Occup. Med. 1992; 42: 163-166
DISASTER SERIES
Management of post-incident
trauma: afireservice perspective E. McCloy Medical Adviser, Greater Manchester Fire and Civil Defence Authority, UK
INTRODUCTION
WHAT ARE THE CAUSES OF STRESS?
Post-incident trauma, post-traumatic stress, critical incident stress, all relate to the normal and inevitable results of exposure to death, destruction and violence. The different terminologies are synonymous. Although post-incident trauma has been well recognised in combat situations, some investigators still doubt that it is a valid syndrome1. It is estimated that 30-59 per cent of people may develop post-incident trauma after natural disasters such as the Armenian earthquake and, perhaps, even more after man-made disasters such as Lockerbie in December 1988 and the Ml plane crash in 1989. It affects both victim and rescuer. Everyone will have been the subject of stress at some time although stress means different things to different people. The familiar symptoms of palpitations, sweating, stomach churning and rapid breathing in response to what wefindstressful as individuals are well recognised. They may arise for emergency personnel when the 'call out' signal goes or perhaps before giving a lecture or presentation or, when faced with difficult or unstable personnel situations. A certain amount of stress is necessary for a good performance but when the action has started, whether it be physical or mental, the symptoms subside and often a feeling of relaxation or 'wellbeing' supersedes. Stress is a problem when the individual is no longer in control, when the symptoms do not subside or when they appear in inappropriate situations.
Stress is the result of the interaction of various factors both occupational and domestic. Whereas each factor may be capable of being coped with individually, the coping mechanism becomes saturated if several factors converge.
Correspondence and reprint requests to: Dr E. McCloy, Department of Occupational Health and Safety, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
© 1992 Butterworth-Heinemann for SOM 0962-7480/92/030163-04
STRESS RECOGNITION Individuals may become aware of physiological, mental or personality changes as shown in Table 1 but if they are recognised for what they are and the underlying cause is admitted and evaluated then the individual remains in control. However, in terms of post-incident trauma, defining what may be traumatic for an individual may be difficult. In general, for an event to be universally traumatic it must include three characteristics; a critical high level of stress; which is experienced and reported as traumatic; and results in stress-associated feelings and symptoms following the event2. Features operating to determine whether incidents are critical or traumatic are shown in Table 2. They are situations where the rescuer feels 'powerless' because of the scale of the disaster, because of personal involvement or because of an analogy to his own family, in other words there is a 'trigger'. Post-incident trauma can be defined as a 'complex interaction of environmental and task stress, job competency, perceptional and emotional defences, management and follow-up support3'. Why exposure to certain situations may lead to this response in some people but not others is uncertain. An important factor may be the severity of the stress particularly in terms of gruesomeness. Each person will have their individual
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
Post-incident trauma relates to the results of exposure to death and destruction. It has specific features relating both to the incident and symptoms it produces. Reactive symptoms occur in most people in the immediate after-period but rising or persisting anxiety towards the end of the first week indicates a risk of a serious disorder developing. Management should start immediately after the event and is a three stage process. Immediate management involves de-briefing and peer group support of the participants in the incident. For those who continue to experience rising or persisting anxiety after the first week, referral to occupational health advisers, welfare/counsellors or general practitioners is necessary and, if symptoms persist or recur, tertiary referral to specialist advisers such as psychologists or psychiatrists may be required. The most important factor in the treatment of post-incident trauma is to acknowledge its existence. Whilst the coping mechanisms are well established in theory, they require widespread implementation in practice.
164 Occup. Med. 1992, Vol. 42, No 3 Table 1. Stress-related symptoms Physiological
Mental
Personality
neck, back pain palpitations chest pain breathing difficulty skin rashes headache, fatigue visual disturbance menstrual irregularity
tolerance irritability withdrawal emotional lability sleep disturbance inappropriate behaviour inappropriate dress libido
alcohol smoking eating habit indecision evasion absenteeism excusism erratic mood swings
Table 2. Criteria of a critical incident universally traumatic death/injury of fellow firefighter death/injury of children rescue where it is difficult to reach the victim rescue where victim is known to firefighter
elapse of time experience of the individual failure of interpersonal relationships litigation presence of-depression - substance abuse - impaired personality
threshold above which they may experience postincident trauma. What triggers a 'non-coping' reaction is where one or more of these factors operates for an individual — 'something unusual'. Some symptoms are particularly indicative of post-incident trauma as distinct from stress in general, for example, numbing and withdrawal, the re-experience of the event through thoughts and flash backs which may lead to sleep difficulties, particularly nightmares4. There may be intense guilt feelings that not enough was done at the time and these personal factors may be expressed at work as inefficiency or the application for a change in role such as less responsibility and, at home, with family or marital problems. Traumatic experiences induce reactive symptoms such as trembling, sweating and nightmares, in many if not most people, in the days after the event but these symptoms usually fade away. There are factors, listed in Table 3, which are peculiar to post-incident trauma and which may affect its recognition. Rising or persisting anxiety towards the end of the first week may indicate a risk of a serious disorder developing and suggest the need for early intervention.
TRAUMA
Negative outcome
Positive outcome
Normal duties
Positive outcome
Normal duties
Positive outcome
Normal duties
Continuing symptoms I I . SHORT TERM MANAGEMENT; Negative outcome
Welfare Occupational health General practitioner
Continuing symptoms
Negative outcome
MANAGEMENT To be effective, management should, in fact, start immediately after the event and take place in three stages, immediate, short-term and long-term. The flow
I . IMMEDIATE ACTION; Debriefing Jigsawing Peer support
I I I . LONG TERM MANAGEMENT; Psychiatrist Psychologist
Redeployment Retirement Figure 1. Post-incident trauma - management flow chart
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
Table 3. Post-incident trauma - modifying factors
chart {Fig. 1) shows how management is dictated by the outcome at each stage. Immediate management involves 'debriefing' sessions with peer group support. Within the Fire Service, which is where my own experience of managing post-incident trauma arises, peer group support already exists as the 'Watch', a group of men who live, eat, sleep, attend incidents together, creating a 'family'. This debriefing enables 'jigsawing' to take place, that is, the attempt by the individual to fit his role into the overall picture of the event which is an essential part of the coping mechanism. The opportunity to talk freely with colleagues immediately after the event may remove fears about job competency. This, for many of those attending the Manchester Ringway Airport Disaster in 1985 was effective because, at the end of the shift, the Watch had to stay together whilst statements were taken allowing time for informal debriefing and peer group support to occur. Another more recent example was the attendance of a fire crew at a special service call where a young man had jumped from a motorway bridge in front of an articulated lorry. The normal retrieval procedures took place, the crew relaxed and were
E. McCloy: Post-incident trauma
had not been burnt and therefore although he knew in technical terms the effects and outcome of smoke inhalation he had never witnessed it in practice. He had followed correct procedures and searched the dwelling for other victims before returning to evacuate the child and he had convinced himself that had he removed the child first he/she would have been alive. Having established the cause of his stress he was then taken in detail over training procedures and why they were essential and he accepted that it was because he was a 'good', ie competent firefighter, that he had made the right decision initially. If he had been incompetent and had followed his instincts having made the wrong diagnosis then there would be concrete grounds for doubting his ability in the future. Positive reinforcing that personnel have made the right judgement and undertaken the appropriate actions in a particular circumstance is very important in achieving a return to normal behaviour patterns. In respect of short-term management the occupational health physician or occupational health counsellor is in the best advisory role because of his/her specialist knowledge of the work environment and procedures. There will often need to be liaison with the general practitioner if medication or sickness absence is necessary. If problems persist either in the workplace or at home then specialist referral, Stage III of management is necessary. Treatment of an established disorder is difficult and will require the skills of a psychologist or psychiatrist with options such as cognitive/behavioural techniques and medication for associated disorders such as panic attacks. The final outcome will again be positive or negative the latter leading to recommendation for redeployment or retirement on health grounds. The ideal management of post-incident trauma is preventive. Debriefing should include a description of the incident with participants describing in detail the incident as they remember it. They must be encouraged to tell their own stories and speak about their own feelings which will be the normal results of exposure to the incident such as nausea, revulsion, guilt and inadequacies. The most important factor is to acknowledge the existence of post-incident trauma both as an organization and as an individual. There are personnel factors common to all emergency services which mitigate against this and which, as shown in Table 4, can be identified as selection for the career, expectations and personality. Nevertheless, the coping mechanisms and strategies are now well established in
Table 4. Post-incident trauma - personnel factors Selection
self selection training process
Expectation
superior coping ability
Personality
dominant thriving on challenge public demonstration of skill denial of internal feeling traditional group image
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
heading back to Station when they came across the victim's head a hundred yards down the motorway. It was also retrieved, but the Senior Officer who took the subsequent debriefing was sufficiently concerned about 4 members of the crew to notify me of the incident through our standard procedures. In the event those 4 crew members returned to normal duties the following day and there were no sequelae. However, the system is by no means 100 per cent effective. Who misses out? Firstly, the Officer-inCharge. This is not unique to the Fire Service but affects, in particular, the other emergency services where this first stage of management has not hitherto existed. One of the biggest problems is that stress is still thought of as a weakness. Rescue personnel are often reluctant to admit to symptoms in case colleagues think that they are 'softies'. There is also the concern that admissions of stress might prevent promotion so peer group support must exist at varying levels allowing similar ranking personnel the opportunity to discuss fears and worries without prejudice. When this debriefing situation fails then patterns of abnormal behaviour, both personal and work-related, may surface. Stage II, short-term management, now comes into operation when either the victim of post-incident trauma may self refer or a Senior Officer may refer the individual, as appropriate, to Welfare, Occupational Health Services when available, or advise the individual through counselling to talk to his general practitioner. In order for supervisory officers or managers to carry out this role effectively they must have the necessary training to recognise both abnormal work patterns and symptoms of stress. One incident within the Fire service involved a young, very competent firefighter with approximately four years' experience for whom, after a particular incident, the debriefing process did not occur. The crew had returned to Station at the end of their shift, they had immediately booked off and, for this individual, it was the start of a four day rest period so that when he returned to Station for his next period of duty the incident had, for everyone else, been forgotten. There had been no jigsawing, no peer group support or stories of similar incidents in the past. The particular circumstances for this young firefighter led to self perception of failure and incompetence although routine investigation had revealed that there had been no error of judgement. His work pattern changed, he was no longer 'first in'. He requested to change to driving duties and his involvement with activities on Station became less. He became withdrawn from social activities and at this point he was referred to me by his Senior Officer. Counselling takes time, particularly to find a trigger point for the individual. At the start of our counselling session this young firefighter knew that he could no longer face going to a fire and finding himself in an identical situation but he did not know why he had these feelings. He was taken back over previous events step by step and, it emerged, that a child who had died from smoke inhalation had been totally unmarked. He had never attended a fatality before where the victim
165
166
Occup. Med. 1992, Vol. 42, No 3
theory and rely on peer support, debriefing, family support and appropriate referral. They require, however, the widespread implementation in practice.
REFERENCES 1. 2.
ACKNOWLEDGEMENT This paper is based on a presentation given at a symposium in October 1989 titled 'Post Incident Trauma in the Emergency Services' organized by the Lancashire Group of the Institution of Fire Engineers.
3. 4.
Raphael B, Middleton W. After the horror. Br Med J 1988; 296: 1142-3. Bergmann LH, Queen TR. Reducing the impact of stress among fire fighters. Fire International 1987; 102: 23-4. Docherty RW. Post-disaster stress in the emergency rescue services. Fire Engineers Journal 1989; June: 8-9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders third edition, revised. Washington
DC: APA, 1987.
INTERNATIONAL SYMPOSIUM
LINZ, AUSTRIA 27-30 OCTOBER 1992 ORGANIZED BY International Labour Office Allgemeine Unfallversicherungsanstalt Bundeskammer Fur Arbeiter Und Angestelle This symposium will review the current state of research and practical action in the prevention of work-related diseases. It aims at encouraging an international and interdisciplinary exchange of information as well as developing practical strategies and programmes for implementation. Interest groups: health & safety specialists, practitioners, engineers, occupational physicians, industrial hygienists, scientists, inspectors, managers and employer organisations. Main themes I. Factors at the workplace contributing to specific work-related diseases and their prevention • musculoskeletal disorders/diseases • mental and psychological disorders/ diseases • cardiovascular, gastrointestinal, respiratory, allergenic diseases/disorders II. Concepts, strategies and action programmes in health promotion and prevention • differentiation and interrelationship between health promotion and prevention • role of organizations and institutions • economic, social and psychological aspects • strategies and programmes • concrete actions at enterprise level For further information plea.se contact: Symposium Secretariat, Allgemeine Unfallversicherungsanstalt, Kongressburo, Adalbert-Stifter-Strasse65, A-1200 Vienna, Austria Tel: + + 33 111-558 Fax: + + 33 111-469
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
WORK-RELATED DISEASES; PREVENTION AND HEALTH PROMOTION
DISASTER SERIES
Management of post-incident
trauma: afireservice perspective E. McCloy Medical Adviser, Greater Manchester Fire and Civil Defence Authority, UK
INTRODUCTION
WHAT ARE THE CAUSES OF STRESS?
Post-incident trauma, post-traumatic stress, critical incident stress, all relate to the normal and inevitable results of exposure to death, destruction and violence. The different terminologies are synonymous. Although post-incident trauma has been well recognised in combat situations, some investigators still doubt that it is a valid syndrome1. It is estimated that 30-59 per cent of people may develop post-incident trauma after natural disasters such as the Armenian earthquake and, perhaps, even more after man-made disasters such as Lockerbie in December 1988 and the Ml plane crash in 1989. It affects both victim and rescuer. Everyone will have been the subject of stress at some time although stress means different things to different people. The familiar symptoms of palpitations, sweating, stomach churning and rapid breathing in response to what wefindstressful as individuals are well recognised. They may arise for emergency personnel when the 'call out' signal goes or perhaps before giving a lecture or presentation or, when faced with difficult or unstable personnel situations. A certain amount of stress is necessary for a good performance but when the action has started, whether it be physical or mental, the symptoms subside and often a feeling of relaxation or 'wellbeing' supersedes. Stress is a problem when the individual is no longer in control, when the symptoms do not subside or when they appear in inappropriate situations.
Stress is the result of the interaction of various factors both occupational and domestic. Whereas each factor may be capable of being coped with individually, the coping mechanism becomes saturated if several factors converge.
Correspondence and reprint requests to: Dr E. McCloy, Department of Occupational Health and Safety, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
© 1992 Butterworth-Heinemann for SOM 0962-7480/92/030163-04
STRESS RECOGNITION Individuals may become aware of physiological, mental or personality changes as shown in Table 1 but if they are recognised for what they are and the underlying cause is admitted and evaluated then the individual remains in control. However, in terms of post-incident trauma, defining what may be traumatic for an individual may be difficult. In general, for an event to be universally traumatic it must include three characteristics; a critical high level of stress; which is experienced and reported as traumatic; and results in stress-associated feelings and symptoms following the event2. Features operating to determine whether incidents are critical or traumatic are shown in Table 2. They are situations where the rescuer feels 'powerless' because of the scale of the disaster, because of personal involvement or because of an analogy to his own family, in other words there is a 'trigger'. Post-incident trauma can be defined as a 'complex interaction of environmental and task stress, job competency, perceptional and emotional defences, management and follow-up support3'. Why exposure to certain situations may lead to this response in some people but not others is uncertain. An important factor may be the severity of the stress particularly in terms of gruesomeness. Each person will have their individual
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
Post-incident trauma relates to the results of exposure to death and destruction. It has specific features relating both to the incident and symptoms it produces. Reactive symptoms occur in most people in the immediate after-period but rising or persisting anxiety towards the end of the first week indicates a risk of a serious disorder developing. Management should start immediately after the event and is a three stage process. Immediate management involves de-briefing and peer group support of the participants in the incident. For those who continue to experience rising or persisting anxiety after the first week, referral to occupational health advisers, welfare/counsellors or general practitioners is necessary and, if symptoms persist or recur, tertiary referral to specialist advisers such as psychologists or psychiatrists may be required. The most important factor in the treatment of post-incident trauma is to acknowledge its existence. Whilst the coping mechanisms are well established in theory, they require widespread implementation in practice.
164 Occup. Med. 1992, Vol. 42, No 3 Table 1. Stress-related symptoms Physiological
Mental
Personality
neck, back pain palpitations chest pain breathing difficulty skin rashes headache, fatigue visual disturbance menstrual irregularity
tolerance irritability withdrawal emotional lability sleep disturbance inappropriate behaviour inappropriate dress libido
alcohol smoking eating habit indecision evasion absenteeism excusism erratic mood swings
Table 2. Criteria of a critical incident universally traumatic death/injury of fellow firefighter death/injury of children rescue where it is difficult to reach the victim rescue where victim is known to firefighter
elapse of time experience of the individual failure of interpersonal relationships litigation presence of-depression - substance abuse - impaired personality
threshold above which they may experience postincident trauma. What triggers a 'non-coping' reaction is where one or more of these factors operates for an individual — 'something unusual'. Some symptoms are particularly indicative of post-incident trauma as distinct from stress in general, for example, numbing and withdrawal, the re-experience of the event through thoughts and flash backs which may lead to sleep difficulties, particularly nightmares4. There may be intense guilt feelings that not enough was done at the time and these personal factors may be expressed at work as inefficiency or the application for a change in role such as less responsibility and, at home, with family or marital problems. Traumatic experiences induce reactive symptoms such as trembling, sweating and nightmares, in many if not most people, in the days after the event but these symptoms usually fade away. There are factors, listed in Table 3, which are peculiar to post-incident trauma and which may affect its recognition. Rising or persisting anxiety towards the end of the first week may indicate a risk of a serious disorder developing and suggest the need for early intervention.
TRAUMA
Negative outcome
Positive outcome
Normal duties
Positive outcome
Normal duties
Positive outcome
Normal duties
Continuing symptoms I I . SHORT TERM MANAGEMENT; Negative outcome
Welfare Occupational health General practitioner
Continuing symptoms
Negative outcome
MANAGEMENT To be effective, management should, in fact, start immediately after the event and take place in three stages, immediate, short-term and long-term. The flow
I . IMMEDIATE ACTION; Debriefing Jigsawing Peer support
I I I . LONG TERM MANAGEMENT; Psychiatrist Psychologist
Redeployment Retirement Figure 1. Post-incident trauma - management flow chart
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
Table 3. Post-incident trauma - modifying factors
chart {Fig. 1) shows how management is dictated by the outcome at each stage. Immediate management involves 'debriefing' sessions with peer group support. Within the Fire Service, which is where my own experience of managing post-incident trauma arises, peer group support already exists as the 'Watch', a group of men who live, eat, sleep, attend incidents together, creating a 'family'. This debriefing enables 'jigsawing' to take place, that is, the attempt by the individual to fit his role into the overall picture of the event which is an essential part of the coping mechanism. The opportunity to talk freely with colleagues immediately after the event may remove fears about job competency. This, for many of those attending the Manchester Ringway Airport Disaster in 1985 was effective because, at the end of the shift, the Watch had to stay together whilst statements were taken allowing time for informal debriefing and peer group support to occur. Another more recent example was the attendance of a fire crew at a special service call where a young man had jumped from a motorway bridge in front of an articulated lorry. The normal retrieval procedures took place, the crew relaxed and were
E. McCloy: Post-incident trauma
had not been burnt and therefore although he knew in technical terms the effects and outcome of smoke inhalation he had never witnessed it in practice. He had followed correct procedures and searched the dwelling for other victims before returning to evacuate the child and he had convinced himself that had he removed the child first he/she would have been alive. Having established the cause of his stress he was then taken in detail over training procedures and why they were essential and he accepted that it was because he was a 'good', ie competent firefighter, that he had made the right decision initially. If he had been incompetent and had followed his instincts having made the wrong diagnosis then there would be concrete grounds for doubting his ability in the future. Positive reinforcing that personnel have made the right judgement and undertaken the appropriate actions in a particular circumstance is very important in achieving a return to normal behaviour patterns. In respect of short-term management the occupational health physician or occupational health counsellor is in the best advisory role because of his/her specialist knowledge of the work environment and procedures. There will often need to be liaison with the general practitioner if medication or sickness absence is necessary. If problems persist either in the workplace or at home then specialist referral, Stage III of management is necessary. Treatment of an established disorder is difficult and will require the skills of a psychologist or psychiatrist with options such as cognitive/behavioural techniques and medication for associated disorders such as panic attacks. The final outcome will again be positive or negative the latter leading to recommendation for redeployment or retirement on health grounds. The ideal management of post-incident trauma is preventive. Debriefing should include a description of the incident with participants describing in detail the incident as they remember it. They must be encouraged to tell their own stories and speak about their own feelings which will be the normal results of exposure to the incident such as nausea, revulsion, guilt and inadequacies. The most important factor is to acknowledge the existence of post-incident trauma both as an organization and as an individual. There are personnel factors common to all emergency services which mitigate against this and which, as shown in Table 4, can be identified as selection for the career, expectations and personality. Nevertheless, the coping mechanisms and strategies are now well established in
Table 4. Post-incident trauma - personnel factors Selection
self selection training process
Expectation
superior coping ability
Personality
dominant thriving on challenge public demonstration of skill denial of internal feeling traditional group image
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
heading back to Station when they came across the victim's head a hundred yards down the motorway. It was also retrieved, but the Senior Officer who took the subsequent debriefing was sufficiently concerned about 4 members of the crew to notify me of the incident through our standard procedures. In the event those 4 crew members returned to normal duties the following day and there were no sequelae. However, the system is by no means 100 per cent effective. Who misses out? Firstly, the Officer-inCharge. This is not unique to the Fire Service but affects, in particular, the other emergency services where this first stage of management has not hitherto existed. One of the biggest problems is that stress is still thought of as a weakness. Rescue personnel are often reluctant to admit to symptoms in case colleagues think that they are 'softies'. There is also the concern that admissions of stress might prevent promotion so peer group support must exist at varying levels allowing similar ranking personnel the opportunity to discuss fears and worries without prejudice. When this debriefing situation fails then patterns of abnormal behaviour, both personal and work-related, may surface. Stage II, short-term management, now comes into operation when either the victim of post-incident trauma may self refer or a Senior Officer may refer the individual, as appropriate, to Welfare, Occupational Health Services when available, or advise the individual through counselling to talk to his general practitioner. In order for supervisory officers or managers to carry out this role effectively they must have the necessary training to recognise both abnormal work patterns and symptoms of stress. One incident within the Fire service involved a young, very competent firefighter with approximately four years' experience for whom, after a particular incident, the debriefing process did not occur. The crew had returned to Station at the end of their shift, they had immediately booked off and, for this individual, it was the start of a four day rest period so that when he returned to Station for his next period of duty the incident had, for everyone else, been forgotten. There had been no jigsawing, no peer group support or stories of similar incidents in the past. The particular circumstances for this young firefighter led to self perception of failure and incompetence although routine investigation had revealed that there had been no error of judgement. His work pattern changed, he was no longer 'first in'. He requested to change to driving duties and his involvement with activities on Station became less. He became withdrawn from social activities and at this point he was referred to me by his Senior Officer. Counselling takes time, particularly to find a trigger point for the individual. At the start of our counselling session this young firefighter knew that he could no longer face going to a fire and finding himself in an identical situation but he did not know why he had these feelings. He was taken back over previous events step by step and, it emerged, that a child who had died from smoke inhalation had been totally unmarked. He had never attended a fatality before where the victim
165
166
Occup. Med. 1992, Vol. 42, No 3
theory and rely on peer support, debriefing, family support and appropriate referral. They require, however, the widespread implementation in practice.
REFERENCES 1. 2.
ACKNOWLEDGEMENT This paper is based on a presentation given at a symposium in October 1989 titled 'Post Incident Trauma in the Emergency Services' organized by the Lancashire Group of the Institution of Fire Engineers.
3. 4.
Raphael B, Middleton W. After the horror. Br Med J 1988; 296: 1142-3. Bergmann LH, Queen TR. Reducing the impact of stress among fire fighters. Fire International 1987; 102: 23-4. Docherty RW. Post-disaster stress in the emergency rescue services. Fire Engineers Journal 1989; June: 8-9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders third edition, revised. Washington
DC: APA, 1987.
INTERNATIONAL SYMPOSIUM
LINZ, AUSTRIA 27-30 OCTOBER 1992 ORGANIZED BY International Labour Office Allgemeine Unfallversicherungsanstalt Bundeskammer Fur Arbeiter Und Angestelle This symposium will review the current state of research and practical action in the prevention of work-related diseases. It aims at encouraging an international and interdisciplinary exchange of information as well as developing practical strategies and programmes for implementation. Interest groups: health & safety specialists, practitioners, engineers, occupational physicians, industrial hygienists, scientists, inspectors, managers and employer organisations. Main themes I. Factors at the workplace contributing to specific work-related diseases and their prevention • musculoskeletal disorders/diseases • mental and psychological disorders/ diseases • cardiovascular, gastrointestinal, respiratory, allergenic diseases/disorders II. Concepts, strategies and action programmes in health promotion and prevention • differentiation and interrelationship between health promotion and prevention • role of organizations and institutions • economic, social and psychological aspects • strategies and programmes • concrete actions at enterprise level For further information plea.se contact: Symposium Secretariat, Allgemeine Unfallversicherungsanstalt, Kongressburo, Adalbert-Stifter-Strasse65, A-1200 Vienna, Austria Tel: + + 33 111-558 Fax: + + 33 111-469
Downloaded from http://occmed.oxfordjournals.org/ at University of Sussex on August 28, 2015
WORK-RELATED DISEASES; PREVENTION AND HEALTH PROMOTION
