disturbing, and unwanted memories of the stressful experience?’ and ‘Trouble remembering important parts of the stressful experience?’ In relation to the current topic, an issue with these questions is that they all refer to single incidents, and do not account for the idea of a culmination of different stressful experiences that could be responsible for the PTSD onset.
Paramedics may therefore need to use their initiative when completing the questionnaire and try to select a single, particularly stressful event they experienced or treat questions as if they were plural. This issue may affect the ability of the questionnaire to measure the multiple traumatic experiences that are characteristic of this workforce.
In future, researchers could: devise a questionnaire more suited to factoring in multiple traumatic experiences; continue to use a separate questionnaire for chronic stresses not listed in the DSM–5 such as burnout or compassion fatigue; or use the International Trauma Questionnaire (ITQ) from the International Classification of Diseases (ICD–11) World Health Organization (WHO, 2018).
ICD–11 and complex PTSD
Both DSM-IV and ICD-10 mostly agreed on the definition and categorisation of PTSD (Peters et al, 1999). However, agreement between the two manuals has altered in their latest editions in 2013 and 2018.
While DSM–5 (APA, 2013) made PTSD more inclusive for negative symptoms caused by chronic exposure to critical incidents, ICD–11 (WHO, 2018) argues that there are two sibling disorders that each cover acute trauma and chronic trauma. ICD–11 still retains a definition of PTSD characterised by acute critical incidents resulting in symptoms characterised by hyperarousal. It also defines the sibling disorder, coined as complex PTSD (CPTSD) as being more characterised by affective symptoms often caused by chronic trauma over time, such as childhood abuse, and often occurs in comorbidity with other disorders such as depression (Cloitre et al, 2013; WHO, 2018).
Despite being formally recognised in ICD–11 in 2018, the idea for a separate term of CPTSD has existed since the early 1990s (Herman, 1992; Roth et al, 1997; van der Kolk, 2002). Several researchers have argued for the inclusion of CPTSD in ICD–11 based on the overall literature (Maercker et al, 2013). Before 2018, further analytical evidence was provided to suggest that PTSD could be split into two sibling disorders. Latent profile analysis by Cloitre et al (2013) suggests a distinction between hyperarousal PTSD symptoms and affective PTSD symptoms, with single-event trauma being more predictive of PTSD and chronic trauma being more predictive of CPTSD.
It is difficult to draw a conclusion on the validity of DSM–5 or ICD–11 criteria for PTSD as research is inconclusive, with mixed findings on DSM–5 (Stein et al, 2014; Hansen et al, 2015) and ICD–11 (Hansen et al, 2015; Wolf et al, 2015). Future studies using psychometric measures derived from these diagnostic systems should be compared and evaluated.
International Trauma Questionnaire: potential applicability to paramedics
While more research is needed to investigate how the two diagnostic systems for PTSD relate to paramedics, ICD–11 may provide an advantage that DSM–5 is behind on—the DSM–5 lacks a questionnaire that can proficiently measure the effects of chronic stress on PTSD characterised by affective symptoms.
Based on the definition of PTSD in ICD–11, the ITQ is a self-report diagnostic tool for both PTSD and CPTSD, developed by Cloitre et al (2018). This was developed from a prototype version using random sampling from the general population in the UK.
The ITQ (Appendix 2) provides a clear distinction between symptomatology caused by acute exposure to trauma and that caused by chronic exposure by using two different Likert scales. Therefore, this questionnaire may be more capable of measuring negative PTSD as well as positive PTSD in paramedics.
The ITQ could therefore provide a better reflection of the day-to-day accumulation of stress and trauma in paramedics than the PCL–5.
Issues with the International Trauma Questionnaire
Using the ITQ to measure negative PTSD in paramedics may be promising but there are potential issues. The ICD–11 and ITQ do not allow for a diagnosis for both PTSD and CPTSD, only one or the other (Cloitre et al, 2018). This may not be a suitable approach for paramedics because of the range of both acute and chronic traumatic experiences they have. For instance, their distress may be chronic because of multiple traumatic events but also acute if a patient dies or if they are attacked by violent patients (Regehr et al, 2002).
This is reflected in reports that paramedics often have a complex aetiology of both positive PTSD symptoms and mental health issues associated with chronic stress, such as burnout, depression, numbing and perceived stress (Alexander and Klein, 2001; Fjeldheim et al, 2014; Wild et al, 2016). Therefore, it is likely that the symptomatology in paramedics is a complex interaction between both hyperarousal and affective symptoms, not simply PTSD or CPTSD as ICD–11 and the ITQ propose.
While research specifically on paramedics and ICD–11 is needed to further test this, it already appears to be the case with other populations. Cloitre et al (2013) found that 20% of their participants exposed to acute trauma fell into the CPTSD class, and 23% of their chronic trauma participants fell into their PTSD group. Furthermore, Wolf et al (2015) could not confirm there was a distinction between PTSD and CPTSD in US military veterans. This suggests that a more complex aetiology of PTSD between acute and chronic stress may be present in vulnerable workforces (such as paramedics) where it is difficult to distinguish between the two.
Future questionnaire
The ITQ provides a quick, helpful method of distinguishing between hyperarousal-based PTSD and CPTSD (Cloitre et al, 2018).
It can be argued that the criteria in DSM–5 better reflect the aetiology of PTSD in paramedics. The criteria in DSM–5 combine hyperarousal symptoms, as seen in criteria B and E, and affective symptoms as seen in criterion D. This better reflects the range of affective and hyperarousal symptoms paramedics often display in response to PTSD caused by both acute trauma and chronic trauma.
First, studies are required to investigate the interaction between acute and chronic trauma and PTSD. Second, a revision of or alternative to the PCL–5 is required. A better method of investigating PTSD in paramedics would be the development of a questionnaire based on DSM–5 that, unlike the PCL–5, also reflects criterion A4 by including negative PTSD resulting from repeated exposure to trauma often experienced at work.
This questionnaire should also give the user more freedom to explain what may be a range of experiences that are collectively troubling them, rather than manoeuvring them into giving just one experience.
Conclusion
This article has outlined the history and conceptual issues of PTSD in paramedics. There is a lack of research investigating PTSD characterised by chronic stress and affective symptoms in paramedics.
While recent updates to diagnostic systems are more open to PTSD diagnoses for non-military populations, they are still largely influenced by the form of acute psychological trauma associated with the military, rather than the chronic trauma often observed in paramedics.
Both DSM–5 and ICD–11 contain criteria that may facilitate more appropriate diagnoses of PTSD in paramedics. Criterion A4 in DSM–5 allows for a PTSD diagnosis based on repeated exposure to adverse events in professional duties, while ICD–11 outlines the sibling disorder CPTSD to account for affective symptoms as a result of chronic traumas.
Questionnaires that can sufficiently measure this in paramedics are required to allow research to further explore PTSD in this workforce. Furthermore, it may also be useful if a study compares the severity of PTSD symptomatology between paramedics and military personnel to fill additional gaps in the research literature.