As healthcare, emergency and/or community service professionals we are privileged to be able to offer our skills and compassion to those suffering from physical and emotional health challenges, yet while doing so we must attend to our own needs to sustain our physical, mental, emotional and personal support systems to avoid “compassion fatigue” and burnout.

COMPASSION FATIGUE

What is compassion fatigue? Compassion fatigue is a potential problematic response when caring for others — it is more formally referred to as vicarious or secondary trauma, referencing the way that other people’s trauma can become our own.

Compassion fatigue occurs when we, consciously or unconsciously, take on the suffering of patients who are experiencing or have experienced extreme stress, trauma and/or tragedy. It is a common occupational hazard of professionals who work intimately with others and it represents a potential psychological stress from working to help heal those who are hurt or harmed.

When present, compassion fatigue can reduce your capacity to deliver optimally empathic and supportive professional care while also intruding on your thoughts, emotions and energy in your personal life.  A common factor contributing to compassion fatigue is the experience of burnout, which arises when an individual is faced with too much work and not enough resources to do that work well.  Combined, secondary trauma and a pressured work flow can result in physical and emotional exhaustion, less enjoyment of work, and may also result in interpersonal and interprofessional conflicts.

To keep compassion fatigue from developing or to address it emerges, compassion fatigue experts suggest that healthcare providers do the following:

Recognize the signs:  Some signs include loss of productivity, depression, intrusive thoughts, jumpiness, tiredness, feelings of being on edge or trapped, or inability to separate personal and professional life.

Make self-care part of your routine:   Good self-care means developing a routine that makes each day predictable and that includes: adequate sleep, healthy nutrition, physical activity, relaxation and socializing. The schedule should also include time for a self check-in each morning to assess tension in the body and worries in the mind.

Examine beliefs about self-care: It’s not enough to just go through the motions of self-care, it needs to be a legitimate attempt. In our society, we applaud people who work themselves to death and who neglect their own self-care to help others. We rarely applaud people for taking the day off. We may not reap the benefit of any self-care if we are worrying about work on a day off or feeling guilty for taking time off for fun and relaxation. Even a tiny dose of positive emotion, such as noticing flowers blooming, can help.

Practice self-compassion:   It’s important for caregivers to take time to reflect—alone and with a loving partner, a trusted colleague, religious leader, and/or a therapist—on any personal worries or wounds that may be surfacing because of work (or other life) demands.   Bearing witness to another person’s suffering can ignite distress within ourselves and fostering a compassionate sense of self-regard is vital in maintaining empathic capacity for those in need.

 Help colleagues:  Connecting with like-minded professional peers is another strategy that can help mitigate work related stress. Trusted colleagues can give each other permission to point out potential problems and keep at it despite attempts to deflect or deny.  It’s also important to normalize compassion fatigue. You could say, “These are crazy times, and I’m struggling.” she says. Then ask, “Is that something you’re going through, too?”

Create community:   Staying connected and open to family and friends can be beneficial in identifying early signs and alleviating the impacts of burnout and compassion fatigue.

Focus on compassion satisfaction:   There can be terrible things going on, but focus on the wins. Focusing on gratitude can help.

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Following are some mantras for self-compassion from Reducing Secondary Traumatic Stress: Skills for Sustaining a Career in the Helping Professions By Brian C Miller:

“Almost everything will work again if you unplug it for a few minutes, including yourself.”

“The heaviest burdens that we carry are the thoughts in our head”

“We don’t get to choose what to feel, we only get to choose whether to feel.”

“Words are the most important drug used by mankind”

“Deliberately moving our focus from the rumination (default mode) to task positive mode.”

“Those who thrive in this work do so for the simplest of reasons: They enjoy doing their jobs”

“If you laugh, you think, and you cry, that’s a full day. That’s a heck of a day. You do that seven days a week. You’re going to have something special.”

REFERENCES

https://www.apa.org/topics/covid-19/compassion-fatigue

Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924075/

When compared to non-stimulant FDA approved medications (atomoxetine, alpha agonists) stimulants, such as methylphenidate and amphetamine have a larger effect size (1.0 vs. ~0.7). As a result, these medications are often first line treatment for ADHD.  When prescribed and monitored appropriately, stimulant medications rarely induce major psychiatric side effects such as psychosis and/or exacerbate other disorders, but for some vulnerable youth, particularly adolescents, and in circumstances where the medications are misused (including in combination with illicit substances such as other stimulants or high potency marijuana, amongst others) serious problems can arise.

Whether the ongoing stressors associated with the Covid pandemic, including familial loss, financial strain and other issues, either on their own or in combination with co-occurring substance use  (legal as with ADHD stimulant agents or with illicit drugs) will lead to increased incidence of psychotic and/or other major potentially persisting psychiatric disorders remains to be evaluated.  Clearly as the pandemic has gone on there have been increased symptoms of anxiety and depression in children and adolescents generally (Zeytinoglu et al., 2021; Twenge, 2021) and those challenged with attentional difficulties have been additionally stressed by the challenges of remote learning and the distanced interpersonal environment.

While for some, efforts to enhance the capacities of youth who have challenges with focusing and attentiveness with prescriptions for stimulant or other ADHD medications, ongoing careful oversight, reassessment and monitoring for risk behaviors are recommended approaches.  What impact the pandemic has had and will have on the emergence of psychotic and/or major affective symptoms and pathologies in youth remains to be studied and better understood.  Historically, stressful life changes can exacerbate psychosis and other emotional disorders in vulnerable and at-risk populations, and we likely have seen and will continue to see instances of this among our youth in 2021 and beyond.

In summary, stimulant misuse and abuse is a common cause of psychotic symptoms (Henning et al., 2019) and it is important to consider that stimulant overuse, including higher therapeutic doses of FDA approved stimulants, can also cause these symptoms, as Henning, Kurtom and Espiridion’s referenced case below.  This also reminds us to screen for family history of psychotic and other mental illness in all of our ADHD patients.  Caution with the use of stimulants with youth at risk of experiencing psychotic symptoms is strongly recommended, and psychiatric consultation would be recommended for situations of concern.

References:

Henning, A., Kurtom, M., & Espiridion, E. D. (2019). A Case Study of Acute Stimulant-induced Psychosis. Cureus, 11(2), e4126. https://doi.org/10.7759/cureus.4126

Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. Pediatrics. 2020 Mar;145(3):e20193997. doi: 10.1542/peds.2019-3997. Erratum for: Pediatrics. 2019 Oct;144(4): PMID: 32111626.

Zeytinoglu, S., Morales, S., Lorenzo, N. E., Chronis-Tuscano, A., Degnan, K. A., Almas, A. N., Henderson, H., Pine, D. S., Fox, N. A. (2021) A Developmental Pathway from Early Behavioral Inhibition to Young Adults’ Anxiety During the COVID-19 Pandemic. Journal of the American Academy of Child and Adolescent Psychiatry. doi: 10.1016/j.jaac.2021.01.021

Twenge, J; The mental health of youth and their parents during the pandemic; presentation at 6^th Annual CICAMH conference, 3/19/21; San Diego

Mania and hypomania are mood states characterized by: elevated or irritable mood and a combination of symptoms such as increased energy, decreased need for sleep, irritability, feelings of inflated importance, excessive talkativeness (pressured speech), racing thoughts, exaggerated but poorly judged activities, and increased ‘pleasurable’ high risk behaviors. Mania or hypomania may also co-exist with depressive features in patients with bipolar profiles, so assessment may be challenging, but the presence of manic or hypomanic symptoms is a diagnostic key point. Input from relatives or others may be quite helpful in diagnostic assessment and treatment planning, as patients’ insight into their mood elevation may be impaired.

Levels of Care: When a patient presents with suspected manic or mixed affective symptoms, an early step in the process should include an evaluation as to the level of care needed. Assessment of the patient’s mood state, behavioral profile, and functionality are central to the triage and diagnostic process. Management options will range from acute referral for psychiatric care or prioritized referral for outpatient mental health care, but may also include primary care intervention to stabilize the patient’s symptoms while more intensive specialty care is being arranged. Medical evaluation of potential contributing factors will typically also be warranted as discussed further below.

Mania: In full blown manic states, patients typically present as pressured, intense and are often disorganized or showing restricted, hyper-focused interests. They often engage in harmful activities (e.g., reckless driving, substance use, sexual promiscuity) and may present with grandiose or even frankly delusional thinking, sometimes with psychotic symptoms such as hallucinations. Evaluation for both aggressive behaviors and suicidal tendencies needs to be undertaken and, most typically, referral for emergency psychiatric evaluation is warranted for stabilization and intensive treatment.

Hypomania: More subtle but still prominent changes in mood and behaviors are found in hypomanic states and deviations from a patient’s baseline personality is the central consideration to assess. Changes in sleep profile, an atypical sense of urgency about psychosocial issues, generalized psychological activation (rapid speech, internal thinking), and an altered level of judgment and insight about life activities are significant areas to note. A history of recurrent elevated mood episodes, not related to clear environmental stressors, may be diagnostically relevant.

Acute Stress Reactions: Differentiating manic symptoms from acute stress reactions to major life changes can be challenging as individuals’ responses to a variety of stressors (interpersonal problems, job crises, health problems, trauma exposure, etc.). Symptoms may include disruption in sleep, elevation of anxiety, and depressive mood and thought content. A central differentiating feature would be the absence of elevated mood and a coherence of the patient’s response to the stress.

Medical Concerns: Factors that may cause manic symptoms include medications such as antidepressants, which can trigger mania, as can stimulants and steroids (prescribed or used for body building). Recreational drug abuse or withdrawal may also trigger mania or mimic the symptoms, so obtaining a drug history and drug screen is recommended. Medical exam is important as manic symptoms may be mimicked in hyperthyroidism. A physical exam and a TSH level are indicated. Other medical differentials would include seizures or a stroke.

Primary Care Interventions: Recognition of the symptoms of mania and hypomania and review of the patient’s psychosocial functioning are first steps in PCP efforts. With a provisional diagnosis, medical evaluation and planning for appropriate referral are next steps.

When emergency referral is not needed, yet outpatient intervention is not readily available, efforts to manage disabling symptoms should be considered, typically focusing on sleep issues and psychomotor agitation. Typically, use of a sedating antipsychotic agent, such as quetiapine (Seroquel), or risperidone (Risperdal) in low to moderate dose range (Seroquel 50-100mg HS; Risperdal 1-2mg HS) could be considered as an initial intervention, with titration as indicated by patient response. Longer term treatments such as either lithium carbonate or an anticonvulsant mood stabilizer could also be considered as viable first line alternatives, but do require more lab monitoring (blood levels and LFTs with carbamazepine. Finally, short term use of a benzodiazepine might be considered for sleep and agitation.