Work outcomes in public safety personnel after potentially traumatic events: A systematic review.

BACKGROUND: It is well documented that public safety personnel are exposed to potentially traumatic events (PTEs) at elevated frequency and demonstrate higher prevalence of trauma-related symptoms compared to the general population. Lesser studied to date are the organizational consequences of workplace PTE exposure and associated mental health outcomes such as acute/posttraumatic stress disorder (ASD/PTSD), depression, and anxiety. METHODS: The present review synthesizes international literature on work outcomes in public safety personnel (PSP) to explore whether and how PTE and trauma-related symptoms relate to workplace outcomes. A total of N = 55 eligible articles examining PTE or trauma-related symptoms in relation to work outcomes were systematically reviewed using best-evidence narrative synthesis. RESULTS: Three primary work outcomes emerged across the literature: absenteeism, productivity/performance, and costs to organization. Across n = 21 studies of absenteeism, there was strong evidence that PTE or trauma-related symptoms are associated with increased sickness absence. N = 27 studies on productivity/performance demonstrated overall strong evidence of negative impacts in the workplace. N = 7 studies on cost to organizations demonstrated weak evidence that PTE exposure or trauma-related mental health outcomes are associated with increased cost to organization. CONCLUSIONS: Based on available evidence, the experience of workplace PTE or trauma-related symptoms is associated with negative impact on PSP occupational functioning, though important potential confounds (e.g., organizational strain and individual risk factors) remain to be more extensively investigated.

Methodological correlates of variability in the prevalence of posttraumatic stress disorder in high-risk occupational groups: A systematic review and meta-regression.

BACKGROUND: Although numerous studies have reported on PTSD prevalence in high-risk occupational samples, previous meta-analytic work has been severely limited by the extreme variability in prevalence outcomes. METHODS: The present systematic review and meta-regression examined methodological sources of variability in PTSD outcomes across the literature on high-risk personnel with a specific focus on measurement tool selection. RESULTS: The pooled global prevalence of PTSD in high-risk personnel was 12.1% [6.5%, 23.5%], and was similar to estimates obtained in other meta-analytic work. However, meta-regression revealed that PTSD prevalence differed significantly as a function of measurement tool selection, study inclusion criteria related to previous traumatic exposure, sample size, and study quality. PTSD prevalence estimates also differed significantly by occupational group and over time, as has also been reported in previous work, though exploratory examination of trends in measurement selection across these factors suggests that measurement strategy may partially explain some of these previously reported differences. CONCLUSIONS: Our results highlight a pressing need to better understand the role of measurement strategies and other methodological choices in characterizing variable prevalence outcomes. Understanding the role of methodological variance will be critical for work attempting to reliably characterize prevalence as well as risk and protective factors for PTSD.

Hastening Death in Canadian ICUs: End-of-Life Care in the Era of Medical Assistance in Dying.

OBJECTIVES: Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying. DESIGN: Electronic survey. SETTING: Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation. PARTICIPANTS: We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies. CONCLUSIONS: Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.

PREVALENCE AND PREDICTORS OF POSTTRAUMATIC STRESS DISORDER, DEPRESSION, AND ANXIETY IN PERSONNEL WORKING IN EMERGENCY DEPARTMENT SETTINGS: A SYSTEMATIC REVIEW.

BACKGROUND: Professionals working in the emergency department (ED) are regularly exposed to traumatic events. Rates of posttraumatic mental health conditions vary widely in the literature and there is no agreement that rates in ED staff are elevated relative to other populations. OBJECTIVE: We conducted a systematic review of international literature reporting prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety in ED personnel to determine whether prevalence is elevated compared to the general community, and to evaluate convergent evidence across the literature for predictive factors. To our knowledge, there is no comprehensive review on this topic in the literature at this time. METHODS: Seven databases were searched for studies reporting rates of PTSD, depression, and anxiety in ED personnel. Two independent researchers screened studies and assessed quality using Munn's Prevalence Critical Appraisal Instrument. Best-evidence synthesis determined whether conditions demonstrated elevated prevalence compared to the general population of Canada, a conservative benchmark. RESULTS: Twenty-four studies from 12 countries and a combined sample size of 4768 were included. PTSD rates ranged from 0% to 23.6% (mean 10.47%), depression ranged from 0.7% to 77.1% (mean 24.8%), and anxiety rates ranged from 2.4% to 14.6% (mean 9.29%). Each condition was elevated compared to the general population. Sociodemographic variables were not consistent predictors. Elevated PTSD seemed most strongly related to workplace exposure and maladaptive coping. CONCLUSIONS: ED professionals have an elevated risk of experiencing PTSD, depression, and anxiety. Identification of organizational and workplace predictors are needed to inform interventions that will reduce risk and provide optimal treatment and management of PTSD, depression, and anxiety in ED settings.

The prevalence of PTSD, major depression and anxiety symptoms among high-risk public transportation workers.

OBJECTIVE: Public transportation workers are exposed to higher levels of stress related to accidents, injuries, and person-under-train events when compared to other workers. This systematic review integrates the existing literature on mental health among high-risk public transportation workers to estimate the prevalence of post-traumatic stress disorder (PTSD), major depressive and anxiety symptoms following critical incidents while on duty. METHODS: This systematic review is part of a larger systematic review which examines mental health and work outcomes of individuals working in professions at high risk of critical incident exposure, i.e., high-risk professions. Articles were included if they measured the prevalence of PTSD, Major Depressive Disorder (MDD) and Anxiety Disorder (AD) in a transportation population following exposure to a major incident, for example, a person-under-a-train. RESULTS: Among the ten articles, all reported prevalence of PTSD which ranged from 0.73 to 29.9%. Four articles reported prevalence of depression among transportation workers exposed to a critical incident and prevalence outcomes ranged from 0.05 to 16.3%. Only two reported prevalence of anxiety from 1.3 to 13.9%. CONCLUSIONS: This literature reports that transportation workers are prone to involvement in traumatic accidents leading to higher rates of PTSD compared to the general population. Strategies to reduce transportation accidents and to provide transportation workers follow-up mental health support is needed for this vulnerable population.

Social anxiety and the acquisition of anxiety towards self-attributes.

The current studies examined whether self-attributes can come to elicit anxiety after being paired with negative evaluation. Results from Study 1 suggested that appearing unintelligent and appearing nervous were partially distinct attributes of concern related to social anxiety and validated stimuli used in the subsequent study. In Study 2, participants completed a differential associative learning task in which either words related low intelligence or appearing nervous were paired with negative evaluation. Results suggested that participant anxiety and expectancy ratings increased for words belonging to the attribute category paired with negative evaluation but not the other. Participant social anxiety was not associated with the effects.

Retrieval-induced forgetting in a social task.

Clinical researchers suggest that post-event thinking functions to negatively bias event recall for socially anxious participants. We used a repeated retrieval paradigm to examine the effects of post-event retrieval on memory for social information. Undergraduate participants (n = 214) engaged in an impromptu public speaking task and received a standardised mixture of positive and negative feedback on their speech. Participants in the experimental condition were instructed to repeatedly retrieve the negative feedback items whereas participants in the control condition completed a control task. Both groups were asked to recall the feedback after five minutes and after one week. Results indicated that the experimental group displayed the hypothesised retrieval-induced forgetting effect. In addition, repeated retrieval predicted valence change in that participants recalled the non-retrieved positive feedback items less positively over time. The retrieval-practice effects were distinct from self-reported post-event processing. Contrary to clinical theories, social anxiety did not moderate retrieval-induced forgetting or recall bias. Instead, all participants displayed retrieval-related negatively biased recall.

Systematic review of posttraumatic stress disorder in police officers following routine work-related critical incident exposure.

BACKGROUND: The prevalence of PTSD in police officers has been the subject of a large and highly variable empirical literature. The present systematic review evaluates the extant literature on PTSD in police officers using an international dataset. METHODS: We employed best-evidence narrative synthesis to evaluate whether PTSD prevalence in police is elevated in comparison to the general population of Canada (8%), which itself has a higher lifetime PTSD prevalence than many other regions and thus serves as a conservative standard of comparison. RESULTS: PTSD prevalence in police varied considerably across studies from 0% - 44% (M = 14.87%, Median = 9.2%). Despite this variability, strong evidence exists to suggest PTSD prevalence is elevated in police officers. Examination of possible sources of variability in prevalence outcomes highlighted substantial variability in outcomes due to the selection of measurement tool for assessing PTSD (e.g., DSM vs. IES). Examination of commonly-assessed predictive factors for PTSD risk across the literature showed that individual-difference factors (e.g., age, years of service) bear weak-to-nonexistent relationships with PTSD risk, while incident-specific factors (e.g., severity of exposure) are more strongly and consistently associated with PTSD prevalence. Organizational factors (e.g., low support from supervisor) are at present understudied but important possible contributors to PTSD risk. CONCLUSIONS: PTSD prevalence is elevated in police officers and appears most strongly related to workplace exposure. Measurement variability remains a critical source of inconsistencies across the literature with drastic implications for accurate detection of officers in need of mental health intervention.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives.

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Positive affect predicts avoidance goals in social interaction anxiety: testing a hierarchical model of social goals.

Models of self-regulation suggest that social goals may contribute to interpersonal and affective difficulties, yet little research has addressed this issue in the context of social anxiety. The present studies evaluated a hierarchical model of approach and avoidance in the context of social interaction anxiety, with affect as a mediating factor in the relationship between motivational tendencies and social goals. This model was refined in one undergraduate sample (N = 186) and cross-validated in a second sample (N = 195). The findings support hierarchical relationships between motivational tendencies, social interaction anxiety, affect, and social goals, with higher positive affect predicting fewer avoidance goals in both samples. Implications for the treatment of social interaction anxiety are discussed.

A comparison of coping and safety-seeking behaviors.

BACKGROUND AND OBJECTIVES: Safety behaviors display some similarities to coping behaviors, raising questions about whether the two sets of behaviors display distinct associations with anxiety symptoms. DESIGN AND METHOD: To examine this issue, we conducted two cross-sectional studies in which participants (n = 243 and 157) completed measures of the safety behaviors associated with social anxiety disorder (SAD) and generalized anxiety disorder (GAD), the Brief Ways of Coping Scale (BWOC), and SAD and GAD symptom measures. In Study 1, extant safety-behavior and coping measures were used. In Study 2, the measures were modified so that they followed the same format and instructions. RESULTS: Both studies indicated that the safety behavior measures displayed strong positive associations with their respective symptoms, as did several dysfunctional coping strategies, most notably wishful thinking. CONCLUSIONS: These findings provide preliminary empirical support for the conceptual distinction between safety behaviors and coping, and suggest that assessing both concepts provide a nuanced understanding of responding to anxiety-evoking situations.Highlights• Safety-seeking strategies and coping behaviors have striking similarities• We conducted two studies to compare extant measures of the two constructs• Participants were able to distinguish the two set of behaviors• Both safety behaviors and dysfunctional coping were associated with anxiety symptoms.

Influencing emotion: Social anxiety and comparisons on Instagram.

Individuals with social anxiety are sensitive to social hierarchies and tend to compare themselves unfavorably with others, perceiving themselves as inferior or lower in social rank. The current study explores patterns of change in these negative perceptions, and their associated emotional outcomes, in an online social context. Undergraduate students (N = 291) browsed the profiles of eight Instagram influencers and completed a measure of social comparison after viewing each profile, yielding multiple ratings of their own perceived social rank. Participants completed measures of affect and state self-esteem before and after the profile browsing task. Higher social anxiety predicted lower, and greater declines in, social rank self-perceptions during browsing. Higher social anxiety also predicted greater decreases in positive affect, increases in negative affect, and decreases in state self-esteem from the beginning to the end of the browsing task. Low baseline rank perceptions contributed to change in all three emotional variables. Decreases in rank perceptions contributed further to decreases in positive affect and appearance-related self-esteem. This study elaborates on cognitive-evolutionary theory, suggesting that the inferiority self-perceptions of socially anxious individuals translate to online social contexts, may be strengthened with increased exposure to such contexts, and may have a detrimental emotional impact. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mental Disorders in Firefighters Following Large-Scale Disaster.

Firefighting service is known to involve high rates of exposure to potentially traumatic situations, and research on mental health in firefighting populations is of critical importance in understanding the impact of occupational exposure. To date, the literature concerning prevalence of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) has not distinguished between symptomology associated routine duty-related exposure and exposure to large-scale disaster. The present systematic review synthesizes a heterogeneous cross-national literature on large-scale disaster exposure in firefighters and provides support for the hypothesis that the prevalence of PTSD, major depressive disorder, and anxiety disorders are elevated in firefighters compared with rates observed in the general population. In addition, we conducted narrative synthesis concerning several commonly assessed predictive factors for disorder and found that sociodemographic factors appear to bear a weak relationship to mental disorder, while incident-related factors, such as severity and duration of disaster exposure, bear a stronger and more consistent relationship to the development of PTSD and depression in cross-national samples. Future work should expand on these preliminary findings to better understand the impact of disaster exposure in firefighting personnel.

Social anxiety and social norms in individualistic and collectivistic countries.

BACKGROUND: Social anxiety is assumed to be related to cultural norms across countries. Heinrichs et al. [2006: Behav Res Ther 44:1187-1197] compared individualistic and collectivistic countries and found higher social anxiety and more positive attitudes toward socially avoidant behaviors in collectivistic rather than in individualistic countries. However, the authors failed to include Latin American countries in the collectivistic group. METHODS: To provide support for these earlier results within an extended sample of collectivistic countries, 478 undergraduate students from individualistic countries were compared with 388 undergraduate students from collectivistic countries (including East Asian and Latin American) via self-report of social anxiety and social vignettes assessing social norms. RESULTS: As expected, the results of Heinrichs et al. [2006: Behav Res Ther 44:1187-1197] were replicated for the individualistic and Asian countries, but not for Latin American countries. Latin American countries displayed the lowest social anxiety levels, whereas the collectivistic East Asian group displayed the highest. CONCLUSIONS: These findings indicate that while culture-mediated social norms affect social anxiety and might help to shed light on the etiology of social anxiety disorder, the dimension of individualism-collectivism may not fully capture the relevant norms.

Social anxiety disorder: questions and answers for the DSM-V.

BACKGROUND: This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues. METHOD: A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V. RESULTS/CONCLUSIONS: Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

Pathways to intrusive memories in a trauma analogue paradigm: a structural equation model.

BACKGROUND: Structural equation modeling was used to develop and test an integrated model of how emotional and cognitive factors contribute to the development of intrusive memories after a distressing event. METHODS: The emotional constructs included preexisting emotion and emotional reactivity to the distressing event. Cognitive constructs included peritraumatic cognitive processing and maladaptive coping strategies. RESULTS: Using a prospective design, 148 undergraduate students viewed a distressing film and recorded their film-related intrusive memories over the following week. RESULTS: The results indicated that emotional reactivity and, to a lesser extent, preexisting emotion, predicted peritraumatic cognitive processing during the film, which in turn predicted the use of maladaptive coping strategies (i.e., rumination, thought suppression, and safety behaviors). Furthermore, emotional reactivity and maladaptive coping strategies directly predicted intrusive memories. CONCLUSIONS: The observed model supported the importance of cognitive variables central to cognitive models, placing them in a broader context.

Social anxiety disorder and memory for positive feedback.

Clinical theorists postulate that individuals with social anxiety disorder (SAD) display memory biases such that recall of social events becomes more negative with time; however, alternative memory models have also been proposed. Research has focused predominantly on selective recall of negative information with inconsistent findings. The goal of the current study was to examine potential biases in recall of positive social feedback. Individuals with SAD (n = 59) and nonanxious community controls (n = 63) engaged in an unexpected public speaking task and received standardized positive or neutral feedback on their speech. Participants were asked to recall the feedback after 5 minutes and after 1 week. Results indicated that at delayed recall, individuals with SAD recalled positive feedback as less positive than it had been. The findings support cognitive models of SAD and extend the model to positive social information. Research is needed to understand the mechanisms that underlie fading positivity. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Social rejection in social anxiety disorder: the role of performance deficits, evoked negative emotions and dissimilarity.

OBJECTIVES: Patients with social anxiety disorder (SAD) not only fear social rejection, but accumulating evidence also shows that they are indeed less liked than their non-anxious counterparts. Three factors are hypothesized to play a role in this social anxiety-social rejection relationship: (1) social performance; (2) elicited negative emotions, and (3) perceived similarity. METHOD: Patients with SAD (N=63) and control participants (N=27) were observed during a 5 minutes 'getting acquainted' conversation with a male and female confederate who rated their social performance. Video-observers rated their own negative emotions and perceived similarity with the patients, while other video-observers rated their wish to engage in future contact with them (a measure of social rejection). RESULTS: Analysed by way of structural equation modelling (SEM), the results supported the social anxiety-social rejection relationship. More specifically, poor social performance was associated with perceived dissimilarity ratings and mediated by evoked negative emotions, both of which were in turn associated with social rejection. CONCLUSION: These results suggest that a sequence of events links social anxiety to social rejection. Treatment should aim to improve social performance and perceived similarity to reverse SAD's vicious, negative interpersonal cycle.

The effects of direct versus witnessed threat on emergency department healthcare workers: implications for PTSD criterion A.

We compared post-traumatic stress disorder (PTSD) symptom severity and symptom cluster profiles in hospital emergency department (ED) medical staff (N=100) who experienced an emotionally distressing work event that presented either a direct threat to themselves or a witnessed threat to patients. The two groups displayed similar levels of PTSD symptoms, however, they differed on symptom profiles and work consequences. The direct threat group experienced significantly greater fear during the event, more ongoing arousal symptoms, and more job dissatisfaction than the witnessed threat group. The witnessed threat group was more likely to appraise their PTSD symptoms as reflecting personal weakness. Overall, the results point to the need for further research to identify distinctive features of responses to different types of traumatic stressors.

Social anxiety and the interpretation of positive social events.

We report four independent studies that examined the relationship between social interaction anxiety and the tendency to interpret positive social events in a threat-maintaining manner. Study 1 described the development of a scale that measures negative interpretations of positive social events, the interpretation of positive events scale (IPES). Study 2 cross-validated the structure of the IPES and established that social interaction anxiety explained significant variance in negative interpretations of positive social events beyond negative affect in general. Study 3 demonstrated that negative interpretation of positive events was significantly greater in a clinical sample of patients with generalized social anxiety disorder (GSAD) than a matched group of non-anxious community controls. In addition, within the GSAD group, the IPES was associated with negative social predictions following a positive interaction. Finally, study 4 confirmed that negative interpretations of positive social events mediated the relationship between social interaction anxiety and low positive affect.