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Over the past 2 decades, there has been increased awareness of the consequences of exposure to tragic and gruesome events in emergency-service work and the potential for traumatic stress symptoms. For instance, 30% of ambulance personnel in Scotland reported symptoms in the high range of the Impact of Event Scale (IES) (1). Similarly, a study of firefighters reported rates of significant distress, or severe distress, of 26% on the IES (2). Emergency responders reported symptoms that included recurrent dreams; feelings of detachment, dissociation, anger, irritability, or depression, memory or concentration impairment; somatic disturbances; and alcohol and substance use (1–4). Emergency responders experience posttraumatic stress disorder (PTSD) symptoms that often extend beyond the acute-crisis phase and become chronic in nature (5,6). Moreover, there is evidence that PTSD is associated with long-term functional disability in some individuals. In a sample of Dutch World War II veterans, 29% of those on a disability pension met the criteria for PTSD, compared with 9% of a community sample of veterans (7). Similarly, in a sample of Bosnian refugees living in Croatia, disability levels were markedly increased among individuals with PTSD and depression (8). Factors that predict chronicity include individual vulnerabilities, such as cumulative life stressors (9,10), previous mental health problems (6,11), social supports (12–14), and relational capacity (15). Accompanying this increased awareness of the impact of exposure to traumatic events is a concern that some individuals may falsely report levels of traumatic symptoms for the purpose of secondary gain. This gain could potentially include false claims for workers’ compensation, for other forms of paid time away from work, or for compensation through civil litigation. For instance, since 1980, when the Veterans Administration in the US authorized compensation for veterans suffering from chronic or delayed PTSD, concerns have been raised about the adequacy of the psychiatric assessment process for evaluating such claims (16). Researchers have reported, “extreme exaggeration of psychopathology,” using Minnesota Multiphasic Personality Inventory (MMPI) data in Vietnam veterans seeking compensation for PTSD (17,18). Further, practitioners assessing individuals for PTSD in civil and criminal cases are cautioned to consider malingering motivated by secondary gain as a possibility (19,20). One guideline suggested, “claimants present themselves to examiners fully aware of the checklist of diagnostic features for the disorder” (19, p xxi). These concerns about possible malingering have implications not only for the compensation process but also for treatment. Reports suggest that clinicians working with Vietnam veterans viewed the treatment engagement of those seeking compensation more negatively than they did for those not seeking compensation. Further, these beliefs became more negative with increased work experience with this population (21). Thus, even if individuals have legitimate disability as a result of traumatic experiences in the line of duty, treating and assessing professionals may meet their claims for compensation with suspicion. One possible legitimate claim following a traumatic event in the workplace is sick leave from work. Following the collapse of a Norwegian oil rig in the North Sea, those individuals who survived the collapse had twice as many sick leave incidents and used 4 times as much sick leave time up to 8 years after the event than did a comparison group of oil rig workers (22). Indeed, in 1998, the Workers Safety and Insurance Board amended its regulations to include, for the first time, MHS leave secondary to a traumatic event on the job that was not associated with physical injury (23). Frequently in such cases, psychiatrists and other mental health professionals are called upon to judge the degree of distress that is experienced by an individual following an event and subsequently the degree to which these symptoms impair functioning. One aspect of this is the motivation for recovery, as individuals are rarely universally impaired (24). In this context, secondary gains may interfere with recovery from both physical and psychological injury (25) and can contribute to the maintenance of disability behaviours; namely, avoiding return to work which, in turn, causes greater or extended disability (26). With regard to recovery from physical injury, the process by which secondary factors contribute to prolonged disability has been well documented. For example, avoidance behaviour—a common symptom following exposure to traumatic events—has been found to increase pain, suffering, and disability in individuals already suffering from back pain. Those who suffer from back pain may avoid doing many of the activities that will keep them fit and mobile. This in turn leads to situations that result in the loss of conditioning and flexibility needed to help overcome their back pain. At the same time, such individuals may avoid many other activities that distract from suffering and lose their independence and confidence (27,28). Often, this causes injured parties to become more conscious of their suffering as they become more symptom-focused. Likewise, the longer workers are away from the workplace, the more likely they are to develop anxieties about returning to work; specifically, they may lose confidence in their ability to perform within the work environment. Hence, they may become dependent upon having symptoms to justify their fear of returning to normal activities (26,29–31). This study considers the relation between traumatic stress symptoms and functional disability by examining an anonymous sample of workers not currently seeking compensation. It is anticipated that this approach will offer some insights into the relation between the use of work leave following a traumatic work event, symptoms of traumatic stress, social support, and personality factors. MethodThis research was conducted in an emergency-service organization in Toronto, Ontario, that employs about 800 paramedics. Participants represented a convenience sample of 86 paramedics. The mean age of the participants was 39.68 (SD 8.50) years. The average number of employment years as an emergency worker was 14.52 (SD 8.58) years. Most of the sample (68.6%) were married or living common-law, 15.1% were single, and 16.3% indicated that they were widowed or divorced. Of the respondents, 32% had attained the rank of officer or supervisor. Most (77.2%) had college or university degrees. Most participants (91.9%) were born in Canada, and over 70% had parents who were also born in Canada. All participants indicated that they had been exposed to at least 1 critical event on the job. Of the sample, 25% or 29.1% indicated that they had taken MHS leave from work following exposure to a critical event. MeasuresDemographic variables were collected via a questionnaire that covered age, sex, marital status, education, and years in emergency-service work. The questionnaire also addressed exposure to critical incidents and the use of MHS leave from work. Two sets of psychiatric symptoms were considered to be relevant to this inquiry: depression and posttraumatic stress. The Beck Depression Inventory (BDI) is a self-report scale that assesses the presence and severity of affective, cognitive, motivational, vegetative, and psychomotor components of depression (32). Initially standardized on 606 psychiatric inpatients and outpatients, the reported reliability coefficient is 0.86. The IES assesses the experience of posttraumatic stress for any specific life event (33). This scale is reported to have high internal consistency with a Cronbach’s alpha of 0.86 and a test–retest reliability of 0.87. The Bell Object Relations and Reality Testing Inventory (BORRTI) measured the personality factors hypothesized to influence chronic PTSD or the use of mental health disability leave (34). This 90-item, self-report instrument measures patterns of interpersonal relating. The instrument was tested on a total of 934 subjects, including individuals who sat on the board of directors of a social agency and a business organization, undergraduate students without identified pathology, and psychiatric outpatients and inpatients. The internal-consistency reliability estimate of the subscales (Cronbach’s alpha coefficient) range from 0.90 to 0.78. On the basis of this testing, Bell reports nonpathological norms for all subscales and provides an interpretation of personality profiles associated with elevations of individual subscales and combined subscales (35). Elevations on the alienation subscale indicate a basic lack of trust in relationships, suspiciousness, hostility, and isolation. Elevations on the insecure attachment subscale are associated with sensitivities to rejection and loss, as well as guilt, jealousy, and anxiety in relationships. High scores on the egocentricity subscale suggest mistrust of others’ motivations and a tendency toward demanding, controlling, and manipulative behaviour in relationships. The social incompetence subscale measures the degree of shyness, nervousness, and uncertainty associated with relationships. To determine perceptions of situation-specific support from friends, family, colleagues, and union and employers, participants were asked to rate the support level that they received from others on a scale ranging from 0 (not at all supportive) to 5 (very supportive). In addition, a standardized measure of social support was used to measure more global perceptions of social support. The Social Provisions Scale (SPS) is a brief, 24-item, multidimensional, self-report instrument that offers the possibility of discriminating between 6 distinct types of social support and assessing global support (36). The measure was tested on a total of 1792 respondents, including psychology students, nurses, and teachers. The reported alpha level for the total scale is 0.91.
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