Psychological First Aid and Stress Injuries

Psychological First Aid and Stress Injuries

Laura McGladrey


Few responders travel through their careers without being deeply affected by a stressful event or experiencing the cumulative effects of responding in challenging environments. Few individuals who experience unexpected or overwhelming events in the wilderness will not be impacted by them. Unfortunately, psychological treatment in emergency situations is often neglected, both because it has not been felt to pose a threat to life and because emergency response personnel often feel ill-equipped in recognizing and mitigating psychological injuries. Often providers feel there is nothing to do to prevent psychological injuries, often referred to as stress injuries. A growing body of knowledge suggests the opposite is true. Stress injuries, like physical injuries, can be recognized and mitigated, with practical and accessible tools. Fortunately, for the remote provider, these tools can be practiced and utilized in all remote settings.

The concept of stress mitigation and treatment of psychological trauma is not new. Patients presenting with a number of disturbing psychological symptoms following combat stress in World War I (WWI) were said to have “shell shock.” Treatment consisted of treatment of patients near battle lines, where the din of battle could still be heard, and where soldiers could remain with their units, rather than returning home to peaceful surroundings of home. Indeed, it was found that those who returned home, or experienced delays in treatment, experienced longer lasting and more debilitating symptoms than those who were treated by military personnel who understood their plight and expected them to make a full recovery.1 The principals of treatment of stress injuries during WWI2 such as immediacy, treating patients as soon as possible following the injury, and proximity, treating in the environment in which they occurred, can still be seen reflected in the current recommendations of psychological first aid (PFA).

Field treatment during of psychiatric injuries continued throughout World War II (WWII). In 1944, a staggering 43 in every 1,000 admissions were related to psychiatric causes, compared with 86 per 1,000 for physical injuries3 in WWII. The concept of forward treatment of psychiatrically wounded soldiers was again adopted,4 with soldiers maintained in field hospitals for the first 7 days following the stress injury, rather than being evacuated to long-term treatment away from combat.

The Vietnam war saw continued implementation of the previously developed treatment strategies, such implementing forward treatment of casualties in the war zone, with a resulting lower rate of psychological injuries (11 in 1,000) in combat; however, the lasting effects of psychological trauma were pervasive and devastating among returning veterans. It is estimated that almost a quarter of those who served in Vietnam from 1964 to 1972 required some form of psychological help on return.4 A more recent study demonstrated that four out of five Vietnam Veterans reported symptoms of posttraumatic stress disorder (PTSD) when interviewed 20 to 25 years afterward.5 This phenomenon suggested that more was needed to protect soldiers from stress injuries, and fueled the pursuit of approaches to preventing and treating stress injuries that exist today.

Early models of PFA, as it exists today, began to emerge in the 1980s, with many of the components first discussed in the literature—such as the need for social support, caring for physical needs, and allowing individuals to express their feelings—still utilized today.6 Around the same time, growing effort to address traumatic exposure in emergency medical personnel first took shape as mandatory gatherings referred to as critical incident stress debriefing (CISD). These debriefings were typically initiated when a group of providers had been through an incident that was deemed a “powerful and overwhelming event that lies outside the range of usual human experience”7 thought to hold the potential
to cause psychological harm to the participants. Responders were asked to recount aspects of the event that were particularly troubling to them. Many found this helpful; however, there was growing concern that, while these gatherings did address the issues of the provider witnessing traumatic situations, research began to reflect that they might not be helpful in prevention of stress injury, particularly the mandatory recounting of traumatic details. In 2002, a review of the literature revealed that while several studies demonstrated improvement in stress-related injury, other studies demonstrated no effect in outcome, and even more troubling, two studies demonstrated worsening in outcomes of stress-related symptoms following CISD.8

Out of this concern, the world’s experts on psychological trauma and its mitigation gathered to explore elements of intervention that were confirmed to be helpful in reducing symptoms of stress injuries following traumatic exposures. In 2007, Hobfoll and colleagues recommended five broad, evidenced-based treatment principles that became the cornerstone of a new psychotherapeutic technology, now known as PFA.9 These recommendations include promoting a sense of safety, calm, sense of collective and individual self-efficacy, connectedness and hope serving as a foundation for the majority of recommendations, and programs related to PFA.10

In 2006, the first PFA manual was created by the National Child Traumatic Stress Network (NCTSN) and the National Center for Post-Traumatic Stress Disorder (NCPTSD),11 and now serves as a foundation for other PFA in specific populations, such as combat veterans (Combat and Operational Stress First Aid), fire and rescue (Stress First Aid), schools (PFA-S), and is incorporated by the Red Cross, the Federal Emergency Management Agency (FEMA), and the World Health Organization (WHO) for use in disaster settings.12 PFA is now being taught to wilderness medicine providers. NOLS Wilderness Medicine is now one of several wilderness medicine schools to incorporate treatment of stress injuries into their curriculum.

This chapter discusses stress injuries across the continuum. There are two distinct issues surrounding stress injuries. The first will describe injuries in formation that may be mitigated by PFA, and the second, treatment of presentations related to already formed injuries, and the expression of troublesome reactions that interfere with wilderness travel and expedition behavior. Finally, attention will be given to recognition, support, and prevention of stress injuries in the responder.


The human machine is designed for stress. Stress is the foundation of human growth and survival. Everyone experiences stress throughout their lifetime; most overcome stressful situations and grow from them. According to the NCPTSD, an estimated 6.8% of the adult population in the United States will experience PTSD during their lifetime,13 despite the fact that a majority of individuals in the United States report at least one lifetime stressful incident.14 This implies that most who encounter overwhelming events in their lifetime will not suffer long-term or debilitating effects.

A question resounds among those studying stress injuries:15 Why do some who experience overwhelming events, go on to develop stress injuries, and some, who have experienced the same types of stressors, are never again bothered by symptoms, or even more interesting, thrive because of their experiences? There is no short answer to this human mystery. What is clear is that multiple factors work in congress to protect or predispose a person to stress injury.

It is now clear that vulnerabilities in existence prior to the provoking event, such as earlier traumatic events, genetic and neuroendocrine factors, and family or personal history of mental health disorders sensitize the brain to development of stress injuries in the presence of overwhelming stress. Contributing to each individual’s expression of stress injury will be the confluence of the magnitude of the stressor, how prepared the individual was for the event (financial and emotional resources with contingency for disastrous or catastrophic stressor), and the available support during the initial period immediately following the disaster. Initial response to the trauma (dissociation, activation, or coping responses and participation with one’s own rescue), as well as the post-trauma factors (severity of reaction, availability of social support, and existence of other life stress) work in conjunction to determine the level of each individual’s ongoing distress.16

At the foundation of every stress injury is an event or a stressor that overwhelms the patient’s ability to integrate it. Each person will experience a stressor with a unique landscape and capacity to respond, requiring flexibility and receptivity of the responder, given that no two people will respond to stressful events in the same way.

Signs and Symptoms of Stress Injury

The Diagnostic and Statistical Manual-V describes that the foundation for the most commonly diagnosed stress injury, PTSD, must include a stressor. Specifically identified stressors in DSM-V include death or threatened death, actual or threatened serious injury, and actual or threatened sexual violence.17 The stressor may be subtle, dramatic, or perhaps even a part of one’s routine work responsibility. Stressors can occur as one overwhelming or horrific event, or continuous, insidious exposure to troubling stories or experiences that occur routinely in the course of one’s work experiences, as is often the case of emergency medical service (EMS) providers and military personnel. The DSM-V criteria do not distinguish between personal experience of the stressor and exposure to an experience by someone to whom one feels an emotional connection; both cause a stress injury.

In plain terms, trauma can happen to someone else and still cause stress injury. This includes directly experiencing the stressor, personally witnessing the stressor happening to another, or indirectly experiencing the stressor, for instance, learning that a friend or close relative was injured, killed, or exposed to trauma. Now recognized is the fourth means of experiencing the stressor: repeated or extreme exposure to aversive details of events, usually in the course of professional duties. This could include the park ranger who, as part of her duties, must routinely participate in body recovery and informing next of kin of the news of a loved one’s death.

The description of reactions to stress is clinically categorized into four reaction types: intrusive symptoms, avoidance, alterations in cognition and mood, and alternations in arousal and reactivity. More subtle expressions of stress injury are sometimes left unrecognized.

Intrusive symptoms are likely the most apparent to the outside observer, and those most likely to be identified and associated with PTSD. Reminders of previous trauma retain their capacity, sometimes for months or years after an event, to elicit panic, dread, terror, grief and despair, and the physiologic symptoms that accompany them. Graphic nightmares and vivid daytime images that come without warning, as well as the feeling that one is experiencing the event again in the present (flashback), all intrude on the individual and may interfere with daily activities. Benign sensory reminders of the event, such as the faint smell of smoke in the air, the gathering of thunderclouds overhead, or the sound of rustling outside a tent have the power to evoke mental images, physical sensations, and emotions that were experienced at the time of an overwhelming event.

Reactions of avoidance are the actions an individual takes to avoid reexperiencing the sensations, feelings, and emotions associated with the trauma. For some, this can be subtle or elaborate efforts to reduce the chance of encountering trauma-related stimuli (reminders of trauma). This may include avoiding conversations, situations, people, or activities that serve as reminders. The climbing guide who experienced a terrifying avalanche may convince himself that he no longer likes to ski in an effort to avoid being in a situation that feels similar to the conditions on the day of the avalanche. The EMS provider who responded to a gruesome accident involving a child may respond by wanting to spend less time or avoiding spending time with the children in her life. When avoidance is extreme, it may limit one’s ability to leave the house, work, or live a productive or enjoyable life.

Negative alternations in cognition and mood demonstrate that PTSD is distinct from anxiety disorders, in that the effects of traumatic stressor also alter the individual’s view of themselves and the world around them. This change in world view, for example, a new belief that the world is no longer a safe place, can create persistent thought patterns that change the way one looks at the world after exposure to a traumatic stressor. These reactions are most synonymous with those of depression, including decreased interest in things once enjoyed, isolation, guilt, negative self-beliefs, or contorted beliefs about the event (“this is all my fault”). Persistent moods such as anger, irritability, sadness, and hopelessness are often associated. Concentration and memory can be affected, with decreased ability to concentrate or inability to recall the specific details of the event. Distorted appraisal of the cause of the event, or the bleakness of the future, is not uncommon. A survivor of a serious climbing accident may fixate on the belief that she should have or could have prevented the accident, and that she is not competent to continue her work. Often accompanying this is the feeling of being detached or separate from others, or not able to express positive emotions such as love, joy, or pleasure. It is easy to imagine how this restricted affect would sabotage one’s ability to sustain satisfying work life, marriage, close relationships, and family connections.

Alterations in arousal and reactivity arise from one constantly waiting and anticipating the re-occurrence of the event that one dreads. These reactions are similar and indeed could be mistaken for symptoms of general anxiety or panic disorder, if not for the fact that the symptoms arise as a result of stress injury. Exaggerated startle response and always being “on edge,” searching for exits, or creating “what if ” scenarios all reflect a state of constant arousal and watchfulness that again interferes with one’s ability to enjoy the moment or relax. When a reminder does trigger a reaction, physical reactions of heart racing, sweating palms, difficulty breathing, and shaking can occur immediately and often persist. Hypervigilance, or the constant watching of the environment for escape routes and things that may cause harm, become so intense that it may be mistaken for paranoia.

Behaviors that result from the persistent emotional states described above have been added to the national conversation on stress injury via the DSM-V. These behaviors are often highly risky or self-destructive behaviors such as unsafe sex, reckless driving, or suicidal behaviors. Increased anger and irritability are known to lead to aggression, especially for those whose trauma involves violence, such as combat veterans and law enforcement. The diagnosis of PTSD is often accompanied by comorbid diagnosis, such as substance abuse, depression, anxiety, or other mental health diagnoses.18

It is not uncommon for rescuers to encounter an individual, who, in addition to incurring physical injuries at the scene of an accident, may have already been overwhelmed by reminders of previous trauma when the current trauma occurred. Hyperarousal, hypervigilance, irritability, aggression avoidance, and reexperiencing may all confuse the initial presentation of the individual. Rescuers will do well to engage a high level of clinical curiosity when clusters of the above reactions accompany physical injuries. The helpless feeling that often accompanies the experience of becoming a patient may be all that is needed to trigger the stress response. Rescuers must consider their own safety when encountering a patient who is reexperiencing trauma. Treatment and prevention of PTSD and stress injuries are discussed later in the chapter.

Stress Injury Formation

Under normal circumstances, a stressor signals a cascade of hormonal, behavioral, and emotional responses via the autonomic nervous system and physical responses. The rescuer who suddenly encounters a bear on the trail will likely experience immediate elevation of heart and respiratory rate, fear, and may begin running away, all before the “thinking” aspect of the brain, the cortex, has time interpret or consider what has occurred. These “subcortical” responses, such as sympathetic nervous system stimulation, allow for action and rapid resolution of the crisis.

When a rescuer experiences that the danger has passed, either because the rescuer escapes the bear, or, on second glance, discovers it was not a bear at all, the brain releases an “all clear” signal to the body. This sets off a separate set of chemical mediators to stimulate the parasympathetic nervous system, responsible for slowing heart rate and reestablishing the baseline or pre-arousal state. This state effectively communicates to the body and brain that the threat has passed.

How, then, are stress injuries formed? Much like physiological vulnerabilities that set the stage for overwhelming infection or injury (eg, the elderly diabetic who is more likely to succumb to a urinary tract infection than a healthy teenager), there are genetic, social, and historical factors that contribute to setting the stage for stress injuries. Stress injuries are formed when a stressor or series of stressors overwhelms the person experiencing its capacity to integrate it or make sense of it. The injury often occurs in association with a sense of helplessness, when an individual is not able to respond or defend themselves with definitive actions. Commonly in the remote setting, isolation and prolonged distance from definitive care contributes to a sense of helpless. As discussed previously, individuals who have previously encountered trauma are often sensitized to interpret benign cues as harmful and have already established brain pathways to respond to stressors. When the stressor is introduced, the same protective pathways of hyperarousal are cued, with the resulting signals to the fight or flight system, and initiation of action. All the sensory input stored at the moment of the event is captured, as if on camera. The sights, sounds, smells, and sensations of that moment are imprinted in the brain’s memory, and will later likely become the triggers to tell the nervous system that the stressor may be reoccurring.

What distinguishes stress injury formation from the adaptive response discussed above also includes the failure of the “all clear signal,” alerting the body that the threat has passed. Individuals may continue in the same hyperaroused and hypervigilant state for days or weeks. Indeed, research has demonstrated that those who have elevated resting heart rates one week after the event are more likely to develop symptoms of PTSD.19 This ongoing state of hyperarousal demonstrates that the brain has not registered that the danger has passed, and the individual continues to live in a state of persistent threat and readiness for action. The individual has now established the neurobiological groundwork to respond immediately to any future cues that resemble those associated with the initial event. Smells, sights, sounds, internal states, even elevated heart rate, thoughts, and emotions may all trigger the brain to initiate the same levels of arousal and preparedness for action this time without any real evidence of danger. This is seen in the WEMS helicopter crew member who experiences his heart racing, difficulty concentrating, and excessive worry each time he is in a helicopter taking off on a clear autumn day. Though no clear danger exists in the present moment, the recall of a near miss on a clear day in autumn in a previous year will still signal the brain to ready for danger.

It is important to note that some events are so overwhelming, or the feeling of helplessness so great, that some individuals will experience a phenomenon where the fight or flight response system itself is overwhelmed and a “system shutdown” is initiated. The nervous system or brain causes a slowing of vital processes, such as heart rate and respiratory rate. The individual may look as if they are in shock and be minimally responsive or confused. This state of “overwhelm” is associated with a more serious presentation of ongoing stress injuries, and referral to higher level of care when appropriate should always be the priority.

Anyone can experience a stress injury if the stimulus is sufficiently overwhelming. Still, it is a curious phenomenon that two people can witness the same event and have widely different reactions to it. This should be instructive to providers to anticipate the possibility of stress injury formation, but also to respect and support those who truly deny reactions to what the rescuer may consider a traumatic event or situation.


To discuss the treatment of stress injuries, it is important to discuss the trends in language used to describe these conditions. Rather than semantics, these terminology and language changes represent a significant alteration in perspective and treatment priorities and as discussed below, changing the language may eventually influence the treatment of a stress reaction.

Current Language of Stress Injuries

The discussion of stress-inducing injuries is shifting away from descriptions such as “trauma” and “traumatized” to “stress injuries.” Symptoms are now better described as reactions. In this context, it may be preferential to refer to those having dysphoric reactions
to stress as “patients” or “survivors” rather than “victims.” This discussion has been in the pipeline for more than a decade, and the Inter-Agency Standing Committee (IASC), the primary mechanism for humanitarian response globally, has encouraged disaster workers responding to psychologically overwhelming events to change the way they refer to the individuals they are serving.20 Intrinsic in the words “traumatized” and “victim” is the helplessness projected on those to whom something has happened. Words such as “overwhelmed” and “survivor” normalize and empower. Indeed, suggesting a normalized adaptive response to stress with the word “reaction” is preferable to pathologizing the stress response with the word “symptoms.” In other words, a healthy person has a “reaction”; a sick person has a “symptom.” Reflect again that while the reactions may be interfering with one’s ability to function in a preferred way, the underlying mechanism remains incredibly adapted for survival. This, too, should be reflected to the patient to deflect the shame and isolation that often accompanies stress injuries. Changing the way rescue personnel discuss and treat these injuries will indeed be instrumental in changing the culture of stigma and avoidance often associated with stress injury. See Table 10.1 for examples of recommended language.

Treatment Principles for Acute Behavioral Exacerbations Related to Stress

Acute exacerbations of previous stress injuries may present with extremes of panic, dissociation, reexperience of the stressor, agitation, and dramatic mood presentations. These conditions may require advanced care. Principles of PFA will be discussed below and are often appropriate to help reduced fear, anxiety, and agitation in the presence of preexisting stress injuries. In the remote setting, it may be most helpful to treat each presenting reaction when behaviors are extreme. Acute agitation, panic, self-harm, or extremes of mood are examples of extreme behavioral reactions, and are expressed in detail in Chapter 23.

Table 10.1 Recommended Terminology for Working With Stress-exposed Persons

Recommended Terminology

Commonly Used Terminology





Psychological and social problems


Terrifying/life-threatening/horrific events/devastation

Traumatic events

Reactions to difficult situations Signs of distress Problems


Reactions to difficult situations Signs of distress Problems

Traumatized children or traumatized adults

Structured activities, community social support

Therapy, Counseling, Treatment



From Inter-Agency Standing Committee. Guidance Note for Mental Health and Psychosocial Support. Port of Prince, Haiti: IASC; 2010.

However, the management of PTSD deserves special attention in the context of PFA. PTSD remains difficult to treat once symptoms are well established, and the use of polypharmacy to target all accompanying symptoms is common. Theoretically, support for basic physiologic needs, sense of safety, and assurance of safety, connection with care providers or people important to them should all be initiated as soon after the onset of incident as possible. A multitude of pharmacologic interventions have been proposed; however, no clear evidence-based recommendations have been made for pharmacological interventions preventing chronic symptoms of stress injury. This continues to be an important area of study. Among the multitude of PTSD symptoms, symptoms of hyperarousal and mood (irritability, anger, and depression) are most likely to improve with medication.

Given intensive resources and the time needed for therapeutic first-line treatment modalities of PTSD such as treatment-focused trauma therapy, field treatment of existing PTSD is not realistic. The PFA principles discussed below will support stabilization. Specific medications such as venlafaxine (Effexor) and sertraline (Zoloft) are considered to be the most effective SSRI/SNRIs in their treatment class.21 However, response to medication requires up to 4 to 6 weeks to reach full affect, and some will experience debilitating side effects such as increased anxiety, increased suicidal thoughts and insomnia, making them unsuitable for treatment to be initiated.

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Oct 16, 2018 | Posted by in EMERGENCY MEDICINE | Comments Off on Psychological First Aid and Stress Injuries

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