PTSD in Physicians

Dr. Art Lazarus invited me and another colleague, Dr. Steve Moffic, to join him in a workshop that he put together for the recent American Psychiatric Association Annual Meeting in Toronto. He called it “PTSD in Psychiatrists: A Hidden Epidemic”. I want to share some of what I presented, which was in keeping with Art’s premise that we not be overly rigid. He wanted us to talk about situations we’ve encountered in our clinical practices that do not always meet full criteria for a DSM-5 diagnosis of posttraumatic stress disorder (PTSD) but nevertheless are concerning and warrant treatment.

Here is an example from a previous publication (1):

Dr. Brown, a 29-year-old resident in psychiatry, was referred to a psychiatrist for the following symptoms: unrelenting fluctuating anxiety, broken sleep, nightmares, intrusive imagery of a pistol being held to someone’s head, emotional lability, crying, and numbness. Her symptoms began 10 days earlier when she was seeing patients in the outpatient department of a teaching hospital. Suddenly she heard a loud angry voice coming from the waiting room. She excused herself and went into the hall where she witnessed a large man with a pistol in his hand yelling “Where is he? Where’s my doctor? I’m going to kill him! He’s been fucking with my mind!” Terrified, she ran back into her room, rang the help alert buzzer, and called hospital security. There was no lock on the door, but she and her patient barricaded the door with the desk and waited. Minutes felt like hours. The man kept yelling as he ran from office to office but no shots were heard. He did not attempt to enter her office. Soon she heard sirens and heard the voices of police officers. The patient was subdued, and no one was hurt. Dr. Brown was diagnosed PTSD and she responded nicely to medication and cognitive behavioral therapy.

Not all physicians will consult mental health professionals with such a classic or dramatic presentation. Anyone treating symptomatic medical students or residents is wise to remember that our trainees are subject to other clinical situations that they might find disturbing, especially when they are new to a service or are psychologically unprepared.

Examples might include: treating patients with mutilating injuries from high speed motor vehicle accidents, falls, or burns; assessing and treating battered infants; watching an amputation of a limb in the operating room; first exposure to an intensive care unit; assisting at an unsuccessful cardiac arrest, especially in a young or previously healthy patient; listening to the painful story of someone who has been brutally raped; witnessing the labored breathing of someone who is in pulmonary edema and who is fully conscious and terrified. These same patients may feel that they are not entitled to feel wobbly and disarmed by these exposures. Our interest, active listening, and empathy will soothe them a lot.

Given the research noting that 13% of residents meet diagnostic criteria for PTSD (20% of the women and 9% of the men) (2), it is essential that we diligently apply our biopsychosocial model to ensure diagnostic accuracy and broad-based treatment with our doctor-patients. Some will have a history of childhood trauma that has lain dormant and is reactivated in medical training or practice. Some will have comorbid conditions, especially mood and substance use disorders.

Medication alone is never enough but must always be combined with psychotherapy, especially cognitive behavior therapy, but also supportive psychotherapy. The two techniques of normalizing and validating are so helpful in traumatized physicians, given how commonly they try to minimize their symptoms or recoil from the associated shame. Group therapy, especially Balint groups, can be very effective for physicians living with and overcoming trauma. Couples therapy is an appropriate adjunct when the traumatic experience has compromised relationship communication, intimacy, and healthy function.

In my next piece, I will examine vicarious trauma in physicians, especially psychiatrists. 

References

1. Myers MF. The support and welfare of the student. In: Gask L, Coskun B, Baron D, eds. Teaching Psychiatry. London, UK: John Wiley & Sons; 2011:235.

2. Klamen DL, Grossman LS, Kopacz D. Posttraumatic stress disorder symptoms in resident physicians related to their internship. Acad Psychiatry.1995;19:142-149.

   Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.  

   The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.