Post-traumatic stress disorder as a result of occupational injury: the case of a bank employee

Abstracts

Este artigo relata o caso de um gerente de banco atendido por uma equipe multidisciplinar através de anamnese psiquiátrica e ocupacional e aplicação de entrevista psiquiátrica semi-estruturada (SCID) para transtorno de estresse pós-traumático (TEPT). O objetivo do artigo é exemplificar, com um caso clínico, as relações entre o TEPT e eventos traumáticos ocorridos no trabalho, demonstrando que o TEPT pode ser uma conseqüência de acidente de trabalho bancário. A visão do TEPT como doença ocupacional é um conceito novo e relevante devido aos índices elevados de violência no Brasil. O reconhecimento do TEPT no contexto do trabalho bancário é importante para orientar serviços de saúde, administradores e profissionais de recursos humanos na prevenção de TEPT (treinamento adequado, suporte psicológico, emissão de Comunicação de Acidente de Trabalho, intervenções na organização do trabalho), visando à melhoria da qualidade de vida.

Transtorno de estresse pós-traumático; acidente de trabalho; assalto a banco

CASE REPORT

Post-traumatic stress disorder as a result of occupational injury: the case of a bank employee

Trastorno por estrés postraumático como accidente laboral en un bancario: relato de caso

Erika Bucasio^I; Isabela Vieira^I; Dulcéa Martins^II; Carmelita Souza^III; Carmelita Souza^IV; Deborah Maia^II; Ivan Figueira^V; Sílvia Jardim^VI

^IPsychiatrist. Project for workers'mental health care (Projeto de Atenção à Saúde Mental dos Trabalhadores - PRASMET). Program of stress-related mental disorders (Programa de Transtornos Mentais relacionados ao Estresse). Psychiatry Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil

^IIPsychiatrist. Project for workers' mental health care (PRASMET). Program of stress-related mental disorders (Programa de Transtornos Mentais relacionados ao Estresse). Psychiatry Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil

^IIISocial worker. PhD student, School of social work at Universidade Federal do Rio de Janeiro, RJ, Brazil

^IVNurse. MSc. Psychiatry Institute - Universidade Federal do Rio de Janeiro, RJ, Brazil

^VProfessor. Psychiatry Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil

^VIPhD. Coordinator of PRASMET. Psychiatry Institute - Universidade Federal do Rio de Janeiro, RJ, Brazil

^{Correspondence}

ABSTRACT

This article reports the case of a bank manager assessed by a multidisciplinary team using psychiatric and occupational history taking and a semi-structured interview (SCID) for post-traumatic stress disorder (PTSD). The aim of this article is to use a clinical case to illustrate the relationship between PTSD and traumatic events in the workplace, showing that PTSD may result from an occupational injury. The notion of PTSD as an occupational disease is a new and relevant concept due to high levels of violence in Brazil. Acknowledging PTSD in the context of bank workers is important to guide health services, administrators, and human resource professionals in applying preventive measures (appropriate training, psychological support, filling out of Work Injury Reports and interventions in the organization of work) that will provide improved quality of life.

Keywords: Post-traumatic stress disorder, work injury, bank robbery.

RESUMEN

Este artículo relata el caso de un gerente de banco atendido por un equipo multidisciplinar a través de anamnesia psiquiátrica y ocupacional, y aplicación de entrevista psiquiátrica semi-estructurada (SCID) para trastorno por estrés postraumático (TEPT). El objetivo del artículo es ejemplificar, con un caso clínico, las relaciones entre TEPT y eventos traumáticos ocurridos en el trabajo, demostrando que el TEPT puede ser una consecuencia de accidente de trabajo bancario. La visión del TEPT como enfermedad ocupacional es un concepto nuevo y relevante, debido a los índices elevados de violencia en Brasil. El reconocimiento del TEPT en el contexto del trabajo bancario es importante para orientar los servicios de salud, administradores y profesionales de recursos humanos en la prevención del TEPT (entrenamiento adecuado, soporte psicológico, emisión de comunicación de accidente de trabajo, intervenciones en el ordenamiento del trabajo), visando a la mejoría de la calidad de vida.

Palabras clave: Trastorno por estrés postraumático, accidente de trabajo, asalto a banco.

INTRODUCTION

The diagnosis of post-traumatic stress disorder (PTSD) was first included as part of an official psychiatric classification system in 1980,¹ after studies on the topic had been carried out in several countries and with different populations.² PTSD is a prevalent, chronic, incapacitating, resistant to treatment and rarely diagnosed disorder that may be associated with alcoholism, suicide, dissatisfaction with work, absenteeism and early retirement.^3-6

Traumatic situations experienced at work and resulting from urban violence, such as bank robberies, are increasingly frequent.⁷ In 1986, 37.5% of armed robbery victims developed PTSD.8 Different studies on bank robberies have shown how these events affect the mental health of workers and their performance at work.^9-13 The Rio de Janeiro Civil Police recorded five bank robberies in May 2004, and three in the same month in 2003.¹⁴ Data from June 2003 from the Rio Grande do Sul State Department of Justice reveal that the number of bank robberies has increased twice in the state capital Porto Alegre and other towns from 2002 to 2003.¹⁵ A significant percentage of bank workers have reported that they feel nervous, tense, worried (66,4%) and fear robbery (48,6%)¹⁶ during their working hours.

The main goal of the present article is to exemplify the relationship between PTSD and traumatic events at work by reporting the case of a bank employee. We intend to show that PTSD could be viewed as an occupational hazard. These issues have not been widely studied in Brazil,¹⁷ in spite of the high violence rates.

CASE PRESENTATION

A 44 year-old white male with a university degree, separated with one son, was the victim of a robbery at the bank where he was an administrative manager three years ago. Four armed men, one of them carrying a hand grenade, entered the bank, threatened and injured him. Fearing he would be killed, the manager opened the safe containing the largest amount of money. He had a gun put to his mouth and was locked inside the safe for about one hour. After the robbers left the bank, this individual received no help and had to go to the police headquarters by himself.

In the following days, he was only able to start working after going back and forth through the access turnstile several times, was easily startled, and shivers and chills. He lost 12 kg in two months. Since the event, he is unable to stay remain in closed spaces or use the elevator, even though he has to go up more than 10 floors. He doesn't drive anymore and is always on the alert, with a feeling that he is being followed by someone or feeling that something bad can happen with him anytime. He feels threatened, especially in the presence of black males (one of the robbers was black). His heartbeat speeds up, he has shortness of breath and discomfort. He reports frequent nightmares about the robbery and associated facts. This man feels insecure in the evening and avoids going out at night. After the robbery, he exhibited a slowed-down appearance, became distant from friends and relatives, had crying outbursts, difficulty to concentrate and suicidal ideation.

In June 2002, he was referred to psychiatric treatment. The psychiatrist completed a Work Injury Report (WIR) form, which was not accepted by the bank. The manager was then referred to the Rio de Janeiro City workers health department and to the Bank Workers Union, and later to the Project for workers mental health care service at the Federal University of Rio de Janeiro/Psychiatry Institute for assessment of the causal relationship between his clinical status and his work occupation.

Currently, his mood has improved but he is still afraid of closed spaces and suffers with feelings of insecurity, especially when alone. Sometimes he feels that he is being followed. He does not stand being close to armored cars and no longer drives. He is on psychiatric and psychotherapy treatment (cognitive-behavioral therapy) and takes fluoxetine hydrochloride (40 mg/day), mirtazapine (30 mg/day), alprazolam (3 mg/day), risperidone (2 mg/day), flurazepam (30 mg/day). He is also being treated for systemic hypertension and mitral valve prolapse. He has been on health leave since October 2002.

He has family history of systemic arterial hypertension and heart disease.

DISCUSSION

The clinical case reported above fulfills the criteria for PTSD. This disorder is characterized by a triad of psychopathologic dimensions: 1) recollections of the event; 2) avoidance of stimuli associated with the trauma and affective detachment; and 3) increased symptoms of arousal.^18,19

The PTSD case reported here was classified as work-related because the trauma was secondary to an occupational injury, defined as "events during the execution of work or arising from it, causing permanent or temporary health damage, as well as loss and decrease of work capacity ( ) resulting from aggressive acts, sabotage or terrorism practiced by a third party or workmate.²⁰

According to the Manual of Management of Work-Related Disorders (Manual de Manejo da Lista de Doenças Relacionadas ao Trabalho) of the Federal Ministry of Work, "in the case of workers who experience symptoms described in the definition of PTSD, the disorder, after other non-operational causes have been ruled out, can be classified as Grade I of Schilling, that is, the 'job' or 'occupation' are 'necessary causes', meaning that the disorder would be unlikely outside the environment."^21,22

We suggest that a WIR form be completed in the presence of occupational PTSD. This form will reach sanitary vigilance authorities, which is an important step for primary prevention. The acknowledgement of PTSD in the context of bank workers is important to guide health services, administrators and human resources personnel in promoting the prevention of PTSD by developing interventions in terms of the organization of work processes. Such measures will ensure more protection to workers, adequate training, psychological support and access to healthcare services, and improved quality of life.

REFERENCES

Received on September 8, 2004.

Reviewed on September 27, 2004.

Accepted on November 3, 2004.

• ¹
  American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington: American Psychiatric Press; 1980.
• 2. Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346(2):108-14.
• 3. Regehr C, Goldberg G, Glancy G, Knott T. Posttraumatic symptoms and disability in paramedics. Can J Psychiatry. 2002;47:953-8.
• 4. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 1991;48:216-22.
• 5. Davis GC, Breslau N. PTSD in victims of civilian trauma and criminal violence. Psychiatr Clin N Am. 1994;17:289-99.
• 6. Jardim S. Ética e saúde mental do trabalhador: a legitimidade do transtorno de estresse pós-traumático relacionado ao trabalho. In: Moraes T, org. Ética e psiquiatria forense. Rio de Janeiro: IPUB-CUCA; 2001. p. 57-84.
• 7. Richards DA. Traumatic stress at work: a public health model. Br J Guidance Counselling. 1994;22(1):51-64.
• 8. Tunnecliffe M, Green S. Trauma in the workplace: dealing with stress reactions after armed hold-ups. In: Morrison D, Hartley L, Kemp D, eds. Trends in the ergonomics of work. Proceedings of the 23rd Annual Conference of the Ergonomics Society of Australia, 1986.
• 9. Miller-Burke J, Attridge M, Fass P. Impact of traumatic events and organizational response. A study of bank robberies. J Occup Environ Med. 1999;41(2):73-83.
• 10. Kamphuis J, Emmelkamp P. Crime-related trauma: psychological distress in victims of bank robbery. J Anxiety Disord. 1998;12(3):199-208.
• 11. Harrison C, Kinner S. Correlates of psychological distress following armed robbery. J Trauma Stress. 1998;11(4):787-98.
• 12. Richards DA. Symptom severity, personal and social variables after armed robbery. Br J Clin Psychol. 2000;39(4):415-9.
• 13. MacDonald HA, Colotla V, Flamer S, Karlinsky H. Posttraumatic stress disorder (PTSD) in the workplace: a descriptive study of workers experiencing PTSD resulting from work injury. J Occup Rehabil. 2003;13(2):63-77.
• 14. Polícia Civil do Estado do Rio de Janeiro. Sete tipos de crimes sofrem queda no mês de maio. Disponível em: http://www.policiacivil.rj.gov.br/noticia.asp?id=1291
• 15. Federação dos Bancários. Bancários e banqueiros debatem segurança nesta sexta. Disponível em: http://www.bancnet.com.br/artigo.asp?PRID=1576
• 16. Silva Filho JF, et al. Estudo das relações entre a prevalência de doenças mentais e a organização do trabalho bancário no Município do Rio de Janeiro. In: Textos para discussão 7 - Fórum de Ciência e Cultura. Rio de Janeiro: UFRJ; 1993.
• 17. Glina D, Rocha L, Batista M, Mendonça M. Saúde mental e trabalho: uma reflexão sobre o nexo com o trabalho e o diagnóstico com base na prática. Cad Saude Publica. 2001;17(3):607-16.
• ¹⁸
  American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Press; 1994.
• ¹⁹
  Organização Mundial da Saúde. Classificação de transtornos mentais e de comportamento da CID-10: descrições clínicas e diretrizes diagnósticas. [Tradução: Dorgival Caetano]. Porto Alegre: Artes Médicas; 1997.
• ²⁰
  Ministério da Previdência e Assistência Social (MPAS). Regulamento dos benefícios da previdência social. Decreto nº 2172 de 05/03/1997.
• ²¹
  Ministério da Saúde. Lista de doenças relacionadas ao trabalho. Brasília: Ministério da Saúde; 2000.
• ²²
  Ministério da Saúde. Doenças relacionadas ao trabalho: manual de procedimentos para os serviços de saúde. Brasília: Ministério da Saúde; 2001.

Publication Dates

• Publication in this collection
  15 Sept 2005
• Date of issue
  Apr 2005

History

• Received
  08 Sept 2004
• Reviewed
  27 Sept 2004
• Accepted
  03 Nov 2004