Title: An Overview Of Post-Traumatic Stress Disorder: What Vocational Rehabilitation Specialists Need to Know
1An Overview Of Post-Traumatic 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
2Synopsis of Presentation
- Overview of PTSD and other Stress Disorders
- Comorbid/Coexisting Issues
- Implications of PTSD on Vocational Status
- Therapeutic Assessment and Intervention
- Referral Consideration
3Relevance 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
4National 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)
5Relevance 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 post-deployment
(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
6- 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
7Definition 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)
-
8PTSD Stressors
- Violent human assault
- Natural catastrophes
- Accidents
- Deliberate man-made disasters
-
9Signs and Symptoms
- Depends on a variety of individual, contextual,
and cultural factors
10Combat Fatigue
- Immediate psychological and functional impairment
that occurs in war-zone/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
11Acute 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)
12- 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 ones
surroundings, derealization, depersonalization,
or dissociative amnesia - ASD is considered a predictor or PTSD, though not
a necessary precondition
13Post Traumatic Stress Disorder
- Chronic phase of adjustment to stressor across
lifespan
14Symptoms of PTSD
- Recurrent thoughts of the event
- Flashbacks/bad dreams
- Emotional numbness (it dont 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
15DSM-IV Criteria
- Essential Clusters of PTSD
- Re-experiencing symptoms (nightmares, intrusive
thoughts) - Avoidance of trauma cues and Numbing/detachment
from others - Hyperarousal (i.e. increased startle,
hypervigilance)
16Duration 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)
17Potential Consequences of PTSD
-
- Physiological Concerns
- Physical complaints are often treated
symptomatically rather than as an indication of
PTSD
18Potential Consequences of PTSD
- Social and Interpersonal
- Problems
- - Relationship issues
- - Low self-esteem
- - Alcohol and substance abuse
- - Employment problems
- - Homelessness
- - Trouble with the law
- - Isolation
19Potential Consequences of PTSD
- Self-Destructive/Dangerous
- Behaviors
- - Substance use
- - Suicidal attempts
- - Risky sexual behavior
- - Reckless driving
- - Self-injury
20Complex 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
21Complex PTSD
- Symptoms include
- Alterations in emotional regulation
- Alterations in consciousness
- Changes in self-perception
- Alterations in interpersonal relationships
- Changes in ones system of meanings
- Issues with misdiagnoses (i.e., Borderline)
- Ongoing research regarding its efficacy in
categorizing symptoms of prolonged trauma
22Comorbid/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
23TBI 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)
24Blast 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
25Why 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
26Enduring sequelae post TBI can result in
- Motor and sensory deficits
- Thinking, memory and learning difficulties
- Behavioral issues
- Higher rates of suicidal behaviors
- Psychiatric problems
27PTSD 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
-
28TBI ? 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
29- 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
30Difficulties 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
31Vocational 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
32Work Accommodation Considerations
- Reduce distractions
- Provide private space
- Music via headset
- Lighting
- Divide large assignments
- Plan uninterrupted work time
33Work Accommodation Considerations
- 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
34Work Accommodation Considerations
- 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
35Work 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
36Work Accommodation Considerations
- 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
37Work Accommodation Considerations
- 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
38Work Accommodation Considerations
- 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
39Work Accommodation Considerations
- 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
40Managing 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 -
41Care 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 -
42Considerations for Comprehensive Assessment of
OIF/OEF veterans
- Work functioning
- Interpersonal functioning
- Recreation and Self-care (i.e. sleep hygiene
- Physical functioning
- Psychological symptoms
- Past distress and coping
- Previous traumatic events
- Deployment-related experiences
43Primary 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.. - 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
44Identifying 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
45Therapeutic Approaches/Techniques
- Recovery plan and process
- Empirically Supported
Psychotherapies - Exposure Therapies
- Anxiety Management Training
- Medications SSRIs
- Connecting and Networking
46Specific 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
47Dealing with anger/irritability
- Anger is often the most troublesome problem
- Attempt to understand anger from the
individuals perspective - Intervene
- Recognition
- Establish boundaries/ rules
- Using time outs
- Follow emergency procedures if necessary
48Helpful 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
49- RESOURCES
- Veterans 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.coms trauma resource page - Department of Health Services- in the blue
government pages of the phone book
50- 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/
51See 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) SAMHSAs 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/blast
injury.html Projects for Assistance in
Transition from Homelessness (PATH)
1.800.795.5486 Job Accommodation Network
www.jan.wvu.edu
52Resources 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
53Take 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
post- deployment/civilian environment all
contribute to the level, severity and duration
of stress reactions
54Courage is learning to ask for help
55Thank YouJennifer.Olson-Madden_at_va.gov
56References
- 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 Clinicians 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
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Association, 295, 1023-1032. - Insurance Information Institute.
http//www.iii.org.