An Overview Of Post- Traumatic Stress Disorder: What Vocational Rehabilitation Specialists
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Transcript An Overview Of Post- Traumatic Stress Disorder: What Vocational Rehabilitation Specialists
An Overview Of PostTraumatic Stress Disorder:
What Vocational
Rehabilitation Specialists
Need to Know
Jennifer Olson-Madden, PhD
VISN 19 Eastern Colorado Healthcare System
Mental Illness Research, Education and Clinical
Center
Synopsis of Presentation
Overview of PTSD and other Stress
Disorders
Comorbid/Coexisting Issues
Implications of PTSD on Vocational Status
Therapeutic Assessment and Intervention
Referral Consideration
Relevance of the Topic
Operation Enduring
Freedom/Operation Iraqi Freedom
Particular impact of combat
Impact manifests across the lifespan
Individualized and personal accounts
of trauma
Each veteran will have unique set of
social, psychological, and psychiatric
difficulties
National Center for Post
Traumatic Stress Disorder
Statistics
7.8% of Americans experience PTSD
(Keane et al., 2006)
Women = 2X risk
30% of combat veterans experience PTSD
•
•
Approximately 50% of Vietnam veterans experience
symptoms
Approximately 8% of Gulf War veterans have
demonstrated symptoms (Duke and Vasterling, 2005)
www.ncptsd.va.gov
Relevance for
Vocational Rehabilitation
Specialists
Individuals with
traumatic stress
reactions may not seek
mental health care but
do seek out other health
related services
Only 1/3 of Iraq war
veterans accessed
mental health services
first year of postdeployment (Hoge, Auchterloine &
Milliken, 2006)
Recognition of PTSD or
other trauma-related
symptoms can:
Optimize clients’ overall
healthcare and treatment
through referral and triage
Aid in understanding and
taking action around clients’
difficulties in the work setting
Disclaimer
Information during this presentation is
for educational purposes only – it is
not a substitute for informed medical
advice or training. You should not use
this information to diagnose or treat a
mental health problem without
consulting a qualified
professional/provider
Definition of PTSD
An anxiety disorder resulting
from exposure to an
experience involving direct
or indirect threat of serious
harm or death; may be
experienced alone
(rape/assault) or in
company of others
(military combat)
www.ncptsd.va.gov
PTSD Stressors
Violent human assault
Natural catastrophes
Accidents
Deliberate man-made disasters
Signs and Symptoms
Immediate
Acute
Chronic
Depends on a variety of individual,
contextual, and cultural factors
www.ncptsd.va.gov
“Combat Fatigue”
Immediate psychological and functional
impairment that occurs in warzone/battle or during other severe
stressors during combat
Caused by stress hormones
Features of the stress reaction include:
Restlessness
Psychomotor deficiencies
Withdrawal
Stuttering
Confusion
Nausea
Vomiting
Severe suspiciousness and distrust
APA, 1994
Acute Stress Disorder
Anxiety occurring within one month
after exposure to extreme traumatic
stressor
Total duration of disturbance is two
days to a maximum of four weeks
(i.e., occurs and resolves within one
month)
APA, 1994
Symptoms of ASD include:
One
re-experiencing symptom
Marked avoidance
Marked anxiety or increased arousal
Evidence of significant distress or impairment
Three dissociative symptoms: a subjective sense of
numbing/detachment, reduced awareness of one’s
surroundings, derealization, depersonalization, or
dissociative amnesia
ASD
is considered a predictor or PTSD, though
not a necessary precondition
APA, 1994
Post Traumatic Stress Disorder
•
Chronic phase of adjustment to
stressor across lifespan
APA, 1994
Symptoms of PTSD
Recurrent thoughts of the event
Flashbacks/bad dreams
Emotional numbness (“it don’t matter”); reduced interest or
involvement in work our outside activities
Intense guilt or worry/anxiety
Angry outbursts and irritability
Feeling “on edge,” hyperarousal/ hyper-alertness
Avoidance of thoughts/situations that remind person of the trauma
APA, 1994
DSM-IV Criteria
Essential Clusters of PTSD:
1. Re-experiencing symptoms (nightmares,
intrusive thoughts)
2. Avoidance of trauma cues and
Numbing/detachment from others
3. Hyperarousal (i.e. increased startle,
hypervigilance)
APA, 2000
Duration of PTSD
- To meet criteria for PTSD, symptom
duration must be at least one month
Acute PTSD: duration of symptoms is
less than 3 months
Chronic PTSD: duration of
symptoms is 3 months or more
- Often, the disorder is more severe
and lasts longer when the stress is of
human design (i.e., war-related trauma)
APA, 1994
Potential Consequences of PTSD
Physiological Concerns
Physical complaints are often treated
symptomatically rather than as an indication of
PTSD
www.ncptsd.va.gov
Potential Consequences of
PTSD
Social and Interpersonal
Problems:
- Relationship issues
- Low self-esteem
- Alcohol and substance
abuse
- Employment problems
- Homelessness
- Trouble with the law
- Isolation
www.ncptsd.va.gov
Potential Consequences of
PTSD
Self-Destructive/Dangerous
Behaviors:
- Substance use
-
Suicidal attempts
Risky sexual behavior
Reckless driving
Self-injury
www.ncptsd.va.gov
“Complex PTSD”/DESNOS
Long-term, prolonged (months or years),
repeated trauma or total physical or emotional
control by another
-
Concentration camps
- Prisoner of war
Prostitution brothels
- Childhood abuse
- Long-term, severe domestic
or physical abuse
APA, 1994
“Complex PTSD”
Symptoms include:
• Alterations in emotional regulation
• Alterations in consciousness
• Changes in self-perception
• Alterations in interpersonal relationships
• Changes in one’s system of meanings
Issues with misdiagnoses (i.e., “Borderline”)
Ongoing research regarding its efficacy in
categorizing symptoms of prolonged trauma
APA, 1994; 2000
Comorbid/Coexisting Problems
Veterans with PTSD are also at risk for:
Depression and Anxiety
Substance abuse
Spectrum of severe mental illnesses
Aggressive behavior problems
Sleep problems like nightmares, insomnia or irregular
sleep schedules
Acquired Brain Injury
- Traumatic Brain Injury
It can be difficult for healthcare providers to prioritize target
treatment areas given the range of symptoms and difficulties
seen among veterans
www.ncptsd.va.gov
TBI Comorbidity
Head injury is damage to any part of
the head
TBI is damage to the brain triggered
by externally acting forces (i.e., direct
penetration, sustained forces, etc.)
A significant portion of soldiers from
OEF/OIF have sustained a brain
injury
Blast injuries are the leading
cause of injury in the current conflict
(DVBIC, 2005)
Blast injuries
• Blast injuries are injuries that result from the complex
pressure wave generated by an explosion
• Ears, lungs, and GI tract, brain and spine are especially
susceptible to primary blast injury
• Those closest to the explosion suffer from the greatest
risk of injury
• Additional means of impact:
Being thrown, debris, burns
dvbic.org
Why blast injuries are of
interest now
Armed forces are sustaining attacks
by rocket-propelled grenades,
improvised explosive devices, and land
mines almost daily in Iraq and
Afghanistan
Injured soldiers require specialized
care acutely and over time
DVBIC, 2005
Enduring sequelae post TBI
can result in:
– Motor and sensory deficits
– Thinking, memory and
learning difficulties
– Behavioral issues
– Higher rates of suicidal
behaviors
– Psychiatric problems
PTSD and TBI symptom
overlap:
Emotional lability
Difficulty with attention and concentration
Amnesia for the event
Irritability and anger
Difficulty with over-stimulation
Social isolation/difficulty in social situations
TBI PTSD
Research shows that
among TBI patients who
have a memory for the
event, they were more
likely to develop PTSD
than those with no
memory
dvbic.org
Among TBI patients, greater
risk for PTSD if:
•
History of ASD
•
Memory of trauma that
resulted in TBI
•
Co-morbid psychiatric
disorders
•
Avoidant coping style
Harvey & Bryant, 1998; 2000
Difficulties with PTSD
Diagnosis
Onset of symptoms may not occur for
months to years after trauma
Professionals may misdiagnose or not
recognize symptoms
Individual psychosocial factors may
interfere with individuals seeking help
Avoidant behaviors may result in an
inability for others to recognize the
need for treatment
Vocational Implications
•
•
•
•
•
Impact on well-being
Employability
Challenges for reservists
Military vs. civilian life issues
Job turnover and maintenance
Steady employment is one
predictor of better long-term
functioning
Work Accommodation
Considerations
•
•
•
Lack of concentration
•
•
•
Reduce distractions
Provide private space
Music via headset
Lighting
Divide large
assignments
Plan uninterrupted
work time
Work Accommodation
Considerations
Effective supervision
• Give information in writing
• Provide detailed, daily
feedback and guidance
• Provide positive
reinforcement
• Provide clear expectations
and consequences
• Develop strategies
together for dealing with
conflict
Work Accommodation
Considerations
•
•
•
Coping with stress
•
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•
Longer/frequent breaks
Backup coverage
Additional time for new
responsibilities
Restructure duties
during times of stress
Time off for therapy
Assign one mentor,
manager, supervisor
Work Accommodation
Considerations
Interacting with
co-workers
• Encourage the employee to
walk away
• Allow employee to work from
home part-time
• Provide partitions or closed
doors for privacy
• Provide disability awareness
training to coworkers/
supervisors
Work Accommodation
Considerations
•
•
Dealing with Emotions
•
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Refer to EAPs and vet
centers
Use stress management
techniques
Allow for a support
animal
Allow telephone calls
during work hours to
doctors, counselors
Allow frequent breaks
Work Accommodation
Considerations
•
•
Sleep disturbance
•
•
Allow employee one
consistent schedule
Allow for flexible start
time
Combine regularly
scheduled breaks into one
longer break
Provide place for
employee to sleep during
break
Work Accommodation
Considerations
•
•
Absenteeism
•
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•
Allow for flex time
Allow for work at home
Provide straight shift or
permanent schedule
Count one occurrence for all
PTSD-related absences
Allow the employee to make
up time missed
Work Accommodation
Considerations
•
Panic Attacks
•
•
Allow for a break or place
to go to use relaxation
techniques or contact a
support person
Identify and remove
environmental triggers
Allow presence of a
support animal
Managing Treatment
Referral
Identify at-risk individuals
History of psychiatric problems
Poor coping resources or capacities
Past history of trauma/mistreatment
ASD
Isolated
Financially burdened
Limited or no respite from work, family and social
demands
Stigma or faulty belief systems around seeking help
Care providers’ play a big role
Likelihood of interacting with
individuals with chronic PTSD is
high
Early assessment and
intervention is crucial
Understanding the presentation
of PTSD is important
Your role in the process of
identification and referral will be
key
Considerations for
Comprehensive Assessment of
OIF/OEF veterans
Work functioning
Psychological symptoms
Interpersonal
functioning
Past distress and coping
Recreation and Selfcare (i.e. sleep hygiene
Physical functioning
Previous traumatic
events
Deployment-related
experiences
Cozza et. al., 2004
Primary Care PTSD screen
(PC-PTSD)*
“In your life, have you had any experiences that
were so frightening, horrible, or upsetting that in the
past month you..”
a)
b)
c)
d)
Have had nightmares about it or think about it when you
did not want to?
Tried hard not to think about it or went out of your way to
avoid situations that remind you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your
surroundings?
* Endorsement of three items suggests that PTSD follow-up is
warranted for a formal diagnosis
Prins, et.al., 2004
Identifying PTSD
consultants/specialists
Expert therapists
Psychiatrists (MD/DO)
Clinical Psychologists (Ph.D./Psy.D.)
Social Workers (LCSW/MSW)
Psychiatric Nurse
VA Medical Centers/ VA PTSD programs/
VA Vet centers/ VA Community Based
Outpatient Clinics (CBOCs)
Phone Book
Hospital/Medical Clinic Affiliation
Local and National Psychological
Association
Therapeutic
Approaches/Techniques
Recovery plan and process
Empirically Supported
Psychotherapies:
Exposure Therapies
Anxiety Management Training
Medications: SSRIs
Connecting and Networking
Keane, et.al., 2006
Specific procedures to follow if a
client demonstrates PTSD
symptoms during your meeting:
Display calmness
Provide reassurance
Orient to place
Make periodic “check-ins” with the
client
Take a break
Guide
Implement an appropriate referral
Dealing with anger/irritability
Anger is often the most
troublesome problem
Attempt to understand anger from
the individual’s perspective
Intervene
Recognition
Establish boundaries/ “rules”
Using “time outs”
Follow emergency procedures if
necessary
Helpful Tips for Dealing with
Angry Clients
Preemptively discuss the advantages and
disadvantages of anger expression (i.e. in
the workplace)
Seek consultation
Refer for therapy and psycho-educational
groups/trainings
RESOURCES
•
Veteran’s Affairs services: www.va.gov
•
National Centers for PTSD www.ncptsd.va.gov or
www.ncptsd.org
•
VA Health Benefits Service Center 1.877.222.VETS or
1.800.827.1000
•
Vet Centers’ national number 1.800.905.4675
•
PTSD support groups can be located through VA, National
Alliance for Mental Illness (NAMI), or About.com’s trauma
resource page
•
Department of Health Services- in the blue government
pages of the phone book
The Center for Mental Health Services Locator
http://www.mentalhealh.samhsa.gov/databases/
Anxiety Disorders Association of America (ADAA)
Association for Advancement of Behavioral and
Cognitive Therapies (database for CBT therapists)
http://www.alcoholanddrugabuse.com
National Institute on Alcohol Abuse and Alcoholism
http://www.niaaa.nij.gov/faq/faq.htm
Substance Abuse Treatment Facility Locator
http://findtreatment.samhsa.gov/
http://www.alcoholics-anonymous.org/
Stanford University Center for Excellence in the
Diagnosis and Treatment of Sleep Disorders:
www.med.stanford.edu/school/psychiatry/coe/
See www.mentalhealth.samhsa.gov/hotlines/ for list of
phone numbers
National Mental Health Hotline 1.800.969.NMHA (6642)
National Resource Center on Homelessness and Mental
Illness 1.800.444.7415
National Suicide Prevention Lifeline 1.800.273.TALK
(8255)
SAMHSA’s Center for Substance Abuse Treatment
1.800.662.HELP
Su Familia (Office of Minority Health Resources)
1.866.783.2645
Blast Injury: www.dvbic.org/blastinjury.html
Projects for Assistance in Transition from Homelessness
(PATH) – 1.800.795.5486
Job Accommodation Network: www.jan.wvu.edu
Resources for Families
• “Warzone-Related Stress Reactions: What Families Need
to Know”
• “Families in the Military”
• “Homecoming: Dealing with Changes and Expectations”
• “Homecoming: Tips for Reunion”
Iraq War Clinician Guide, 2nd Edition;
www.ncptsd.va.gov
Take Home Points
Essential Features of PTSD
Re-experiencing symptoms (nightmares, intrusive
thoughts)
Avoidance of trauma cues
Numbing/detachment from others
Hyperarousal (i.e. increased startle, hypervigilance)
A variety of factors including personal, cultural,
and social characteristics, coping abilities,
experiences in war, and the postdeployment/civilian environment all contribute to
the level, severity and duration of stress reactions
“Courage is learning to
ask for help”
Thank You
[email protected]
References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric
Association: Washington, D.C.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised. American
Psychiatric Association: Washington, D.C.
Cozza, S.J., Benedek, D.M., Bradley, J.C., Grieger, T.A. (2004). Topics specific to the psychiatric treatment of military personnel. In Iraq War
Clinician’s Guide (2nd Ed.). http://www.ncptsd.va.gov/war/guide/index.html
Defense and of Veteran Brain Injury Center. http://www.dvbic.org/blastinjury.html. Downloaded 09/15/2007.
Duke, L.M. & Vasterling, J.J. Epidemiological and methodological issues in neuropsychological research on PTSD. In Neuropsychology of PTSD:
Biological, Cognitive and Clinical Perspectives. Vasterling & Brewin, Eds. The Guilford Press: 2005.
Harvey, A.G., & Bryant, R.A. (1998). Predictors of acute stress following mild traumatic brain injury. Brain Injury, 12, (2): 147-154.
Harvey, A.G. & Bryant, R.A. (2000). Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic
stress disorder following traumatic brain injury. The American Journal of Psychiatry, 157, (4): 626-628.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D. (2004). Combat duty in Iraq and Afghanistan, mental health problems and barriers to care.
The New England Journal of Medicine, 35, (1): 13-22.
Hoge, C.W., Auchterloine, J.L., Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from military service
after returning from deplloyment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023-1032.
Insurance Information Institute. http://www.iii.org.
National Center for PTSD. http://www.ncptsd.va.gov
Prins, A., Ouimette, P., Kimerling, R., Camerond, R.P., Hugelshofer, D.S., Shaw-Hegwar, J., Thraikill, A., Gusman, F.D., Sheikh, J.I. (2004).
The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care Psychiatry, 9 (1), January 2004, 9-14.