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


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

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

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
  • Operation Enduring Freedom/Operation Iraqi
  • 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
  • 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
  • Approximately 8 of Gulf War veterans have
    demonstrated symptoms (Duke and Vasterling, 2005)

Relevance for Vocational Rehabilitation
  • 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

  • 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
  • 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)

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

Signs and Symptoms
  • Immediate
  • Acute
  • Chronic
  • Depends on a variety of individual, contextual,
    and cultural factors

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

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)

  • 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

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

Symptoms of PTSD
  • Recurrent thoughts of the event
  • Flashbacks/bad dreams
  • Emotional numbness (it dont matter) reduced
    interest or involvement in work our outside
  • 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

DSM-IV Criteria
  • Essential Clusters of PTSD
  • Re-experiencing symptoms (nightmares, intrusive
  • Avoidance of trauma cues and Numbing/detachment
    from others
  • Hyperarousal (i.e. increased startle,

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
  • 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)

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

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

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

  • 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

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

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

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 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

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
  • Injured soldiers require specialized care
    acutely and over time

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
  • Emotional lability
  • Difficulty with attention and concentration
  • Amnesia for the event
  • Irritability and anger
  • Difficulty with over-stimulation
  • Social isolation/difficulty in social situations

  • 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

  • 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

Difficulties with PTSD Diagnosis
  • Onset of symptoms may not occur for months to
    years after trauma
  • Professionals may misdiagnose or not recognize
  • 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
  • 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
  • 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

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 ?

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

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

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

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
  • Allow the employee to make up time missed

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 ?

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

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
  • 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

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
  • Were constantly on guard, watchful, or easily
  • 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

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
  • Phone Book
  • Hospital/Medical Clinic Affiliation
  • Local and National Psychological Association

Therapeutic Approaches/Techniques
  • Recovery plan and process
  • Empirically Supported
  • Exposure Therapies
  • Anxiety Management Training
  • Medications SSRIs
  • Connecting and Networking

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
  • 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

Helpful Tips for Dealing with Angry Clients
  • Preemptively discuss the advantages and
    disadvantages of anger expression (i.e. in the
  • Seek consultation
  • Refer for therapy and psycho-educational

  • Veterans Affairs services
  • National Centers for PTSD or
  • 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

  • The Center for Mental Health Services Locator
  • Anxiety Disorders Association of America (ADAA)
  • Association for Advancement of Behavioral and
    Cognitive Therapies (database for CBT therapists)
  • http//
  • National Institute on Alcohol Abuse and
    Alcoholism http//
  • Substance Abuse Treatment Facility Locator
  • http//
  • Stanford University Center for Excellence in the
    Diagnosis and Treatment of Sleep Disorders

See 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
injury.html Projects for Assistance in
Transition from Homelessness (PATH)
1.800.795.5486 Job Accommodation Network
Resources for Families
  • Warzone-Related Stress Reactions What Families
    Need to Know
  • Families in the Military
  • Homecoming Dealing with Changes and
  • Homecoming Tips for Reunion

Take Home Points
  • Essential Features of PTSD
  • Re-experiencing symptoms (nightmares, intrusive
  • Avoidance of trauma cues
  • Numbing/detachment from others
  • Hyperarousal (i.e. increased startle,
  • 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

Courage is learning to ask for help
  • 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,
  • 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.).
  • Defense and of Veteran Brain Injury Center.
    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
  • 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)
  • 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.