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

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 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
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
www.ncptsd.va.gov
(Duke and Vasterling, 2005)
 Relevance for
Vocational Rehabilitation
Specialists
Individuals with Recognition of PTSD or
traumatic stress other trauma-related
reactions may not symptoms can:
seek mental health Optimize clients overall
care but do seek out healthcare and treatment
other health related through referral and triage
services
Aid in understanding and
taking action around
Only 1/3 of Iraq war clients difficulties in the
veterans accessed work setting
mental health
services first year of
post-deployment (Hoge,
Auchterloine & Milliken, 2006)
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)

www.ncptsd.va.gov
 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
www.ncptsd.va.gov
 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

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
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

ASDis considered a predictor or PTSD,

though not a necessary precondition
APA, 1994
 Post Traumatic Stress
Disorder
Chronic phase of adjustment to
stressor across lifespan

APA, 1994
 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

APA, 1994
 DSM-IV Criteria

Essential Clusters of PTSD:

1. Re-experiencing symptoms
(nightmares, intrusive thoughts)
2. Avoidance of trauma cues and
Numbing/detachment from others
3. Hyperarousal (i.e. increased startle,
hypervigilance)

APA, 2000
 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

Physiological Concerns

Physical complaints are often treated

symptomatically rather than as an
indication of PTSD

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

www.ncptsd.va.gov
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

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

APA, 1994; 2000

 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

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
dvbic.org
 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:
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

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
 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; 20
00
 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

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
Reduce distractions
Provide private
space
Lack of concentration Music via headset
Lighting
Divide large
assignments
Plan uninterrupted
work time
 Work Accommodation
Considerations
Give information in writing
Provide detailed, daily
feedback and guidance
Provide positive
Effective supervision reinforcement
Provide clear expectations
and consequences
Develop strategies
together for dealing with
conflict
 Work Accommodation
Considerations
Longer/frequent
breaks
Backup coverage
Additional time for
Coping with stress new responsibilities
Restructure duties
during times of stress
Time off for therapy
Assign one mentor,
manager, supervisor
 Work Accommodation
Considerations
Encourage the employee
to walk away
Allow employee to work
Interacting with from home part-time
co-workers Provide partitions or
closed doors for privacy
Provide disability
awareness training to
coworkers/ supervisors
 Work Accommodation
Considerations
Refer to EAPs and vet
centers
Use stress
Dealing with Emotions management
techniques

Allow for a support
animal
Allow telephone calls
during work hours to
doctors, counselors
Allow frequent breaks
 Work Accommodation
Considerations
Allow employee one
consistent schedule
Allow for flexible start
Sleep disturbance time
Combine regularly
scheduled breaks into
one longer break
Provide place for
employee to sleep
during break
 Work Accommodation
Considerations

Allow for flex time

Allow for work at home
Provide straight shift or
Absenteeism permanent schedule
Count one occurrence for
all PTSD-related absences
Allow the employee to
make up time missed
 Work Accommodation
Considerations
Allow for a break or
place to go to use
relaxation techniques
Panic Attacks or contact a support
person
Identify and remove
environmental triggers
Allow presence of a
support animal
 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

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 Psychological symptoms

Interpersonal Past distress and coping

functioning
Previous traumatic
Recreation and Self- events
care (i.e. sleep hygiene
Deployment-related
Physical functioning experiences

Cozza et. al., 2004

 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..

a) Have had nightmares about it or think about it when

you did not want to?
b) Tried hard not to think about it or went out of your
way to avoid situations that remind you of it?
c) Were constantly on guard, watchful, or easily startled?
d) 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
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

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:
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 workplace)

Seek consultation

Refer for therapy and psycho-

educational groups/trainings
 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
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/
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)

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/blastinjury.html

Projects for Assistance in Transition from Homelessness

(PATH) 1.800.795.5486

Job Accommodation Network: www.jan.wvu.edu

 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
 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
Courage is learning
to ask for help
 Thank You

Jennifer.Olson-Madden@va.gov
 References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
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 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.
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,
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,
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,
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,
Psychiatry, 9 (1), January
2004, 9-14.