When the Psychiatrist Has PTSD

Dr John Bradford of Ottawa, Canada, had a long, successful career as a forensic psychiatrist, spanning several decades. Bradford’s extensive experience with brutal people, such as sexual sadists and killers, led him to believe that he was resilient to trauma. The years of work, however, may have taken their toll. After watching highly disturbing video evidence of 2 women being assaulted as part of a high-profile case, Bradford began drinking excessively, and became depressed as well as suicidal.¹ Despite 2 years of initial denial, he ultimately sought treatment for PTSD and admirably now speaks out about his experience. Although he still practices, Bradford avoids cases that involve graphic videos. His example illustrates that even seasoned professionals may fall prey to PTSD, and the toughest psychiatrists are not immune.

Michael F. Myers, MD, Professor of Clinical Psychiatry in the Department of Psychiatry & Behavioral Sciences at SUNY Downstate Medical Center in Brooklyn, New York, spoke at the American Psychiatric Association (APA) meeting in Toronto, Canada, in May 2015. His presentation “PTSD in Psychiatrists: A Hidden Epidemic” underscored the under-recognition of this prevalent condition in those who treat mental health conditions and discussed methods for increased recognition of PTSD as well as its treatment.

[[{"type":"media","view_mode":"media_crop","fid":"28795","attributes":{"alt":"","class":"media-image media-image-right","height":"156","id":"media_crop_4141830503460","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4793","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"169"}}]]Ironically, mental health care providers may readily encourage their patients to confront psychiatric issues, but they are not always as willing to identify and address these problems in themselves, despite the frequent occurrence of PTSD in physicians. The lifetime prevalence of PTSD is between 8% and 9% in the general population, but is higher in physicians. For example, PTSD rates in physicians exposed to war range between 11% and 18% and are about 12% in those who practice emergency medicine.² It makes sense that the prevalence of PTSD would be high in psychiatrists as well, owing not only to frequent traumatic encounters with those who have serious psychiatric conditions, but also to the vicarious transfer of their patients’ experiences.

PTSD can strike at any professional stage, from the experienced psychiatrist such as Dr John Bradford, to physicians in training. In his talk at the APA meeting, Myers presented data from several studies that focused on medical students and PTSD. The hazing and overworking of medical students is a tradition that continues, possibly with the notion that extremely difficult conditions will prepare students for a doctor’s life. The practice may however come with a cost. According to one study, 73% of medical students reported witnessing or experiencing mistreatment.³ In another study, 13% of 212 residents met the diagnostic criteria for PTSD based on a standard questionnaire; women were more often affected (20%) than men (9%). Lack of social support increased the risk of PTSD.⁴

Myers cautioned that residents may experience PTSD because they are not psychologically prepared for the traumatic events they might witness.⁵ He discussed several clinical situations that could be disturbing to physicians in training, including observing severe injuries, treating battered infants, seeing amputations, or observing death in a young, healthy-seeming individual. Even being put-down and humiliated by a senior physician might trigger PTSD, something for traditionalists who think students need “toughening up” to consider.

According to Myers, circumstances that may precipitate PTSD include not only medical training but also traumatic events that took place before medical school. For example, immigrants who left war-torn countries or physicians who are specifically training to deal with traumatic situations may be vulnerable; military psychiatrists also may be particularly susceptible.

Adding to the list of those at risk provided by Myers, Dr Arthur Lazarus has identified several types of physicians who might be at elevated risk for PTSD.⁶ These include:

• Emergency physicians

• Physicians practicing in remote areas with limited medical services

• Physicians involved in malpractice litigation

• “Second victims,” physicians who are exposed to trauma via their patients

Certainly psychiatrists would fall under the last category and may be members of the other categories as well. Understanding who is at risk can help predict and assess symptoms of PTSD in susceptible individuals.

Identification is of course the first step; however, treatment is crucial for improvement in the lives of the individual psychiatrists, as well as for those they affect professionally and personally. But if PTSD in psychiatrists is so deeply buried because of denial and a lack of social acceptance, what can be done about this problem?

Myers suggests several tactics. First, the culture of medicine needs to change. Physicians in training can be better prepared for possibly upsetting situations through debriefing, normalizing, and learning to accept the events. New institutional attitudes are needed, specifically encouraging physicians with PTSD symptoms to come forward and seek help early. The stigma and belief system that views physicians as being bulletproof to PTSD needs to change. Finally, coworkers should realize that some physicians will live chronically with residual symptoms. Again, acceptance is a key to improving the situation.

For the psychiatrist treating a colleague with possible PTSD, Myers recommends getting buy-in as a first start: for example, “see whether your patient is in agreement” when suggesting possible PTSD, and ask how the symptoms are affecting that person’s ability to work. Reassurance that treatment is effective can be helpful, as well as noting that help through therapy or medication will positively affect the psychiatrist’s professional and personal life.

But what if you are the psychiatrist or mental health care professional with PTSD? Myers believes that the signs can be there, but as psychiatrists “there can be a certain amount of denial at first. We practice differently: we don’t listen as carefully; we shut the person down and reach for the prescription pad.” To these individuals, he evokes the adage “physician, heal thyself.” He suggests that psychiatrists should seek assistance and advice from a colleague and should not feel that they must abandon the profession. Treatment can actually maintain their ability to be effective psychiatrists.

Recognition naturally needs to be followed by treatment, including a complete assessment of PTSD symptoms as well as of comorbid symptoms. PTSD treatment may include medication, individual cognitive-behavioral therapy, and group therapy as needed. However, care does not stop at the individual with PTSD symptoms, since treatment of the family and marital therapy can also help. Balint groups-the presentation of clinical cases among physicians-help prepare people working together to deal with PTSD in psychiatrists specifically. Myers encourages the psychiatrist to “be an advocate and change maker.”

Indeed, for PTSD in psychiatrists and other mental health care providers to finally be addressed, a major shift in medical culture and thinking is needed. Psychiatrists will hopefully learn to recognize signs of PTSD in their colleagues and also in themselves. The condition exists in psychiatrists and may even be common, and it needs to be treated.

References:

1. Cobb C. “Tough forensic guy” John Bradford opens up about his PTSD. Ottawa Citizen. November 2013. http://www.ottawacitizen.com/health/Tough+forensic+John+Bradford+opens+about+PTSD/ 9152171/story.html. Accessed October 13, 2015.

2. Wilberforce N, Wilberforce K, Aubrey-Bassler FK. Post-traumatic stress disorder in physicians from an underserviced area. Fam Pract. 2010;27:339-343.

3. Heru A, Gagne G, Strong D. Medical student mistreatment results in symptoms of posttraumatic stress. Acad Psychiatry. 2009;33:302-306.

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

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

6. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30:131-134.