Frozen moments: flashback memories of critical incidents in emergency personnel Birgit Kleim1,2, Martina-Barbara Bingisser3, Maren Westphal4,5 & Roland Bingisser3 1Department of Experimental Psychotherapy, University of Zurich, Zurich, Switzerland 2Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital Zurich, Zurich, Switzerland 3Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland 4Department of Psychology, Pace University, Pleasantville, New York 5New York State Psychiatric Institute, Columbia University, New York, New York Keywords Abstract Anxiety, burnout, depression, emergency department, emotional memory, flashback, Background: Emergency Department personnel regularly face highly stressful intrusion situations or critical incidents (CIs) that may subsequently be recalled as unbid- den intrusive memories. In their most extreme form, such memories are reex- Correspondence perienced as if they were happening again in the present, as flashbacks. This Birgit Kleim, University of Zurich, Department study examined (1) which CIs are associated with flashback memories; (2) can- € of Experimental Psychotherapy, Binzmuhles- didate person and work-related features that predict flashback memories; and trasse 14, Box 26, 8050 Zurich,€ Switzerland. (3) the association between flashback memories and anxiety, depression, and Tel: +41 44 635 7377; Fax: 41 44 635 73 59; N = E-mail: [email protected] emotional exhaustion. Methods: Emergency nurses ( 91; 80.2% female) were recruited from two urban teaching hospitals and filled in self-report ques- Funding Information tionnaires. Results: A majority (n = 59, 65%) experienced intrusive memories; This research was funded by grants almost half of the sample reported that their memories had flashback character. PZ00P1_126597, PZ00P1_150812 awarded Those involved in resuscitations in the past week were at a fourfold risk for to Birgit Kleim, Department of Psychology, experiencing flashbacks. Having worked more consecutive days without taking University of Zurich, by the Swiss National time off was associated with a somewhat lower incidence of flashbacks. More- Science Foundation. over, older individuals who reported more work-related conflicts were at greater Received: 6 May 2014; Revised: 8 December risk for experiencing flashback memories than their younger colleagues with 2014; Accepted: 22 December 2014 heightened work conflict and flashback memory scores, respectively. Flashback memories were associated with heightened symptoms of anxiety, depression, Brain and Behavior, 2015; 5(7), e00325, and emotional exhaustion. Conclusions: The present findings have implications doi: 10.1002/brb3.325 for evidence-based health promotion in emergency personnel and other individ- uals regularly exposed to CIs. Introduction events as if they were happening again in the present moment. Participants in the present study reported reex- Emergency Department personnel regularly face a variety periencing, for instance, a situation where distressed of challenging situations or “critical incidents” (CI) such parents were present when resuscitation attempts of as being confronted with the death of patients, including their 4-year-old daughter were terminated, or treating a young children, assisting victims of violent crimes and patient with 80% burn injuries, or a patient speaking traffic collisions, and witnessing failed resuscitation about their upcoming holidays, who died 5 min later. attempts. Such CIs may subsequently be recalled as While such intrusive memories may occur in healthy unbidden, intrusive memories, that tend to occur mostly individuals in the wake of stressful incidents, flashbacks in perceptual form, such as images or “frozen and persistent distressing intrusions are a hallmark moments”, but they can also consist of verbal thoughts, symptom of posttraumatic stress disorder (PTSD). Intru- sounds, smells and tastes (Ehlers et al. 2004). In their sions may appear “out of the blue”, in very different most extreme form, they are reexperienced as “flash- contexts than the original incident, tend to be highly backs”, that is, a very intense reliving of traumatic distressing, and may persist for years as prominent ª 2015 The Authors. Brain and Behavior published by Wiley Periodicals, Inc. Brain and Behavior, doi: 10.1002/brb3.325 (1 of 8) This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Flashback Memories in Emergency Personnel B. Kleim et al. symptoms of many types of psychopathology, such as 1999; Tolin and Foa 2006). Alcohol has also been impli- depression or anxiety (Brewin et al. 2010). cated as a likely contributor to stress and burnout in From a public health perspective, a better understand- medical professions (Hochberg et al. 2013). Another open ing of intrusions is important, as experiencing intrusions question is whether and how person- and work-related could impact work performance, lead to absenteeism, and factors interact in increasing risk of developing intrusive may eventually evolve into long-term disability in popula- CI memories. For instance, female or older emergency tions repeatedly exposed to CIs such as emergency per- personnel reporting more frequent resuscitation situations sonnel (Laposa et al. 2003). Considering the growing role or greater workloads may be especially prone to develop- in hospital admissions and the heavy workload of EDs ing intrusions. Due to the mixed findings on the associa- (Schuur and Venkatesh 2012), the question arises as to tion of age on psychological symptoms in the context of how we can support those who experience CI flashback work- stress, we explored interaction hypotheses with memories and how such unbidden memories may be pre- regards to age, but had no directional hypotheses. Finally, vented. Very few studies have investigated intrusive mem- it is important to know about the psychological toll such ories and flashbacks of CIs in emergency personnel. Half memories might exact. Specifically, anxiety, depression, of the ambulance workers in one study endorsed symp- and emotional exhaustion are features of burnout that toms of intrusive memories and nearly all of the intru- have been frequently reported by emergency personnel sions were about incidents involving the death of another (Declerque et al. 2011). Intrusive memories may be key person, often including children (Alexander and Klein factor involved in the evolution and maintenance of such 2001). Other studies identified distressing CIs, such as symptoms. caring for a patient who is a relative or close friend and Empirical answers to these three interrelated questions is dying or in a serious condition, caring for a child vic- could help screen emergency personnel vulnerable to tim, or threatened physical assault of self as most upset- experiencing flashback memories of CIs and could assist ting events (Clohessy and Ehlers 1999; Declerque et al. in developing prevention and intervention programs. 2011). First, the present study examined prevalence, characteris- The above studies did not address the question of tics and content of intrusive memories and their flashback which CIs are subsequently reexperienced as intrusive characteristic in a sample of emergency department nurs- memories. It is possible that some CIs are more psycho- ing personnel. Second, we investigated the influence of logically “toxic” than others, in which case early recogni- person- (e.g., age, sex, relationship status, alcohol con- tion and targeted interventions might be useful to prevent sumption) and work-related features (e.g., working pre- adverse long-term psychological effects of such events. dominantly day vs. night shifts and part vs. full-time, Another unaddressed question is the relative contribution time since last taken days off work, critical resuscitation of work-related stressors and person-related factors to the experiences in the past week, conflicts at work, such as prevalence of intrusive memories among emergency per- arguments, disagreements or direct confrontations with sonnel. Work volume, patient load, number of nightshifts, colleagues or patients) on intrusive memories. Relatedly, and number of consecutive work days since last taking we investigated the association between selected interac- time off are work features that have been associated with tions between age, sex and work-related variables predict stress reactions and burnout in medical professions (Ali- the experience of CI flashbacks. Third and finally, we moglu and Donmez 2005; Rosenstein 2013) and thus may examined associations between flashback memory experi- present important risk factors for the emergence and ences and symptoms of anxiety, depression, and emo- maintenance of intrusive memories. In emergency person- tional exhaustion and predicted greater symptoms of nel, time pressure and shiftwork, working full-time as psychopathology in those who experienced CI flashbacks compared to part-time and not taking time off work may compared to those who did not. contribute to overall stress levels and thus lead to greater likelihood of experiencing intrusive memories (Clohessy Methods and Ehlers 1999). In terms of person-related factors, pre- vious studies have linked both younger (Alimoglu and Participants and procedures Donmez 2005), as well as older age (Streu et al. 2013) to increased work stress and burnout in medical professions, The local