An Overview Of Post-Traumatic Stress Disorder: What Vocational Rehabilitation Specialists Need to Know

1. 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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. PTSD Stressors • Violent human assault • Natural catastrophes • Accidents • Deliberate man-made disasters

9. Signs and Symptoms • Depends on a variety of individual, contextual, and cultural factors • Immediate • Acute • Chronic www.ncptsd.va.gov

10. “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

11. 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

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 one’s surroundings, derealization, depersonalization, or dissociative amnesia ASD is considered a predictor or PTSD, though not a necessary precondition APA, 1994

13. Post Traumatic Stress Disorder • Chronic phase of adjustment to stressor across lifespan APA, 1994

14. 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

15. 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

16. 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

17. Potential Consequences of PTSD Physiological Concerns • Physical complaints are often treated symptomatically rather than as an indication of PTSD www.ncptsd.va.gov

18. 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

19. Potential Consequences of PTSD Self-Destructive/Dangerous Behaviors: - Substance use - Suicidal attempts - Risky sexual behavior - Reckless driving - Self-injury www.ncptsd.va.gov

20. “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

21. “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

22. 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

23. 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)

24. 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

25. 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

26. 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

27. 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

28. 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

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 Harvey & Bryant, 1998; 2000

30. 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

31. 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

32. Lack of concentration  Reduce distractions Provide private space Music via headset Lighting Divide large assignments Plan uninterrupted work time Work Accommodation Considerations

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. Therapeutic Approaches/Techniques • Recovery plan and process • Empirically Supported Psychotherapies: • Exposure Therapies • Anxiety Management Training • Medications: SSRIs • Connecting and Networking Keane, et.al., 2006

46. 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

47. 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

48. 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

49. 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

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/