An Overview Of PostTraumatic Stress Disorder: What Vocational Rehabilitation Specialists Need to Kno

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An 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

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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

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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

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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)

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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 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

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• 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

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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)

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PTSD Stressors

• Violent human assault
• Natural catastrophes
• Accidents
• Deliberate man-made disasters

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Signs and Symptoms

• Immediate
• Acute
• Chronic

• Depends on a variety of individual, contextual,
  and cultural factors

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Combat 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

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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)

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• 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

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Post Traumatic Stress Disorder

• Chronic phase of adjustment to stressor across
  lifespan

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Symptoms 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

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DSM-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)

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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)

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Potential Consequences of PTSD

• Physiological Concerns
• Physical complaints are often treated
  symptomatically rather than as an indication of
  PTSD

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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

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Potential Consequences of PTSD

• Self-Destructive/Dangerous
• Behaviors
• - Substance use
• - Suicidal attempts
• - Risky sexual behavior
• - Reckless driving
• - Self-injury

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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

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Complex 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

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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

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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)

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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

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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

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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

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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

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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

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• 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

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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

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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

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Work Accommodation Considerations

• Lack of concentration ?

• Reduce distractions
• Provide private space
• Music via headset
• Lighting
• Divide large assignments
• Plan uninterrupted work time

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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

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Work 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

• Coping with stress ?

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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

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Work Accommodation Considerations

• Dealing with Emotions ?

• 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

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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

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Work Accommodation Considerations

• Absenteeism?

• 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

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Work 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

• Panic Attacks ?

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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

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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

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Considerations 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

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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..
• 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

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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

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Therapeutic Approaches/Techniques

• Recovery plan and process
• Empirically Supported
  Psychotherapies
• Exposure Therapies
• Anxiety Management Training
• Medications SSRIs
• Connecting and Networking

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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

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Dealing 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

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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

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• 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

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• 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/

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See www.mentalhealth.samhsa.gov/hotlines/ for
list of phone numbers National Mental Health
Hotline [phone].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
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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

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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
  post- deployment/civilian environment all
  contribute to the level, severity and duration
  of stress reactions

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Courage is learning to ask for help
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Thank YouJennifer.Olson-Madden_at_va.gov
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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
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  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.
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• Harvey, A.G., Bryant, R.A. (1998). Predictors
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• Harvey, A.G. Bryant, R.A. (2000). Two-year
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  The American Journal of Psychiatry, 157, (4)
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• Hoge, C.W., Castro, C.A., Messer, S.C., McGurk,
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• Hoge, C.W., Auchterloine, J.L., Milliken, C.S.
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• Insurance Information Institute.
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