Recognizing and treating PTSD speeds recovery
Recognizing and treating PTSD speeds recovery
Here are tips on managing post traumatic stress
Case managers understand physical trauma. It’s very easily identified and measured. Psychological trauma is often harder to recognize, yet left untreated, post-traumatic stress disorder (PTSD) may prevent your client from returning to the workplace.
"As case managers, as you work with people who have injuries, you must consider the role of trauma. Talking about psychological trauma is difficult because there is a subjective quality to it," says John H. Hung, PhD, LP, senior partner of Health Psychology Consultants in Edina, MN, and clinical assistant professor of family practice and community health at the University of Minnesota Medical School.
Any time a person experiences an event outside normal everyday experience, such as violence, illness, or injury — something unusual for that person — there is a response, notes Hung. Common responses to trauma, such as a work-related injury, include:
• shock;
• denial;
• disorganization;
• depression;
• guilt;
• anxiety;
• aggression;
• resolution and acceptance;
• reintegration.
"We know that following any type of trauma, those are universal human reactions. We need to be able to express our emotions freely to recover from a traumatic event. We need to cry, feel anger, feel sadness. We need to discuss what happened," says Hung.
However, not every client feels these needs immediately. "Your client may not need to talk about the accident until six weeks after the event. Others will start talking while they are still in the hospital," he explains.
But there is a difference between the normal human need to express anger or sadness over a traumatic event and PTSD. Not every client who experiences a traumatic event develops PTSD, and even among those who do, many recover without any treatment, notes Hung. "About 60% of clients with PTSD recover on their own. Of the remaining 40% many will have some symptoms but still function normally. It’s just a small percentage, perhaps as few as 10%, who can’t cope or resolve their symptoms without help," he explains.
Case managers should expect most clients to have decreased stress symptoms six to eight weeks after a traumatic event. "But if you are looking at a client who has been off the job for six months post injury and still refuses to return to the workplace, assess the possibility of PTSD."
PTSD is a psychiatric diagnosis that requires that clients meet specific criteria, says Hung. Those criteria include:
• Exposure to a traumatic event. "Without a traumatic event, there is no PTSD. If your client is fearful of a variety of things, you may be dealing with an anxiety disorder, but you aren’t dealing with PTSD," says Hung. "A traumatic event is one which involves a threat to one’s life or physical safety or the witnessing of a horrifying event out of the ordinary human experience."
• Re-experiencing of a traumatic event. To meet this criterion, the re-experience must be intrusive. "If six months after I lose my hand due to injury, I walk around and suddenly, not because some sight triggers a memory, I think about my hand — I remember vividly how it was caught in the die machine — I find that very upsetting because it is not under my control," says Hung.
Nightmares also may cause your client to re-experience the traumatic event. "Maybe I dreamt I was working on the die machine again and my hand was caught and I couldn’t get it out. Or I was being chased by someone and I couldn’t escape because I didn’t have my hand to open the door."
Sometimes, clients with PTSD have flashbacks. They don’t simply remember the event, they actually feel as if it was happening again. "I’ve seen Vietnam vets sitting in a room talking, and they will hear something that sounds similar to a helicopter and suddenly dive under a table."
• Avoidance or numbing phenomena. "This doesn’t mean simply avoiding the activity that lead to the injury. I consider that fairly normal. This means an avoidance of activity: withdrawal."
• Symptoms of increased arousal. Some clients exhibit irritability or outbursts of anger, notes Hung. "Clients may also have an exaggerated startle response — you come up behind them and they jump and run out of the room."
• Duration of greater than one month.
• Distress or impairment in function.
There are several key considerations for case managers working with PTSD patients, Hung notes. Those include:
• Timing of interventions. "I generally recommend that a case manager become involved with a PTSD case as quickly as possible. That doesn’t necessarily mean you jump in full blast, but establish contact. Let the client know you are available and express your concerns with the treating physician," recommends Hung.
• Debriefing. "This is very important from the employers’ standpoint. The case manager or the psychiatrist should put the employer, the employee, and the co-workers through a debriefing after a traumatic event in order to ease return to work down the road."
• Assessment of risk factors and complicating factors. "The greater the exposure, the greater the risk for PTSD. If I suffered an injury that took me off the job and then dragged out my benefits checks and I lost my house, then my wife left me after I lost the house, the greater the support [I would need]. Each exposure — the injury, the delayed payments, the loss of home, and the loss of the spouse — is an additional displacement.
"Review the details of the injury. If instead of losing consciousness when my hand got caught in the die machine and waking up in the hospital without my hand, I saw what happened, my exposure is much greater. My hand was caught in the machine for 20 minutes and I had to watch. I was afraid to move. That’s much worse than if your client lost consciousness and has no real memory of the trauma."
What’s your coping style?
It’s also important to understand your client’s coping mechanisms. "If my personality style has always been to deny or minimize negative situations, that is likely to continue. If my coping behavior when I’m under stress is not to answer the phone but to escape by reading or watching television, I may take longer to recover from trauma," notes Hung. "If my coping style is to call my friends and tell them I need some support, then it will help me a great deal and I’m likely to recover on my own."
He suggests case managers ask questions that help reveal their clients’ coping styles. "Ask family and friends, as well, how your client has handled experiences in the past."
Hung also recommends that case managers assess the "recovery environment." Issues to consider include:
— Social supports. What family is available? How is the family reacting to the trauma? Are the client’s friends accepting the trauma, or are they treating the client differently?
— Demographic profile. Children generally recover more quickly from trauma than adults, notes Hung. In addition, better-educated clients generally recover more quickly.
— Cultural characteristics. "If your client comes from a culture, like many Asian cultures, that places heavy emphasis on the appearance of the face, and your client has an injury which leaves a facial scar, your client’s reaction to the injury may be more dramatic than you would normally expect from such an injury," Hung says.
• Referral for professional treatment. "If your client is more than six weeks past a traumatic event, physically stable, but is still not sleeping and has started to abuse alcohol, that’s enough to refer them for psychiatric treatment," he says.
• Pharmacological management. Antidepres sants and anti-anxiety drugs may be effective in treating PTSD, says Hung.
• Returning to the environment where the trauma occurred. "Returning to the workplace is really one of the last tasks you must help your client through," says Hung. "You must be fairly confident that your client is recovered fully, or simply revisiting the machine that caused the injury may set your client back six months."
As a case manager, it may be your job to rule out PTSD rather than help identify it, Hung says. He was called in to evaluate a roofer who had fallen off a roof and suffered massive injuries. Although the man was fully recovered physically, he firmly refused to return to the job. Hung’s evaluation revealed that the man suffered from no flashbacks, startle response, or sleep disturbances.
"The man finally admitted that he was simply afraid to go back up on a roof. He told me he had always known he had a dangerous job even before his accident. He simply felt if he went back up on a roof again, he would be injured again. While I empathize, that’s not a psychiatric condition; I consider that quite sane. Unfortunately, there’s no good way to address that in workers’ comp."
In that case, Hung suggests the case manager intervene with the employer and attempt to find the employee another job within the company.
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