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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. Synopsis of Presentation.

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slide1

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

synopsis of presentation
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
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
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 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

Relevance for Vocational Rehabilitation Specialists
slide6
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
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
PTSD Stressors
  • Violent human assault
  • Natural catastrophes
  • Accidents
  • Deliberate man-made disasters
signs and symptoms
Signs and Symptoms
  • Depends on a variety of individual, contextual, and cultural factors
  • Immediate
  • Acute
  • Chronic

www.ncptsd.va.gov

combat fatigue
“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

APA, 1994

acute stress disorder
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

slide12
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
Post Traumatic Stress Disorder
  • Chronic phase of adjustment to stressor across lifespan

APA, 1994

symptoms of ptsd
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
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)

APA, 2000

duration of ptsd
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
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 ptsd18
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 ptsd19
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
“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
“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
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
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
  • 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
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
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
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
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

slide29

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
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
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
work accommodation considerations33
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
work accommodation considerations34
Coping with stress 

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
work accommodation considerations35
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
work accommodation considerations36
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

Work Accommodation Considerations
work accommodation considerations37
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
work accommodation considerations38
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

Work Accommodation Considerations
work accommodation considerations39
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

Work Accommodation Considerations
managing treatment referral
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
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

Interpersonal functioning

Recreation and Self-care (i.e. sleep hygiene

Physical functioning

Psychological symptoms

Past distress and coping

Previous traumatic events

Deployment-related experiences

Considerations for Comprehensive Assessment of OIF/OEF veterans

Cozza et. al., 2004

primary care ptsd screen pc ptsd
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

Prins, et.al., 2004

identifying ptsd consultants specialists
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
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
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
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
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
slide49
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

slide50

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/

slide51

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
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
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
references
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.