Encouraging Positive Outcomes when Working with PTSD and TBI

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A Testimony: . When he admitted problems about midway through a tour in Iraq, Army veteran Ron DeVoll Jr. of Cedar Falls says supervisors' attitudes changed. They talked down to me, called me a coward. You're supposed to be tough. You're supposed to be a man." I thought I was,' he says. In the

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Encouraging Positive Outcomes when Working with PTSD and TBI

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1. Encouraging Positive Outcomes when Working with PTSD and TBI Jeanne Barter, MS and CRC Vocational Rehabilitation Specialist North Eugene OVRS Mark Laughlin, MS and CRC Vocational Rehabilitation Specialist North Portland OVRS

2. A Testimony: “When he admitted problems about midway through a tour in Iraq, Army veteran Ron DeVoll Jr. of Cedar Falls says supervisors’ attitudes changed. ‘They talked down to me, called me a coward. “You’re supposed to be tough. You’re supposed to be a man.” I thought I was,’ he says. “In the course of seeking help, DeVoll told superiors he was having nightmares. ‘They said, “That’s normal. You’ll get over it”.’ The response DeVoll received in 2003 echoes that from earlier eras” (PTSD Combat).

3. PTSD – A Definition: Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop in response to exposure to an extreme traumatic event. These traumatic events may include military combat, violent personal assaults (e.g., rape, mugging, robbery), terrorist attacks, natural or man-made disasters, or serious accidents. The trauma can be directly experienced or witnessed in another person, and involves actual or threatened death, serious injury, or threat to one’s physical integrity. The person’s response to the event is one of intense fear or helplessness.

4. PTSD – Another Definition: Many people with PTSD repeatedly re-experience (crit. B) their ordeal (crit. A) in the form of flashback episodes, intrusive recollections of the event and nightmares. A stress reaction may be provoked when individuals are exposed to events or situations that remind them of the event. Avoidance of these triggering cues (crit. C) is a very significant feature of PTSD. Symptoms of PTSD may also include feeling detached from others, emotional “numbing,” difficulty sleeping, problems concentrating, irritability, being hyper-alert to danger, feeling “on-edge,” and an exaggerated startle response (crit. D).

5. PTSD – Another Definition (cont.): PTSD symptoms usually emerge within a few months of the traumatic event; however symptoms may appear many months or even years following a traumatic event. It is normal for most people to experience some symptoms following a traumatic event. PTSD diagnoses are based on the intensity and duration of these symptoms. For many, PTSD symptoms will resolve completely while, for others, symptoms may persist for many years (America’s Heroes at Work).

6. PTSD Assessment According to DSM-IV -Criterion A: Traumatic Stressor: actual or threatened death or serious injury, threat to physical integrity of self or others; in which the person’s response involved intense fear, helplessness, or horror.

7. Criterion B: Persistent Reexperiencing (one or more of the following): intrusive thoughts, images, perceptions; nightmares or distressing dreams; event recurrence or flashbacks; intense psychological distress with cue exposure; or physiological reactivity upon cue exposure.

8. Criterion C: Persistent Avoidance, Numbing of Responsiveness (three or more of the following): avoid thoughts, feelings, conversations; avoid activities, places, people; inability to recall important aspect of trauma; diminished interest or participation in activities; feeling detached or estranged from others; restricted range of affect; or foreshortened future.

9. Criterion D: Persistent Increased Arousal (two or more of the following): difficulty falling or staying asleep; irritability or anger outbursts; difficulty concentrating; hypervigilance; or exaggerated startle.

10. Criterion E: Duration of Symptoms B, C, and D > 1 month

11. Criterion F: Disturbance Causes Clinically Significant Impairment in Social, Occupational, or Other Important Areas of Functioning: Specify if acute: duration of symptoms < 3 months chronic: duration of symptoms > 3 months delayed Onset: symptom onset is at least 6 months after trauma (Lu).

12. PTSD Statistics: Of U.S. population, 8% (approximately 24 million people) develop PTSD during their lives. About one in five service members returning from Afghanistan and Iraq have symptoms of PTSD or depression. Only 23-40 % of the soldiers sought professional help, fearing this would hurt their military careers. Of veterans, 6 in 10 unlikely to seek help, fearing commanders and fellow troops would treat them differently.

13. PTSD and Perceived Barriers to Care: 41% - too embarrassing; 50% - it would harm my career; 51% - my leaders would blame me for the problem; 55% - getting off work for treatment would be difficult; 59% - members of my unit would have less confidence in me; 63% - my unit leadership might treat me differently; and 65% - I would be seen as weak.

14. Causes of TBI: open head injury – penetration of the skull (i.e., bullet wounds, etc.); closed head injury – no penetration of the skull (i.e., slip, fall, motor vehicle accidents, etc.); deceleration injuries – the skull is hard and inflexible while the brain is soft with the consistency of gelatin – the movement of the skull through space (acceleration) and the rapid discontinuation of this action (the skull meets a stationary object – deceleration) causes the brain to move inside the skull; chemical / toxic – harmful chemicals damage the neurons (i.e., insecticides, solvents, lead poisoning, etc.);

15. Causes of TBI (cont.): hypoxia (lack of oxygen) – blood flow is depleted of oxygen (i.e., heart attacks, respiratory failure, drop in blood pressure, or low oxygen environment); tumors – cancer growing over a portion of the brain; infections – viruses and bacteria can cause serious and life-threatening encephalitis or meningitis; or stroke – if blood flow is blocked through a cerebral vascular accident, cell death in the area deprived of blood will result.

16. Levels of TBI Severity: GCS PTA LOC mild 13-15 <1 hour <30 minutes moderate 9-12 30 1-24 minutes to hours 24 hours severe 3-8 >1 day >24 hours

17. TBI Severity Using PTA Alone: Severity PTA very mild <5 minutes; mild 5-60 minutes moderate 1-24 hours severe 1-7 days very severe 1-4 weeks extremely severe >4 weeks

18. Effects of TBI: mild TBI - loss of consciousness and/or confusion and disorientation is shorter than 30 minutes and cognitive problems may include headache, difficulty thinking, memory problems, attention deficits, mood swings, and frustration; or severe TBI – loss of consciousness is greater than 30 minutes and loss of memory is longer than 24 hours. “The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking or emotional problems. The range of injuries and degree of severity is very variable and varies on an individual basis.”

19. TBI Statistics: Veterans’ advocates believe between 10 and 20% of Iraq veterans have some level of TBI. Among wounded troops, rate of TBI rises to 33%.

20. PTSD with Co-occurring TBI: “Clinical guidelines not yet available” (Lu). “PTSD symptoms are common following severe TBI” (Williams, Evans, Wilson, and Needham).

21. Concussion and PTSD: “ ‘My brain has been rattled,’ is how a recently retired Marine…described the 50 to 60 explosions he estimates he felt while part of an ordnance disposal unit.” “TBIs are considered similar to a concussion, but because symptoms may not be apparent immediately, many soldiers are exposed multiple times, despite evidence from the sports world that damage can add up, especially if there’s little time between assaults” (Neergaard).

22. Loss of Consciousness and PTSD: of soldiers reporting loss of consciousness lasting a few seconds to two or three minutes, 43.9% met PTSD criteria; soldiers who lost consciousness were nearly three times more likely to meet criteria for PTSD; and these soldiers were significantly more likely to report poor general health, missed workdays, medical visits, and somatic and postconcussive symptoms than were soldiers with other injuries.

23. TBI with PTSD – The Debate: “The possibility that posttraumatic stress disorder (PTSD) can develop following traumatic brain injury (TBI) has been the subject of considerable debate. The traditional view has held that impaired consciousness that occurs with TBI precludes encoding of the traumatic experience, and this prevents subsequent reexperiencing symptoms….This review concludes that TBI populations provide a useful means by which the role of traumatic memories (and impaired memories) in posttraumatic adjustment can be studied” (Bryant).

24. Mild TBI and PTSD: “…the overall evidence confirms that PTSD is more likely to be a complicating comorbidity in people who suffer a mild TBI than among those who suffer a more severe injury….It is thought that a critical precedent for the development of PTSD is memory of the trauma itself associated with overwhelming feelings of horror/helplessness/fear followed by persistent reexperience or reminders that lead to anxiety/arousal and attempts to avoid these reminders or feelings. Since people with moderate to severe injuries are much less likely to retain memories of the trauma itself, they are much less likely to develop PTSD” (Heintz).

25. TBI and PTSD Symptoms: depression and anxiety; lapses in attention and concentration; sleep problems; emotional disturbance; social withdrawal; adjustment problems; fatigue; hyperarousal; and avoidance. Symptom flair-ups of one condition can intensify the symptoms of the other.

26. Factors Differentiating PTSD and Persistent Post-Concussive Symptoms (PPCS) PTSD re-experiencing symptoms; shame; and guilt. PPCS headache; sensitivity to light and sound; memory deficit; and dizziness.

27. Stigma Occurs When Others: don’t understand PTSD or think it a laughing matter; don’t realize PTSD is an illness that can be treated; think mental illness is “your own fault” or you can “get over it”; fear they might become mentally ill themselves; or think PTSD makes you dangerous.

28. The Threat Posed to the Individual or Others: people do not pose direct threat to themselves or others solely by virtue of PTSD diagnosis; employees managing symptoms through medication or psychotherapy unlikely to pose threat to themselves or others; and employers can reduce overall stress in work environment or mitigate known vulnerabilities to stress by providing job accommodations.

29. Helping Others to Better Understand PTSD: PTSD is medical condition that can be treated; highlight individual strengths and talents – PTSD does not need to restrict others from what they want to do; individuals may need breaks during activities and symptoms may make it harder to focus for a long time; and set, with family and doctors, manageable goals – clarify and accept desired (and reasonable) life changes.

30. PTSD and Another Disorder: it is common to have PTSD at same time as another mental health problem; depression, alcohol or substance abuse problems, panic disorder, and other anxiety disorders often occur with PTSD; often, PTSD treatments help with the other disorders, also; and best treatment results occur when PTSD and other problems are treated together rather than individually.

31. Treatment of PTSD: cognitive therapy helps client understand and change his or her thoughts about trauma and its aftermath; and therapy’s goal is to understand certain thoughts about trauma causing stress and worsening symptoms: ~ learn to identify thoughts about world and self leading to fear or anxiety; ~ replace inaccurate thoughts with more accurate and less distressing thoughts; and ~ learn ways to cope with feelings such as anger, guilt, and fear.

32. Treatment Progression: assessment and stabilization; functional goal setting; individualized therapies / rehabilitation; family support; accessing adjunct supports; and return to work. treatment for PTSD can last 3 to 6 months; and with additional mental health disorders, treatment may last 1 to 2 years or longer.

33. Creating Emotional Containment and External Executive Functioning: Problem: damage often results in emotional lability, impulse control problems, vulnerability to easily feeling overwhelmed, and impairment of ability to organize and implement planning successfully. Solutions: creation of external structure and processes which reduce environmental complexities and task demands, and provision of models, controls, and supports for emotional stability and successful adaptive functioning (Haciak).

34. The Role Employment Plays in Recovery: employment enables full participation in society; employment leads to higher life satisfaction and better adjustment; employment generates income vital to individual and family economic well-being; identity is closely tied to occupation - employment plays critical role in maintaining self-concept; employment affords opportunities to experience success, build self-esteem, and maintain psychological health; and work facilitates social interaction and connections reducing the isolation common in depression and PTSD.

35. Questions to Consider: if limitations are present, how do these affect employee and his or her job performance? what specific job tasks are affected by limitations? what accommodations are available to reduce or eliminate these problems? are all possible resources being used to determine possible accommodations? has employee with PTSD been consulted regarding possible accommodations? once accommodations are in place, would it be useful to meet with employee with PTSD to evaluate effectiveness of accommodations and determine need for additional accommodations? and do supervisory personnel and employees need training regarding PTSD?

36. Accommodations – Memory: provide written instructions; post written instructions for use of equipment; use wall calendar; use daily or weekly task list; provide verbal prompts and reminders; use electronic organizers or hand held devices; allow employee to tape record meetings; provide written minutes of each meeting; and allow additional training time.

37. Accommodations - Lack of Concentration: reduce distractions in work environment; provide space enclosures or a private space; allow for use of white noise or environmental sound machines; allow employee to play soothing music using cassette player and headset; increase natural lighting or increase full spectrum lighting; divide large assignments into smaller goal oriented tasks or steps; and plan for uninterrupted work time.

38. Accommodations - Time Management: make daily TO-DO lists and check items off as completed; divide large assignments into smaller tasks and steps; schedule weekly meetings with supervisor, manager, or mentor to determine if goals are being met; and remind employee of important deadlines via memos or e-mail.

39. Accommodations - Disorganization: use calendars to mark meetings and deadlines; use electronic organizers; hire professional organizer or organizational coach; and assign mentor to assist employee.

40. Accommodations - Coping with Stress: allow longer or more frequent work breaks; provide backup coverage when employee needs to take breaks; provide additional time to learn new responsibilities; restructure job to include only essential functions; allow time off for counseling; and assign a supervisor, manager, or mentor to answer employee’s questions.

41. Accommodations - Working with a Supervisor: give assignments, instructions, or training in writing or via e-mail; provide detailed day-to-day guidance and feedback; provide positive reinforcement; provide clear expectations and consequences of not meeting expectations; and develop strategies to deal with problems.

42. Accommodations – Relating with Co-workers: encourage employee to walk away from frustrating situations and confrontations; allow employee to work from home part-time; provide partitions or closed doors to allow for privacy; and provide disability awareness training to coworkers and supervisors.

43. Accommodations – Dealing with Emotions: refer to employee assistance programs (EAP); use stress management techniques to deal with frustration; allow use of a support animal; allow telephone calls during work hours to doctors and others for needed support; and allow frequent breaks.

44. Accommodations – Sleep Disturbance: allow employee to work one consistent schedule; allow for flexible start time; combine regularly scheduled short breaks into one longer break; and provide place for the employee to sleep during break.

45. Accommodations – Muscle Tension or Fatigue: build in “stretch breaks” during the workday; allow private space to meditate or do yoga; allow time off for physical therapy or massage therapy; and encourage use of company’s wellness program.

46. Accommodations – Absenteeism: allow for flexible start time or end time, or work from home; provide straight shift or permanent schedule; and modify attendance policy: ~ count one occurrence for all PTSD-related absences, or allow the employee to make up the time missed.

47. Accommodations – Panic Attacks: allow employee to take break and go to place he/she feels comfortable to use relaxation techniques or contact support person; identify and remove environmental triggers such as particular smells or noises; and  allow the presence of a support animal.

48. Accommodations – Diarrhea/Nausea: allow flexible bathroom breaks; move employee to location where he/she can access bathroom discreetly; and provide space for storing extra clothing or personal hygiene products.

49. Accommodations – Headaches: provide alternative lighting; provide breaks from computer work or reading print material; and practice stress-relieving techniques.

50. Accommodations – Transportation Issues: eliminate non-essential travel; provide driver; allow extra time for travel; and allow employee to bring a support person (Duckworth).

51. Army Responses to TBI and PTSD: The Army is training officers and senior executive service civilians “…how to recognize and help distressed Soldiers who may or may not recognize their unseen injuries.” “…leaders shouldn’t assume that because Soldiers have no visible injuries that all is well mentally.” Sometimes “…even the strongest of Soldiers are affected so severely that they need additional help,..so it’s important for leaders and Soldiers to be aware, recognize symptoms and watch for them in themselves and in their fellow Soldiers.”

52. Army Responses to TBI and PTSD (cont.): “The Army provides many sources to help Soldiers suffering from PTSD and mild TBI or other behavioral-health problems. These include chaplains, deployable stress-control teams, medical and behavioral-health clinics, and the Military One-Source hotline at 1-800-342-9647” (Leipold).

53. Potential Resources: Numerous resources to help employers and workforce development professionals address needs of employees with PTSD are found at America’s Heroes at Work (www.AmericasHeroesAtWork.gov). This source offers fact sheets on PTSD-related job accommodations and links to the Web sites of other organizations such as:

54. Potential Resources (cont.): The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury - http://www.ncptsd.va.gov/ncmain/index.jsp; Employer Support of the Guard and Reserve - http://www.esgr.org/; Hire Vets First - http://www.hirevetsfirst.gov/; The Job Accommodation Network - http://www.americasheroesatwork.gov/exit_jan.html; and Vocational Rehabilitation and Employment - http://www.vetsuccess.gov/.

55. References: America’s Heroes at Work. (n.d.). Frequently Asked Questions About Post-Traumatic Stress Disorder (PTSD & Employment. Retrieved 03-11-09from http://www.americasheroesatwork.gov/FAQPTSD.html. Brain Trauma Foundation. (n.d.). TBI in the Military. Retrieved 03-10-09 from http://www3.interscience.wiley.com/journal/110499079/abstract?CRETRY=1&SRETRY=0. Bryant, Richard A. Posttraumatic stress disorder and traumatic brain injury: can they co-exist? Clinical Psychology Review (Vol. 21, Issue 6, August 2001). Duckworth, Kendra M. (n.d.). Job Accommodation Network. Accommodation and Compliance Series: Employees with Post Traumatic Stress Disorder. Retrieved 03-11-09 from http://www.jan.wvu.edu/media/ptsd.html.

56. References (cont.): Dziedzic, Jessica. (March 2008). NeuroPsychiatry Review. Mild TBI Among US Soldiers Leads to PTSD and Physical Health Problems. Retrieved 03-11-09 from http://www.neuropsychiatryreviews.com/08mar/TBI_Soldiers.html. Epstein, Jack and Miller, Johnny. (June 22, 2005). San Francisco Chronicle. U.S. Wars and post-traumatic stress disorder. Retrieved 03-10-09 from http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/06/22/MNGJ7DCKR71.DTL&type=health. Haciak, Jacek (Jack) A., M.D. Oregon State Hospital Community Transition. The Brain Injury Association of Oregon Conference. “Brain Injury and PTSD: Finding a Sense of Control When Faced With Internal Chaos.” 03-06-10.

57. References (cont.): Heintz, Ron, M.D. Oregon State Hospital. The Brain Injury Association of Oregon Conference. “Traumatic Brain Injury.” 03-06-09. Hoge, Charles W., M.D., McGurk, Dennis, Ph.D., Thomas, Jeffrey L., Ph.D., Cox, Anthony L., M.S.W., Engel, Charles C., M.D., M.P.H., and Castro, Carl A., Ph.D. (January 31, 2008). The New England Journal of Medicine. Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. Retrieved 03-31-09 from http://content.nejm.org/cgi/content/full/358/5/453. Leipold, J.D. (August 1, 2007). Army News Service / America’s North Shore Journal. PTSD, Mild TBI Chain Teaching Begins at Pentagon. Retrieved 03-31-09 from http://northshorejournal.org/ptsd-mild-tbi-chain-teaching-begins-at-pentagon.

58. References (cont.): Lu, Mary, MD. PTSD Clinical Team, Portland VA Medical Center. The Brain Injury Association of Oregon Conference. “Postraumatic Stress Disorder in Returning Veterans.” 03-07-09. National Center for Posttraumatic Stress Disorder. (n.d.) Treatment of PTSD. Retrieved 03-10-09 from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.html?opm=1&rr=rr32&srt=d&echorr=true. Neergaard, Lauran. (November 10, 2009). Associated Press. Scanning Invisible Damage of PTSD, Brain Blasts. Retrieved 11-10-09 from http://www.google.com/hostednews/ap/article/ALeqM5gNBx5XTa06GwCmJTafpezew_SR1AD9BSHS7O1.

59. References (cont.): Powers, Ryan. (n.d.). PTSD, Work, and Your Community. Retrieved 03-11-09 from http://health.yahoo.com/hormone-resources/ptsd-work-and-your-community/healthwise--ad1040spec.html. PTSD Combat: Winning the War Within (April 6, 2006). PTSD Statistics, WWII to Iraq. Retrieved 03-10-09 from http://ptsdcombat.blogspot.com/2006/04/ptsd-statistics-wwii-to-iraq.html Williams, W. H., Evans, J. J., Wilson, B. A., and Needham, P. (2002) Brain Injury. Prevalence of post-traumatic stress disorder symptoms after severe traumatic brain injury in a representative community sample. Retrieved 03-10-09 from http://cat.inist.fr/?aModele=afficheN&cpsidt=13827646.

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