PTSD, Acute Stress, Performance and Decision-Making in Emergency Service Workers Cheryl Regehr, PhD, and Vicki R. LeBlanc, PhD Despite research identifying high levels of stress and traumatic stress symptoms among those in the emergency services, the impact of these symptoms on performance and hence public safety remains uncertain. This review paper discusses a program of research that has examined the effects of prior critical incident exposure, acute stress, and current post-traumatic symptoms on the performance and decision-making during an acutely stressful event among police officers, police communicators, paramedics and child protection workers. Four studies, using simulation methods involving video simulators, human-patient simulators, and/or standardized patients, examined the performance of emergency workers in typical workplace situations related to their individual profession. Results varied according to level of acuity of stress and the nature of performance and decision-making. There was no evidence that PTSD had a direct impact on global performance on tasks for which emergency responders are highly trained. However, PTSD was associated with assessment of risk in situations that required professional judgement. Further, individuals experiencing PTSD symptoms reported higher levels of acute stress when faced with high acuity situations. Acute stress in these studies was associated with performance deficits on complex cognitive tasks, verbal memory impairment and heightened assessment of risk. J Am Acad Psychiatry Law 45:184 –92, 2017 Society relies on professionals in emergency service oc- cupations to make sound judgements and perform ef- fectively in response to highly stressful, life-threatening events. Yet, as a result of working in such environ- ments, individuals in the emergency services are prone to high rates of stress-related problems 1 in- cluding posttraumatic stress disorder. 2 Studies of paramedics report trauma symptoms in a range con- sistent with PTSD in 20 to 30 percent of respon- dents. 3–5 A study of police communicators found that 31 percent reported symptoms at a level consis- tent with a diagnosis of PTSD. 6 Child protection workers, charged with assessing children at risk of abuse, report high levels of posttraumatic symptoms related not only to exposure to the trauma of others, but also to threats and assaults against themselves. 7 Following a critical event such as a police shooting of a civilian, trauma symptoms in the high or severe range can affect as many as 46 percent of the officers involved. 8 This association between emergency service work and posttraumatic stress has been recognized by or- ganizations providing disability insurance to workers such as the U.S. Federal Employees’ Compensation Act (FECA). 9 More explicitly, Section 24.2 2 of the Alberta (Canada) Workers’ Compensation Act that came into effect in December 2012 provides that: If a worker who is or has been an emergency medical tech- nician, firefighter, peace officer or police officer is diag- nosed with post-traumatic stress disorder by a physician or psychologist, the post-traumatic stress disorder shall be pre- sumed, unless the contrary is proven, to be an injury that arose out of and occurred during the course of the worker’s employment in response to a traumatic event or series of traumatic events to which the worker was exposed in car- rying out the worker’s duties [10]. This approach suggests an underlying assumption that PTSD, impairment of functioning, and disabil- ity are linked. To this end, psychiatrists and other mental health professionals are frequently called Dr. Regehr is Professor, Factor-Inwentash Faculty of Social Work, Faculty of Law and the Institute for Medical Sciences at the University of Toronto, Ontario, Canada. Dr. LeBlanc is Associate Professor and Chair of the Department of Innovation in Medical Education, Uni- versity of Ottawa, Ontario, Canada. Presented at the 43rd Ameri- can Academy of Psychiatry and the Law Annual Meeting, Mon- treal, Que ´bec, Canada, October 25–28, 2012, and at the 17th Canadian Academy of Psychiatry and Law Annual Meeting, Whis- tler, British Columbia, Canada, March 4 –7, 2012. Address correspon- dence to: Cheryl Regehr, PhD, Faculty of Law, University of Toronto, 27 King’s College Circle, Toronto, Canada, M5S 1A1. E-mail: cheryl.regehr@utoronto.ca. Disclosures of financial or other potential conflicts of interest: None. 184 The Journal of the American Academy of Psychiatry and the Law SPECIAL SECTION: STRESS AND TRAUMA