Occupational Medicine 2007;57:404–410
doi:10.1093/occmed/kqm070

IN-DEPTH REVIEW

...............................................................................................................................................................................................

Post-traumatic stress disorder in occupational
settings: anticipating and managing the risk
Alexander C. McFarlane1 and Richard A. Bryant2
...................................................................................................................................................................................

Background Post-traumatic stress disorder has had a substantial impact on employer liability for workplace
psychological injury. The emergency services are an example of high-risk workforces that demand
clear policies and procedures within an organization. The challenge is to minimize the injury to
individuals and lessen the cost to organizations through the optimal application of preventative
strategies.
...................................................................................................................................................................................

Methods

This ﬁeld is not well represented in standard keyword searches and Medline was examined with
linked ﬁelds of practice and research. Consensus guidelines that refer to this domain were also
utilized. Few conclusions can be reached from the literature which directly examined occupational
settings.

...................................................................................................................................................................................

Results

Organizations need to anticipate the possible traumatic exposures that may affect the workforce and
have strategies to deal with the effects in the workplace, particularly the negative mental health
outcomes in some personnel. This domain is relevant to all employers as accidents and violence
are possible in most workplaces. Screening should be considered for high-risk individuals, particularly following a major traumatic event or cumulative exposure, such as in the emergency services.
While psychological debrieﬁng has no demonstrated beneﬁt, the beneﬁts of early intervention necessitate ready access to evidence-based treatments that have minimum barriers to care. Employers
should be aware that distress may present indirectly in a similar way as conﬂict with management,
poor performance and poor general health.

...................................................................................................................................................................................

Conclusion

The knowledge about the impact of traumatic events obliges employers to have an active strategy to
anticipate and manage the aftermath of such events as well as cumulative traumatic exposures.

...................................................................................................................................................................................

Key words

Emergency services; introduction; occupation; prevention; PTSD; risk management; screening.

...................................................................................................................................................................................

Introduction
Post-traumatic stress disorder (PTSD) and its predecessor, traumatic neurosis, have evoked a great deal of interest and controversy in the workplace because of the
related issues of compensation and employer negligence.
The inclusion of PTSD in DSM-III has transformed the
interest in the management of workplace psychiatric disability. The impact has been most apparent in the recognition of workplace injuries for emergency service and
military personnel. However, it has equally reformulated
the appraisal of the impact of single accidents occurring
1
Centre of Military and Veterans Health, University of Adelaide, 122 Frome
Street, Adelaide, South Australia 5000, Australia.
2
School of Psychology, University of New South Wales, Sydney NSW 2052,
Australia.

Correspondence to: Alexander C. McFarlane, Centre of Military and Veterans
Health, University of Adelaide, 122 Frome Street, Adelaide, South Australia
5000, Australia. Tel: 161 303 5200; fax: 161 303 5368;
e-mail: alexander.mcfarlane@adelaide.edu.au

in the workplace. The deﬁnition of PTSD has spurred an
emerging body of research which has provided a rich
knowledge base for informed prevention [1], early identiﬁcation and treatment of psychological workplace injury.
Both employees and employers have a great deal to
gain from effective prevention [2] and early intervention
to prevent secondary disabilities and premature retirement. While every workplace is at risk of unpredictable
catastrophic disasters and accidents, there are several
occupations that have a predictable and foreseeable risk
of being exposed to threat, horriﬁc injury and death. The
emergency services, military, acute medical services,
bank ofﬁcers and train drivers have had notable attention
in the literature. However, the most accident-prone industries such as mining, agriculture and ﬁshing should
not be forgotten although they have gained little systematic attention. The existence of a foreseeable risk is the
bedrock upon which the law of negligence is built and
hence occupational health personnel cannot avoid being
drawn on to give advice and assistance in this domain. It

Ó The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
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A. C. MCFARLANE AND R. A. BRYANT: POST-TRAUMATIC STRESS DISORDER IN OCCUPATIONAL SETTINGS 405

needs to be recognized that there is a balance between the
duty of care to the individual and the need to ensure that
any impairment suffered does not compromise the operational capacity of the organization.

Methods
This paper will review the consequences of exposure to
traumatic stress in different workplaces and the application of knowledge to the development of strategies for
prevention, which involves managing repeated exposure,
and ensuring early identiﬁcation and screening. The literature search could not solely depend on keywords, as
much of the relevant literature is not directly linked to this
topic. The keywords ‘PTSD’ and ‘emergency service
workers’ identiﬁed 17 references, missing many seminal
papers. ‘Screening’ and ‘PTSD’ resulted in 4583 references with excessive truncation when terms such as ‘work
place’ were added. As a consequence, a systematic review
using the terms PTSD and occupational stress led to 484
references being identiﬁed and was chosen above alternative searches such as PTSD in occupational settings
which led to the identiﬁcation of 10 references. PsychINFO using the keywords of occupational stress and
PTSD identiﬁed only 67 articles. The literature about the
military was not systematically reviewed because of the
uniqueness of this occupational environment. Instead,
linked conceptual literature was explored. The consensus
guidelines by National Institute for Clinical Excellence [3]
and National Health Medical Research Council (NHMRC)
[4], which addressed screening were speciﬁcally examined as were the recommendations of the US Preventative
Services Task Force [5]. The summary of this review
highlighted that there is scant literature on assessing or
managing PTSD reactions in the context of occupational
work trauma. In contrast, there is an enormous literature
pertaining to these issues from civilian trauma. Accordingly, we summarize the major lessons learnt from civilian
trauma and extrapolate to how this evidence should inform practices that aim to manage occupationally related
PTSD.

Table 1. Examples of work place stresses
Occupational—(these can be caused by psychiatric disorders rather
than being causal)
Supervisor relations
Group morale and cohesion
Administrative procedures
Workload
Shift duties
Resources
Interpersonal conﬂict
Traumatic events
Mass disasters
Serious accidents
Threat of death and injury
Death of colleagues
Witnessing death, suffering and injury
Assault

in any attempt at quantiﬁcation. However, an awareness
of these issues does allow a general proﬁle from an individual event to be calculated [6]. Although many highrisk occupational groups will be exposed to trauma, it is
reasonable for employers to attempt to identify those who
are at a higher risk for developing post-traumatic disorders.
Pre-trauma factors
There is increasing evidence concerning the risk factors
for PTSD that antedate the exposure, such as prior traumatic exposures, previous psychiatric or physical injury
[7]. There is also an emerging literature that has assessed
pre-trauma factors and related these to subsequent posttraumatic stress. For example, there is evidence that ﬁreﬁghters who engage in catastrophic thinking about life
events before they enter the ﬁre brigade are more likely
to develop post-traumatic stress after commencing active
duty [8]. Although the evidence on these pre-disposing
factors is scant at this time, it will be important for
employers to monitor this growing literature because it
will provide an evidence base from which employers can
identify those who are most at risk of adverse effects of
trauma exposure.

Modelling risk

Trauma exposure factors

The risk of developing a psychiatric disorder following
exposure to traumatic events is similar to any toxic exposure where a gradient of risk exists. Secondly, the cumulative impact of repeated exposures needs to be
anticipated (see Table 1). Signiﬁcant challenges exist in
scaling exposure because of the conceptual challenge of
the quantitative relationship between the different components of these events. For example, a single traumatic
event may involve witnessing horriﬁc sights of death and
mutilation, injury to oneself or others, threat of death or
injury, mass destruction, the duration of exposure and the
death or injury of colleagues which should all be reﬂected

There is much literature demonstrating that the work of
police [9], ambulance ofﬁcers [10–12] and ﬁre ofﬁcers
[9,13] are intrinsically likely to confront them with traumatic events where they have to witness and manage
death and suffering from crime and accidents. The ofﬁcers themselves can also be put at considerable direct risk
of injury or death. The nature of the exposures experienced in emergency service personnel is notably different
in that these personnel are speciﬁcally trained in a variety
of intervention strategies and skills to deal with threat and
danger, which is part of their operational role. A variety of
systems are put in place to minimize the risk of these

406 OCCUPATIONAL MEDICINE

operational exposures. The more typical scenario is
where the individual breaks down after repeated experience of a variety of traumatic incidents [12], which entail
varying degrees of a sense of personal threat often combined with the witnessing harm or death to others rather
than after a single incident [9].
A speciﬁc incident that results in the ofﬁcer making
some personal identiﬁcation with the event [14] or the
victim plays an important role determining the vulnerability of the individual to subsequent traumatic exposures. Repeated intense exposures over a period of time
leads to an accumulated risk requiring that the assessment of emergency service personnel should focus on
the lifetime exposure as well as the immediate antecedent
event that may have prompted the presentation for treatment [15]. From a clinical perspective, military and emergency service personnel due to their multiple traumatic
exposures may present differently from other victims
where a single traumatic event is the primary focus of
their traumatic ruminations.
Major terrorist incidents [16], disasters with multiple
loss of life, epidemics [17] and exposure to particularly
gruesome or horriﬁc accident scenes also carry a signiﬁcantly greater risk for emergency personnel. Increasingly,
as the armed services are involved in humanitarian and
peacekeeping duties [18], they can be exposed to situations of considerable human suffering without any immediate threat to themselves. In this regard, in the last decade
the exposures of military personnel have an increasing
commonality with that of the emergency service workers.
The core concept in the accumulated risk of repeated
exposure is sensitization, which refers to a process where
there is a progressive increase in the reactivity of the individual to trauma-related cues [19,20]. There is a critical
period in the aftermath of traumatic exposure during
which irreversible neuronal changes may occur in those
who develop PTSD [19]. The epidemiological literature
highlights this accumulating risk that represents a major
challenge in occupational settings, with the aim in an
occupational setting being to minimize this process.
Post-trauma factors
In the aftermath of the event, a range of factors can modify the recovery or escalate distress such as social support
and stress that emerge in the aftermath of the event such
as continued exposure to the distress of the victims or
critical legal investigations of the circumstances of the
event where blame is involved [21].

Risk management
One of the challenges for identifying risk is the limited
research on the sensitivity and speciﬁcity of using any
potential marker for identifying an individual as being
high risk for post-traumatic disorders. Research typically

reports statistical relationships between variables, which
are useful for increasing our knowledge about risk factors.
These relationships do not provide cut-offs that would
guide an employer to reliably identify an employee as
being at high risk. An example of this problem is the recent tendency for researchers to use resting heart rate
levels as simple markers to identify people immediately
after trauma exposure who will subsequently develop
PTSD. Although there are numerous studies attesting
to the statistical relationship between elevated resting
heart rate after trauma and PTSD, all attempts to use
cut-offs to mark those who are high risk have failed
[22]. The most appropriate means for employers to use
the current evidence is to focus on those individuals who
have displayed the high risk factors (e.g. prior psychiatric
history, repeated exposure to fatalities or very grotesque
events, observed deﬁciency in performance or increase in
interpersonal difﬁculties) and ensure that these individuals are monitored and offered the opportunity for mental
heath assistance. This approach would utilize current
knowledge in a way that focuses resources on those who
are most likely in need of them but also does not make the
mistake of presuming that these risk factors necessarily
point to disorder.
Given that there are foreseeable risks to various occupational groups, the central challenge is to identify strategies that may minimize the adverse outcomes. One
strategy is to deal with the predictable exposures in
a workforce such as high-risk emergency services. A systematic assessment should be conducted of the progressive burden of exposure that individuals endure. A
strategy developed based on the principles of the known
risks of prolonged military combat exposure [23] to have
a rotation of duties so that there is an opportunity for the
restoration of the normal patterns of psychophysiological
arousal. To enact these principles, an organization
requires a range of roles that allow rotation on a ﬂexible
basis for a given individual. This strategy represents a ﬁnancial challenge as there is a cost to an organization
having a stafﬁng plan that offers such opportunities for
rotation of roles. This cost has to be counter balanced
against the expense to an organization of losing highly
trained personnel through compensable injury.
The further strategy involves the organization having
a system in place that anticipates the adverse outcome of
the exposures on some individuals (see Table 2). These
adverse outcomes can manifest in a variety of ways, including delayed traumatic reactions [24] and non-speciﬁc
physical symptoms [25]. Supervisors should be trained to
detect these indirect manifestations and behaviours as
being possible signs of the effects of exposure to traumatic
events and institute the appropriate requests for independent health assessments rather than depending on punitive administrative procedures alone. The general sense
of camaraderie and collegial support in these organizations often assists the individual in maintaining a facade

A. C. MCFARLANE AND R. A. BRYANT: POST-TRAUMATIC STRESS DISORDER IN OCCUPATIONAL SETTINGS 407

Table 2. Responsibilities of occupational health services
Management related
Advice about monitoring trauma exposures
Assist in identiﬁcation of individuals at risk
Advice about work place rotations in highly exposed individuals
Train supervisors in the manifestations of traumatic stress
Train individuals in strategies for resiliency and health behaviour
Liaise with senior managements regularly
Design policy and procedures, and monitor implementation
Maintain relevant organizational knowledge base
Health service delivery
Multi-disciplinary team with skills to provide evidence treatment
Quality assurance processes
Continuing professional development of personnel
Establish and monitor screening of high-risk employees
Train individuals in strategies for resiliency and health behaviour
Monitor re-exposure of injured workers returned to work
Accessible treatment services
Psychological assessment of non-speciﬁc physical symptoms

of functioning and can lead to the tolerance of changed
individual performance. It is critical that operational
managers have a high index of suspicion so as not to delay
assessment and intervention [26].
A major challenge in occupational settings is to address the accumulating risk, with repeated exposures
and the secondary issue of identifying workers who have
seemingly coped well with a major trauma but have a pattern of delayed emergence of symptoms, sometimes triggered by the exposure to secondary stressors. The core
concept explaining the accumulated risk of repeated exposure is sensitization, which refers to a process where
there is a progressive increase in the reactivity of the individual to trauma-related cues [19,20,24,27].

Screening
Screening for psychological disorders is an effective strategy in workers who are at signiﬁcant risk because of their
levels of trauma exposure [28]. Such a strategy involves
identifying individuals at risk and screening them in the
immediate aftermath and again approximately 6 months
later. Screening prior to exposure generally has little to
offer [29]. Screening questionnaires have false negative
and positive rates and those individuals who are identiﬁed
as being at risk and a small proportion of those who score
just below the cut-offs should be interviewed. The setting
of these interviews provides an opportunity for the provision of general support and the identiﬁcation of other
organizational and management issues that cause concern
and put the individual at risk [30]. Wessely [31] and others
[32] have raised the possibility that an unwanted impact of
screening is to inadvertently encourage individuals to
complain of symptoms despite evidence that giving information, if anything, improves outcomes [33]. Also screening is only effective if it leads to the implementation of

treatment when the health services are appropriately
resourced and have appropriate training as has been
shown with the screening and treatment of depression in
general practice [34]. Screening for alcohol abuse, which is
followed by single session interventions in general practice
sessions, has been shown to be remarkably effective [5].
Any system of screening in an occupational setting
should be carefully managed to deal with the issues of
potential disadvantage and discrimination of those being
identiﬁed as being at risk. For this reason, there can be
under-reporting by individuals who are symptomatic and
this should be addressed in the thresholds for determining who should receive a diagnostic interview. A range of
psychometric instruments has been trialled in emergency
services for the monitoring of the emergence of symptoms. Any screening process should also regularly involve
a ﬁxed proportion of people who are asymptomatic also
being given a diagnostic assessment to remove the stigma
of referral for follow-up. While there are well-established
measures from epidemiological research, a range of
shorter screening measures have been developed and
can be used as long as they are regularly validated against
a structured diagnostic interview [35].
Although debrieﬁng has been shown to have no preventative value, a number of organizations continue to use
this approach, in the context of peer support systems [36]
and Critical Stress Management. The sometimes heated
debate around these issues should not distract employers
from recognizing the need for support from employees in
the aftermath of traumatic events. Screening can provide
a setting where individuals are offered general support
and preventive health messages and a broad range of occupational issues, such as morale and leadership concerns
can be addressed simultaneously.

Signs of possible psychological
dysfunction
In many occupational settings, it can be useful if supervisors can detect signs that may indicate that an individual
is experiencing some PTSD reactions. The negative impact of traumatic events can manifest in a variety of indirect ways which employers should be alert to.
Increased alcohol use [9]
Interpersonal and/or family conﬂict [13]
Social withdrawal
Depression [37]
Somatic distress [9]
Performance deterioration [10]

Issues of secondary prevention
A recent case (Burton versus the State of New South
Wales [38]) has placed an important obligation on

408 OCCUPATIONAL MEDICINE

employers in certain jurisdictions. In this case, the negligence of the employer arose, not from being responsible
for the traumatic exposure, which led to the plaintiff’s
symptoms, but rather the failure to monitor his health
and to ensure early treatment. Such a case brings into
focus the potential possible gains from early treatment,
given the evidence about the availability of a range of
effective interventions. Hence, an obligation emerges
for an employer to detect individuals who are symptomatic so that treatment can be instigated. Secondary prevention involves early detection and prompt effective
intervention [39] that decrease the risk of the emergence
of the chronic disease states and the associated disabilities, impairments and social disadvantage. It is in this
window of opportunity that the gains from early treatment are most apparent [40]. The aim of effective treatment is to minimize these disabilities before they emerge.
While single-session debrieﬁng or counselling in the
immediate aftermath of such events has no direct beneﬁt,
[41,42], one indirect consequence of any system providing acute support is that it provides a mechanism for
giving information to individuals and confronting some
of the issues of stigma that frequently create barriers to
care [40]. A practical system of care, which ensures early
identiﬁcation and diagnosis, is central to early treatment.
Furthermore, a major risk to a symptomatic individual
arises from further exposures and a critical responsibility
of an employer is to prevent further injury by the worker’s
continued exposure through his/her duties.
Employers need to recognize that there is a responsibility to follow current scientiﬁc evidence in developing any
intervention that aims to reduce post-traumatic psychological impairment. In the US Supreme Court’s 1993
decision in Daubert versus Merrell Dow Pharmaceuticals, Inc. [43], it was ruled that admissible evidence
needed to satisfy speciﬁc scientiﬁc standards. This ruling
has resulted, to varying degrees, in courts ruling that
employers are negligent [44,45] if they are not aware of
current knowledge about evidence-based interventions
[3,4]. In the context of managing early interventions to
emergency service personnel who require assistance,
there is now considerable evidence that secondary prevention of civilians within a month of trauma exposure
can markedly limit PTSD reactions. Using cognitive behaviour therapy, Bryant et al. [46] have demonstrated
over a series of controlled trials that early intervention
leads to more than half of people who would otherwise
develop PTSD recovering from the condition.
While several studies have compared the beneﬁt of
early versus late treatment and have not shown any adverse consequences of delay [47,48], these studies were
inadequate to answer this question. However, a signiﬁcant body of knowledge based on observational studies
and basic biological research argues that early treatment
is likely to prevent the underlying neurobiological mechanisms becoming increasingly resistant to modulation

and control because delayed treatment allows the processes of progressive sensitization and kindling. The
literature about the beneﬁts of early treatment in depression provide parallel evidence for this challenge
[27,49,50] because .50% of individuals with a PTSD
at some point will have a co-morbid major depressive
disorder and as outlined above depression is not an infrequent consequence of trauma exposure.

Conclusion
The predictable risk from traumatic exposure and the
many barriers to care pose a particular challenge in the
management of traumatic events in the workplace. Optimally, an occupational health service should identify and
manage the risks at an organizational level as well as providing readily accessible evidence-based treatment in
a timely manner to those individuals identiﬁed to be
symptomatic. There is remarkably little literature examining screening, monitoring and the effectiveness of evidence-based treatments in different occupational groups.
The absence of direct studies in occupational settings
means that there is a critical need for research in these
populations. Nonetheless, there is considerable indirect
evidence to shape the practice of employers so that evidence accrued from civilian and military settings may
form the basis of risk assessments, monitoring practices
and interventions.

Funding
NHMRC programme grant number 300304 held by
A.C.M. and R.A.B.

Conﬂicts of interest
None declared.

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