Embed Size (px)
Citation preview
D I A G N O S T I C C H A N G E S , T R E AT M E N T, A N D A C C O M M O D AT I O N S
Post-traumatic Stress Disorder (PTSD)
Suzanne G. Martin, PsyD, MPHRegion 3 Mental Health Specialist
&
Kimberly Knodel, MARegions 5/6 Disability Coordinator
October 2014
2
BackgroundRisks and Variables
3
Background
PTSD necessarily involves exposure to a traumatic stressor.
Not everyone exposed to these events develops PTSD.
However, among those who develop PTSD, significant impairments in daily functioning (including interpersonal and academic functioning) are observed.
4
Who’s at Risk?
PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. This includes war veterans and survivors of physical and sexual assault, abuse, accidents, disasters, and many other serious events.
5
PTSD VariablesType of event
Predictability
Assaultive interpersonal violence
Fatalities
Severity of injury
Duration of event
Intensity of event
Exposure to event Physical and emotional proximity
What are some examples of traumatic events that JC
students might have experienced?
(Please enter your answer in the chat box.)
7
Diagnostic Considerations
Criterion and Symptoms
8
Diagnostic Considerations for PTSD
Based on Diagnostic and Statistical Manual 5th Edition (DSM 5)
9
Criterion A for PTSD
The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
10
Symptom Summary
A traumatic event plus: 1 or more Re-experiencing
symptoms
3 or more Avoidance symptoms
2 or more Increased arousal symptoms
Negative thoughts and mood or feelings*
*New to DSM 5
11
Re-experiencing Elements
Recurrent and intrusive distressing memories of the event
Recurrent dreams of the event
Sudden acting or feeling as if the traumatic event were recurring
Intense psychological distress at exposure to things that symbolizes or resembles an aspect of the trauma, including anniversaries thereof
Physiological reactivity when exposed to internal or external cues of the event
12
Avoidance Features
Efforts to avoid the thought or feelings associated with the trauma
Efforts to avoid activities, places, people or situations that arouse recollection of the trauma
Inability to recall an important aspect of the trauma (psychological amnesia)
Markedly diminish interest in significant activities
Feelings of detachment or estrangement from others
13
Avoidance Features
Restricted range of affect -unable to have loving feelings
Sense of foreshortened future - does not expect to have career, marriage, children or normal life span
14
Increased Arousal (not present before trauma)
Difficulty falling asleep or staying asleep
Irritability or outburst of anger (may lead to rage)
Difficulty concentrating
Hypervigilence (may look like paranoia)
Exaggerated startled response
15
Negative Thoughts/Mood
Feelings may vary from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event
16
Symptoms in Adolescents
With age, symptoms become increasingly similar to adult manifestations (Cohen et al., 2000). For example—a sense of
foreshortened future (e.g., diminished expectations of getting married, establishing a career, and experiencing a normal life span).
17
Symptoms in Adolescents
Those with chronic PTSD may present with self-injurious behaviors, suicidal ideation, conduct problems, dissociation, depersonalization, and/or substance abuse, which can mask the posttraumatic etiology of the disorder. (Cohen et al., 2000; Johnson, 1998)
* Childhood Posttraumatic Stress Disorder: Diagnosis, Treatment, and School Reintegration., By: Cook-Cottone, Catherine, School Psychology Review, 02796015, 2004, Vol. 33, Issue 1
18
Types of PTSD
1. Acute PTSD: Symptoms less than 3
months
2. Chronic PTSD: Symptoms more than 3
months
19
Two New Subtypes
PTSD Preschool Subtype, which is used to diagnose PTSD in children younger than 6 years
PTSD Dissociative Subtype, which is chosen when PTSD is seen with prominent dissociative symptoms
20
Immediate Onset Delayed Onset
Better response to treatment
Better prognosis (i.e., less severe symptoms)
Fewer associated symptoms or complications
Symptoms are resolved within 6 months
Characterized by an onset of symptoms at least 6 months after the stressor
Associated symptoms and conditions develop
Condition more likely to become chronic
Possible repressed memories
Worse prognosis
Time of Onset
21
PTSD Course
The symptoms and the relative predominance of re-experiencing, avoidance, and increased arousal symptoms may vary over time
Duration of symptoms also varies: Complete recovery occurs within 3-6 months after the trauma in approximately half of the cases
Others can have persisting symptoms for longer than 12 months after the trauma
22
Course Considerations
The severity, duration, and proximity of an individual’s exposure to a traumatic event are the most important factors affecting the likelihood of developing PTSD
Social supports, family history, childhood experiences, personality variables, and pre-existing mental disorders may influence the development of PTSD
23
Course Considerations
PTSD can also develop in individuals without any predisposing conditions, particularly if the stressor is extreme
The disorder may be especially severe or long lasting when the stressor is of human design (torture, rape, domestic violence, child abuse etc.) and/or ongoing over time
24
What might be some associated features you may see in a JC
student with PTSD?
(Please enter your answer in the chat box.)
25
Resilience Factors in PTSD
Seeking out support from other people, such as friends and family
Finding a support group after a traumatic event
26
Assessment Tools
Two main categories of PTSD evaluations are structured interviews and self report questionnaires Clinician Administered PTSD Scale
(CAPS) developed by National Center for PTSD structured interview
Post-traumatic Check List (PCL) self report
27
Self-report Questionnaires
Several self-report measures have been developed as a cost and time efficient way of obtaining information about PTSD distress. These measures provide a single score representing the amount of distress an individual is experiencing. PCL -- This measure comes in two versions. One is for
civilians and another specifically designed for military personnel and veterans.
Impact of Event Scale-Revised (IES-R)
28
Self-report Questionnaires Kean PTSD Scale of the
MMPI-2
Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians
The Post Traumatic Diagnostic Scale (PDS)
29
Differential Diagnosis
PTSD is frequently co-morbid with other psychiatric disorders including: Anxiety disorders
Acute stress disorder
Obsessive compulsive disorder
Adjustment disorder
Depressive disorders
Substance abuse disorders
30
Differences between
Diagnostic DisordersTypes, Course, Diagnosis
31
Differences between PTSD and Acute Stress Disorder
In general, the symptoms of acute stress
disorder must occur within four weeks of a
traumatic event and come to an end within
that four-week time period.
If symptoms last longer than one month and
follow other patterns common to PTSD, a
person’s diagnosis may change from acute
stress disorder to PTSD.
* http://psychcentral.com/lib/2006/differential-diagnosis-of-ptsd-symptoms
32
Differences between PTSD and Obsessive-Compulsive Disorder
Both have recurrent, intrusive thoughts as a symptom, but the types of thoughts are one way to distinguish these disorders.
33
Differences between PTSD and Adjustment Disorder
PTSD symptoms can also seem similar to adjustment disorder because both are linked with exposure to a stressor.
* http://psychcentral.com/lib/2006/differential-diagnosis-of-ptsd-symptoms
34
Differences between PTSD and Depression
Depression after trauma and PTSD both may present with numbing and avoidance features, but depression would not induce hyperarousal or intrusive symptoms.
35
Why PTSD Victims might be Resistant to Getting Help
It is sometimes hard because people expect to be able to handle a traumatic event on their own.
People may blame themselves.
Traumatic experience might be too painful to discuss.
Some people avoid the event altogether.
36
Why PTSD Victims might be Resistant to Getting Help
PTSD can make some people feel isolated making it hard for them to get help.
People don’t always make the connection between the traumatic event and the symptoms.
37
Neurobiology and Therapies
38
Role of Neurotransmitters
Norepinephrine Mobilizing fear, the flight response, sympathetic
activation, consolidating memory Too much = hypervigilence, autonomic arousal, flashbacks, and
intrusive memories
Serotonin Self-defense, rage and attenuation of fear
Too little = aggression, violence, impulsivity, depression, anxiety
39
Psychotherapy Approaches
Exposure Therapy Education about common reactions to
trauma, breathing retraining, and repeated exposure to the past trauma in graduated doses. The goal is for the traumatic event to be remembered without anxiety or panic resulting.
Cognitive Therapy Separating the intrusive thoughts from
the associated anxiety that they produce.
40
Psychotherapy Approaches
Stress Inoculation Training (SIT) Variant of exposure training
teaches client to relax. Helps the client relax when thinking about traumatic event exposure by providing client a script.
41
Psychotropic Medication
SSRIs Such as sertraline (Zoloft), Paroxetine (Paxil),
Escitalorpram (Lexapro), Fluvoxamine (Luvox), Fluxetine (Prozac)
Tricyclic Such as Clomiprimine (Anafranil), Doxepin (Sinequan)
Nortriptyline (Aventyl), Amitriptyline (Elavil), Maprotiline (Ludiomil) Desipramine (Norpramin)
Beta Blockers Such as Propranolol and Prazosin
42
Helpful Coping ToolsFree Smart Phone Apps
43
Accommodation Considerations
Strategies vs. Accommodations
44
Strategies vs. Accommodations
Strategies Refers to techniques used to assist one in learning how
to do a task or to accomplish a goal
Accommodations Changes to the environment or in the way things are
customarily done, that give a person with a disability an opportunity to participate in the application process, job, program or activity that is equal to the opportunity given to similarly situated people without disabilities
45
Strategy Accommodation
Use a highlighter to “highlight” key points or key words, etc.
Use relaxation techniques.
Provide a highlighter or provide highlighted content.
Provide a private place to use relaxation techniques.
Let’s Practice
46
SymptomsExamples of Functions
Impacted
Sleep problems
Irritability
Avoidance of certain situations/places
Anxious behavior and jitteriness (CMHC description/word)
Impulsiveness which sometimes is related to aggressive behavior
Depression like symptoms - no interest in activities, sad mood, general numbness, low energy
Concentration
Memory
Mood
Social interactions
Movement/Alertness
Symptoms Experienced by Job Corps Students with PTSD
47
Accommodations: Concentration
Distraction free workspace/secluded space for testing
Reduce visual and audio clutter Noise cancelling headset/MP3
player with soothing music
Limit content on the walls
Vibrating watches/visual timers
48
Accommodations: Concentration
Preferential seating
Break up large assignments into smaller tasks
Extended time for assignments, tasks, or in testing
Increased wait time for responses
Cues to return to task
Allow breaks
49
Accommodations: Memory
Provide written instructions and materials
Create daily task lists
Provide verbal prompts and reminders
Electronic organizers
Copies of notes
Allow to tape record
50
Accommodations: Mood
Irritable, angry, jittery, sad, etc. Some could also assist with sleep disturbance issues MP3 player with soothing/relaxation
music
Use of a therapy support animal
Special lighting
Re-locating or assigning a specific location for work space or sleeping space away from distractions/known stressors
51
Accommodations: Mood
Irritable, angry, jittery, sad, etc. Some could also assist with sleep disturbance issues Special pass to go to Health &
Wellness or other designated person when frustrated, angry, or highly anxious
Frequent breaks or shorter breaks combined into one longer one
52
Accommodations: Mood
Irritable, angry, jittery, sad, etc. Some could also assist with sleep disturbance issues Private space to use relaxation
strategies or other stress management techniques
53
What would be some of the desired self-management goals?
To reduce the need to go and talk to someone when stressed or upset during the workday.
Perhaps plan and use open walk-in hours to see needed staff or check-in with mentors.
Remember, these are future goals/suggestions with independence and employability in mind. The student may have the accommodation to adjust the training day and access needed resources as long as it is needed and remains reasonable.
Learn to use strategies and resources to self-manage moods.
Self-advocate for ability to use strategies and resources in the form of breaks, private space for break, etc.
54
Accommodations: Social Interactions
Set-up workspace so that the person is not surprised by others walking into the area
Permit individual to avoid certain mandated events (i.e. assemblies taped and provided on video tape)
Leave each class a few minutes early to get to next class and avoid crowded halls
Tip – Train student to use
conflict management techniques.
55
Accommodations: Energy Levels/Alertness
Dependent upon where the energy levels are low or high, accommodations might include: Frequent breaks
Vibrating watches
Modify training schedule to place more difficult class or classes in timeframe individual is typically most alert
Break assignments into smaller segments
Provide daily checklists with short term goals that are provided to a designated staff person at the end of the day
56
Accommodations: Self-Regulation
Mindfulness Allow a break to practice
mindfulness and relaxation techniques throughout center Mindful walking
Breathing exercise
Meditation
Mindful listening
Yoga classes
Mindfulness apps
57
Mindfulness Apps:
Stop, Breathe, and Think
https://www.youtube.com/watch?v=rOZeeD-wt08 https://itunes.apple.com/us/app/stop-breathe-think/id778848692?mt=8
Take a Chill
https://www.youtube.com/watch?v=hs60yqYwl7khttps://itunes.apple.com/us/app/take-a-chill-stressed-teens/id496802813?mt=8
Smiling Mind
https://www.youtube.com/watch?v=4myYefPGTn4 https://itunes.apple.com/us/app/smiling-mind/id560442518?mt=8
Accommodations: Self-Regulation
What are some of the accommodations that you have provided on center related to the functional limitation
areas we just covered?
Have you provided any accommodations for a student specific to needs related to PTSD?
59
ResourcesWebsites and Regional Experts
60
Regional Mental Health Specialists
Boston
Dave Kraft, MD, MPH
Maria Acevedo, PhD
Philadelphia/Lead
Valerie Cherry, PhD
Atlanta
Suzanne Martin, PsyD, MPH
Dallas
Lydia Santiago, PhD
Chicago
Helena Mackenzie
San Francisco
Vicki Boyd, PhD
Regional Health Specialists
61
Regional Disability Coordinators
Boston and Philadelphia Regions
Kristen Philbrook
Atlanta Region
Jasmin Merritt
Dallas Region
Laura Kuhn
Chicago and San Francisco Regions
Kim Knodel
Regional Disability Support
62
Job Accommodation Networkaskjan.org
63
Job Corps Health & Wellness Website
64
Job Corps Disability Website
65
Questions
