Article about PTSD and CISS by Nina K. Carroll, M. Sci

By Nina K. Carroll

Critical Incident Stress Syndrome and Post Traumatic Stress Disorder awareness for crime scene cleanup technicians.

Post Traumatic Stress Disorder (PTSD) and Critical Incident Stress Syndrome (CISS) are often misunderstood or confused by lay people who are not aware of the intricate nuances of each disorder. Disorder is really such a strong word that I am loathe to use it for fear of the stigma it places upon those who work in the emergency services field. Perhaps, syndrome is the best possible term to use for both.

Post Traumatic Stress Disorder

PTSD is a psychiatric injury incurred by experiencing an event that is extremely traumatic for the person confronted with the incident. It is generally a single, traumatic event such as the sudden death of loved one, witnessing someone’s death, a horrific accident, a police officer shooting someone in the line of duty, hostage situations, a bank robbery, rape, assault or torture, natural disasters such as hurricanes or tornados, or terrorist attacks. There are an infinite number of incidents that can lead to the development of PTSD. The list could go on and on.

PTSD became almost a household word after Vietnam veterans returned to the U.S. in the 70s and began displaying psychological and physical problems such as flashbacks, spontaneous outbursts of anger/rage, depression, and high incidences of drug and alcohol abuse. PTSD received a great deal of attention after a number of workplace (mostly postal services offices) shootings occurred and the gunmen were found to be veterans suffering from PTSD.

Some of the recent events that have been attributed to causing PTSD include the 2004 Christmas tsunami, the terrorist attacks on 9-11-2001, the Oklahoma Federal Building bombing, etc. Time will tell whether or not the early July bombings of a bus and several subway stations in London and the subsequent police shooting of a suspect in the London Underground, which was witnessed by hundreds of bystanders, will lead to the development of PTSD in the British people affected by the tragedy.

The fundamental element of PTSD is that the symptoms develop after a traumatic event that is outside the range of usual human experience. This excludes events outside of simple grief and/or bereavement, long-term or chronic illness, financial losses, and marital conflict (DSM-III-R 1987, p. 247).
“After a person has been exposed to a traumatic event (an event in which they have experienced, witnessed or were confronted with life threat, serious injury or physical threat to themselves or others), and has experienced intense fear, helplessness, or horror (for children, disorganization or agitation), he or she may develop PTSD or some trauma symptoms.” (Nader 2001).

Symptoms of PTSD are generally divided into two categories: physical and emotional. Some physical symptoms may include “restlessness, nausea, tenseness, digestive trouble, headaches, insomnia, tremors and sexual problems.” (Texas Department of State Health Services 2005).
According to the DSM-III-R, the diagnostic criteria for PTSD are as follows:

A) The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one’s life or physical integrity; serious threat or harm to one’s children, spouse, or other close relatives and friends; sudden destruction of one’s home or community; or seeing another person who has recently been, or is being seriously injured or killed as a result of an accident or physical violence.

B) The traumatic event is persistently re-experienced in at least one of the following ways:

1. Recurrent and intrusive distressing recollections of the event (in young children, repetitive play in which themes or aspects of the trauma are expressed)
2. Recurring distressing dreams of the event
3. Sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon awakening or when intoxicated)
4. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma

C) Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
1. Efforts to avoid thoughts or feelings associated with the trauma
2. Efforts to avoid activities or situations that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma (psychogenic amnesia)
4. Markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills)
5. Feeling of detachment or estrangement from others
6. Restricted range of affect, e.g., unable to have loving feelings
7. Sense of a foreshortened future, e.g., does not expect to have a career, marriage, or children, or a long life

D) Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
6. Physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator)

E) Duration of the disturbance (symptoms in B, C, and D) of at least one month (DSM-III-R 1987, p. 250-51).

Critical Incident Stress Syndrome

CISS is actually a practitioner’s term used to reduce the stigma associated with the term PTSD (Toby Snelgrove, 2005) and most often refers to those who are employed in emergency service occupations such as law enforcement, ambulance drivers and EMS units, funeral home employees, hospice nurses, search and rescue crews, military, or, as in the case with Amdecon, Inc, crime and trauma scene decontamination personnel.

CISS mainly occurs when people working with death, dying, or life-threatening injury on a regular basis have not had time to adequately “purge” these traumatic events in time to emotionally prepare for the next or have not properly addressed how much stress or trauma an incident has inflicted upon them.

“Critical Incident Stress Syndrome (CISS) is the adverse psychological and/or physiological reaction to a stressful incident. Stress does have a cumulative effect on the body. Someone who has been involved in numerous incidents without any lasting complications may suddenly develop the signs and symptoms of a stress reaction.

Critical Incident Stress Syndrome can be triggered by catastrophic events, or even events such as an auto accident, the death of a relative, or the death of a pet. The greater significance with which one views the event in their personal life, the greater stress it brings into their life.

If left untreated, CISS can cause unresolved conflicts and feelings that remain long after the trauma. These side effects range from headache, fatigue, and sexual dysfunction, to terrifying dreams, hallucinations, severe withdrawal and apathy, even suicide. Time to heal is vital. In some cases a debriefing sessions should be arranged with a trained grief counselor” (Amdecon® Technician Manual 2005©)

Secondary Traumatic Stress Disorder is related to Post Traumatic Stress Disorder. It affects those who are closely associated with people who have experienced a traumatic event. This includes friends and family, psychiatrists, firefighters, police, EMTs, and CTS Decon personnel.

Secondary Traumatic Stress Disorder can manifest in many ways, including depression, insomnia, because of terrifying nightmares, and exaggerated startle reactions. Those suffering from STSD often avoid close emotional ties because they feel numb or have diminished emotions. They may have trouble concentrating or remembering current information, and can complete only routine, mechanical activities. STSD can affect their behavior without their even being aware of it. They can sometimes be suddenly irritable or explosive.

Finally, many people with STSD also attempt to rid themselves of their pain by abusing alcohol or other drugs as a “self medication” that helps them to blunt their pain and temporarily forget the trauma. A person with STSD may show poor control over his or her impulses and may even be at risk for suicide” (Amdecon® Technician Manual 2005©).

Workers in these fields tend to have a predisposition to dissociate to a degree from the work they do so as to remain emotionally capable of continuing to do their work without “falling apart” or having a breakdown. Therefore, sometimes they feel as though they should not be affected by these incidents and often “blow them off.” This can result in the “storing up” of psychiatric injuries that, over time, can cause the sufferer serious problems and can even lead to homicide or suicide.

For example, Officer Dan Jeffries, of Hattiesburg, Mississippi Police Department, was named the Officer of the Year in 1993 and was the recipient of numerous medals, accommodations and awards; however, by 1994, he had been arrested for armed robbery of a bank in Mobile, Alabama, and sentenced to prison.

What led to this apparent about-face which stunned an entire community and left a police small, close-knit police department in absolute disbelief? During Officer Jeffries career, he was once forced to kill a suspect to save the lives of innocent people. According to news accounts, he had fired his service weapon only as a last resort, not wanting to kill the suspect. This incident preyed upon his mind and he never fully recovered from the trauma. Within one year, he had lost his job, his wife, his reputation, and almost everything he had spent his life building. And then, he went to prison.

From the research done thus far on PTSD, most experts in the field agree that people who have suffered a previous trauma are at more risk of developing PTSD than those who have not. It is my opinion that Officer Jeffries, after having served as a police officer for many years, probably suffered CISS to some degree even before the fatal shooting. I believe CISS left him vulnerable to suffering PTSD after the shooting incident. Officer Jeffries has been released as of this article’s publication but was unable to be located for an interview.

After the assassination of President John F. Kennedy, the American people went into a period of mourning. People cried, grieved, and were angry and traumatized by the highly publicized and tragic event. While touring the famous Sixth Floor Museum at the Texas Schoolbook Depository in Dallas, I noticed something written beside a photograph that stated: “A national survey showed that the assassination caused more than 2/3 of the American people to experience some physical symptoms of illness and emotional distress; at home and abroad, most compared the loss of the American President to that of a family member or close friend.” (Sixth Floor Museum, July 2005).

My mother was twenty-one years at the time of the Kennedy assassination and can recall the graphic images of that tragic event. She stated that she could not remember even having seen someone killed on television before that day. For many Americans, it may very well have been the first time they had ever seen someone killed also. The deluge of these images on the national news must surely have been horrific and extremely distressing to millions of already distraught viewers.

The only suspect to the November 22, 1963 assassination, Lee Harvey Oswald, was apprehended in Dallas the same day. Two days later, while he was being escorted from the jail, he was shot and killed by Jack Ruby, a local nightclub owner. This murder was also captured on film and highly disseminated to the American public, thereby increasing the already- present trauma of the original tragedy.

I believe this begs this question of whether graphic images in the media contribute to the development of PTSD and/or CISS. Indeed, how many times have we heard people say they can no longer bear to watch the evening news anymore for all the violence and tragedy that is laid bare for the entire world to see? And if, as experts have concluded, seeing or experiencing trauma as children predisposes adults to an increased susceptibility of developing PTSD, could this mean that graphic images of death and violence in the media do not desensitize but could, instead, traumatize?

Conspiracy theories still abound concerning the connection between Oswald, Ruby and the Kennedy assassination. The most likely scenario, however, is that Jack Ruby suffered from PTSD. His bizarre behavior before the incident and statements made after the Oswald shooting indicate that he had experienced the president’s death as something very personal and distressing and was not thinking lucidly.

Ruby had been an eyewitness to the assassination in Dealey Plaza and according to Dr. Kathleen Nader, the level of traumatization can be markedly increased by the closeness or proximity of the witness to the traumatic event. “Among those who are particularly at risk are people who experienced the sights, sounds and smells; who felt the horror…” (Nader 2001).

After his arrest, Jack Ruby was questioned by Secret Service agent, Forest Sorrels. Ruby told Sorrels he “had been grieving about this thing (the assassination of JFK)” and had closed his business three days earlier and not done any business since. He also stated that “when he saw Mrs. Kennedy was going to have to appear for the trial (of Oswald), he thought to himself, why should she have to go through this ordeal for this no good son of a bitch?” He claimed to have been “despondent over the assassination of the President, also Officer Tippit, and that he was a very emotional man, and that out of grief for both these people, was one of the motivations.”

When Ruby was asked why he killed Oswald, he said, “I was in mourning Friday and Saturday. To me, when he shot before me like he did, something in my insides tore out, and I just went blank.” (http://mcadams.posc.mu.edu/ruby.htm)

Also contributing to an increased sense of traumatization is the dynamic of the trauma being one that is “man-made” such as the terrorist attacks of 11 September 2001. “The disorder is apparently more severe and longer lasting when the stressor is of human design.” (DSM-III-R, 1987, p. 248).

PTSD and CISS are both high-risk for emergency service personnel and should be addressed properly by employers so as prevent or treat them before they become an affliction in the workplace or cause undue suffering on the part of the traumatized employee. Several remedies exist such as pre-incident management, BEP (brief eclectic psychotherapy), and various post-incident debriefing strategies. There is some debate concerning the effectiveness of debriefing; although, it appears, if done properly, it can significantly reduce trauma symptoms and the accumulation of stressors.

The Brief Eclectic Psychotherapy (BEP) study conducted in Amsterdam involved officers who voluntarily sought counseling after a traumatic event. One of the various strategies for this study is known as In the Stepwise PTSD Treatment, the officers were encouraged to collect mementos such as articles, photos, and other clippings of the traumatic event. During the 16-week treatment, the officers participated in imaginary reliving of the event, wrote about the event, and discussed/explored the effects of the trauma on the person. After they completed these steps, the officers held a symbolic “ceremony” in which they “destroyed the mementos and celebrated regaining control” of their lives. (EurekAlert! 2000).

Debriefing usually involves a group discussion of the event most often by a trained outside counselor. Research indicates that this is difficult to achieve by a fellow employee or boss due to pre-existing interoffice dynamics. When other underlying issues exist among the workplace, openness and a willing to discuss highly personal emotions and/or experiences can be stifled or impossible.

Easton-Snelgrove of Vancouver offers training courses for CISS management and a range of occupational debriefing services and training. According to Dr. Toby Snelgrove, a pre-incident program is a great tool for employers because when an incident does occur, the framework for addressing the problem is already in place and the employee tends to feel less stigmatized by needing counseling. If the employee perceives that his/her employer expects this to be a normal aspect or occurrence of the job, the employee will feel more comfortable seeking the counseling they need.

Many government agencies such as Dallas County promote and encourage their employees to seek counseling and often provide these services for free or are covered through employee insurance, because often, employees’ physical health can depend greatly on their mental health. This is especially so for those who work in fields such as death investigation, law enforcement, social work (especially with abused children), elderly services, and emergency medical services where “burn-out” is common. For those who wish to make a career out of a job that requires a heightened level of stress on a daily basis, PTSD and CISS are real threats.

Resources
1. DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, The American Psychiatric Association, University of Cambridge Press, 1987.
2. http://giftfromwithin.org/html/articles.html (Dr. Kathleen Nader, D.S.W., 2001.
3. http://www.tdh.state.tx.us/hcqs/ems/epcism.htm (Texas Department of State Health Services) 2005.
4. Amdecon Technician Manual 2005©.
5. Tour of Sixth Floor Museum, Dallas, Texas, July 2005.
6. http://mcadams.posc.mu.edu/ruby.htm, 2005.
7. Dr. Toby Snelgrove, PhD., personal communications, July 2005.
8. http://www.eurekalert.org/, (EurekAlert!) 2000.
9. Personal interview with Dr. Donald Cabana, Chair, Department of Criminal Justice Administration, University of Southern Mississippi, July 2005.
10. Personal interview with Betty Carroll, July 2005.
11. Toby Snelgrove, Proactive Trauma Management: An Intervener’s Resource Manual, Vancouver, BC: Easton Snelgrove, 1999.
12. http://wwwsarbc.org/cis1.html, 2005.
13. Personal interview with Detective Gerald Bordelon, Hattiesburg, Mississippi Police Department, July 2005.