BUILDING A PTSD PREVENTION PLAN DR. ASH BENDER, MD, FRCPC KIM SLADE, DIRECTOR RESEARCH AND PRODUCT DEVELOPMENT PSHSA

Transcription

1 BUILDING A PTSD PREVENTION PLAN DR. ASH BENDER, MD, FRCPC KIM SLADE, DIRECTOR RESEARCH AND PRODUCT DEVELOPMENT PSHSA 1

2 THIS SESSION IS DESIGNED TO HELP YOU Understand what PTSD is and how it might present itself in the workplace Utilize the PTSD Prevention Framework and Toolkit on the site Get started on developing a PTSD Prevention Plan utilizing strategies across prevention, intervention and recovery and return to work 2

3 WORK, STRESS AND HEALTH Specialty program assessing and treating injured Ontario workers since 2002 at CAMH (non- OHIP) Multidisciplinary team Psychiatry and Psychology Occupational Therapy Multidisciplinary treatment Psychological Treatment Medication Management RTW coordination Positive disability outcome in 55% of clients! 3

4 WHAT IS PTSD? 4

5 PTSD IS COMMON General Population Rates 10.4% (W) and 5.0% (M) lifetime prevalence 5%(W) and 1.7%(M) current full PTSD Rates of full PTSD equal those with partial PTSD Higher in Specific Samples Immigrants = 5-75% Sexual assault victims = 20-40% Urban Mental Health Clinics = 42% Soldiers = 12-30% EMS = 7-22% 5

6 RISK FACTORS FOR TRAUMATIC SEQUELAE Younger age (16-20) Female Repeated traumas Violent and assaultive traumas Preexisting and family history of mental disorder Substance use Women more likely to experience dissociation and numbing following assaultive trauma 6

7 OTHER RISK FACTORS Severity of the trauma Proximity to the trauma Other significant negative stressful events prior to the trauma Low supports More psychological symptoms following trauma High degree of physiological hyperarousal following the trauma 7

8 EVOLVING DEFINITIONS OF PTSD The American Psychiatric Association released the DSM-V in May 2013 and criteria for PTSD Narrowed qualifying traumatic events such that the unexpected death of family or a close friend due to natural causes is no longer included. Specific recognition of recurrent workplace exposures affecting police officers and emergency personnel. PTSD diagnosis must include at least one avoidance symptom. Requirement the response to traumatic event involved intense fear, hopelessness, or horror, was removed.

9 DSM-5 CRITERIA FOR PTSD The DSM-5 diagnostic criteria identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual: directly experiences the traumatic event; witnesses the traumatic event in person; learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related). The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol APA Fact Sheet (2013) 9

10 DSM-5 CRITERIA FOR PTSD Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual s response to the event intense fear, helplessness or horror, according to DSM-IV has been deleted because that criterion proved to have no utility in predicting the onset of PTSD. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal. APA Fact Sheet (2013) 10

11 DSM-5 CRITERIA FOR PTSD Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress. Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event. Persistent avoidance of stimuli associated with the traumatic event(s), such as though, feelings, reminders and external stimuli (triggers). Negative cognitions and mood represents myriad feelings, 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. Arousal is marked by aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance or related problems. The current manual emphasizes the flight aspect associated with PTSD; the criteria of DSM-5 also account for the fight reaction often seen. APA Fact Sheet (2013) 11

12 AREAS OF BRAIN AFFECTED BY PTSD Sensory input, memory formation and stress response mechanisms are affected in patients with post-traumatic stress disorder (PTSD). The regions of the brain involved in memory processing that are implicated in PTSD include the hippocampus, amygdala and frontal cortex. While the heightened stress response is likely to involve the thalamus, hypothalamus and locus coeruleus.

13 HOW LONG DOES PTSD LAST? Traumatic Event 1 month 9 months 3 years Usual onset of symptoms Many recover without treatment within months/years of event (45-80% natural remission at 9 months) Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems NICE Guidelines 13

14 PTSD OFTEN NOT THE ONLY ISSUE Mood Disorders Brain Injuries PTSD Anxiety Disorders Substance Disorders 14 Kessler RC. Posttraumatic stress disorder: the burden to the individual and society. J Clin Psychiatry 2000;61 (suppl 5)

15 CANADIAN FORCES 2779 Personnel on deployment to Afghanistan 31% Stress, emotional, alcohol or family issues 20% Concussive injuries 5.3% Anxiety 4.7% Depression 4.6% Acute Traumatic Stress Post-deployment screenings of 16, % Any mental health symptoms 3.3% Minor Depression 3.2% Major Depression 2.8% Posttraumatic Stress Disorder Zamorski MA et al. 2014, Garber et al. 2012

16 SOURCES OF PSYCHOLOGICAL INJURY Nonoccupational stressors Excessive job strain Critical Incident Exposure 16

17 CRITICAL INCIDENT Event or series of stressful events Overwhelms an individuals ability to cope Disrupts an individuals and organizations ability to function normally 17

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19 CRITICAL INCIDENTS IN FIRST RESPONDERS Rare incidents such as major disasters and terrorist events; Witnessing the death or injury of coworkers Sustaining a serious injury Being exposed to hazardous substances Attending multiple fatalities Incidents involving infants, young children and families Risking own life in course of duties

20 PTSD Symptoms Irritability Sadness Anxiety Flashbacks Intrusive Reminders Nightmares Hopelessness Impaired concentration Distractibility Memory problems Sleep changes Fatigue and pain Medication/Treatment Loss of trust Stigma of Mental Illness Emotional Situational Cognitive Physical Values/Beliefs Work Impairment Conflict Isolation Family problems Avoidance of triggers Unexpected reactions Substance use Suicide Reduced productivity Increased errors Loss of confidence Reduced endurance Missed days Problems working shifts Disputes with employer Confidentiality concerns

21 RISK FACTORS FOR TRAUMA DISABILITY Severity of the trauma Proximity to the trauma Dissociation at time of event High degree of physiological hyperarousal following the trauma Other significant negative stressful events prior to the trauma Low supports More symptoms 21 MacFarlane et al., Occup Med, 2007 Cheung et al., Rehab Psychol, 2003

22 ORGANIZATIONAL RISK FACTORS Culture beliefs/myths of resilience which promote denial/stigma Dispute-driven rather than health-driven policy Adversarial approaches to management of those at risk Inadequate resources to address problem 22

23 PTSD AND SUICIDE Suicide is a complex and catastrophic outcome often associated with mental illness Numerous media publications regarding first responders About twice risk in Veteran VA users Male was Female was Trauma survivors with PTSD have a significantly higher risk of suicide than those without PTSD Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessment of suicidal behavior. Journal of Traumatic Stress, 11,

24 Mental Health Continuum Model HEALTHY REACTING INJURED ILL Good Mental health Normal functioning Common, selflimiting distress More severe and persistent functional impairment Diagnosable mental illness Severe and persistent functional impairment Adapted from the US Marine Corps.

25 PTSD PREVENTION FRAMEWORK 25

26 THE POLITICS OF TRAUMA What makes psychological trauma so controversial? Stigma and workplace cultural factors Imposition of causality/liability on employer Suspicion of faking Used as defense in high profile criminal proceedings Mistrust experienced by those suffering Inconsistent approaches to assessment and treatment Difficult to prove and accommodate Risk for future relapse and disability

27 THE NEW LEGISLATION Bill 67 introduced in 2013 by Cheri DeNovo An Act to amend the Workplace Safety and Insurance Act, 1997 regarding posttraumatic stress disorder Referred to Standing Committee in 2014 Passed in March 2016 Presumption re: post-traumatic stress disorder (2) If an emergency response worker suffers from post-traumatic stress disorder, the disorder is presumed to be an occupational disease that occurs due to the nature of the worker s employment as an emergency response worker, unless the contrary is shown.

28 OCCUPATIONAL HEALTH AND SAFETY MANAGEMENT SYSTEM Audit program to assessment management of risks and provide continuous improvement, corrective action recommendations Internal and External Auditing Safety Management Health and Safety Program Policies and Procedures, JHSC Committee/H&S Rep Involvement, Return to Work Risk Management Collect information, analyze risk, understanding exposures, implement controls, evaluate to understand Establish and implement training and education for workers and supervisors/ management Training and Education Incident Investigation Inspection and Reporting Conducting incident investigations Inspections, checklists, exposure reporting/hazard reporting, etc. 28

29 PTSD PREVENTION FRAMEWORK PTSD PREVENTION FRAMEWORK Based on OHS Management Systems Recognizes organizations can be at different stages on a continuum (Reactive to Proactive) and may have strengths or be further along in some areas from Prevention to Recovery and RTW 29

30 JUST GETTING STARTED: INTEGRATING THE PTSD FRAMEWORK AND OHS MANAGEMENT SYSTEM Management knows how to identify and respond to PTSD Roles and responsibilities have been established and communicated to those involved in prevention, intervention, recovery and return to work Workers know how to report psychological injuries when they occur and are supported in doing so Workers and managers participate in awareness and anti-stigma training Interventions have been identified and implemented (training, peer support, EAP, etc.) Managers understand how to accommodate a worker recovering from PTSD Policies and Procedures have been developed to support recovering employees return to work 30

31 TAKING PRO-ACTIVE STEPS: INTEGRATING THE PTSD FRAMEWORK AND OHS MANAGEMENT SYSTEM Management demonstrates their support of anti-stigma training and programs by participating in training, understanding and addressing discriminatory practices Prevention programs have been developed to support policies and procedures Workers and Managers participate in resilience training, mental health, psychosocial first aid training Management is tracking exposures to critical/traumatic incidents Supervisors know how to respond appropriately to workers showing signs of PTSD(encourage help seeking) Employers have established employer funded health benefits supportive resources for workers to receive assistance Organization has knowledge of and access to treatment for PTSD Employer engages the employee early with plan to support RTW to reduce the risk of relapse Start to engage family members in prevention activities 31

32 IMPLEMENTING BEST PRACTICES: INTEGRATING THE PTSD FRAMEWORK AND OHS MANAGEMENT SYSTEM There is Sr. Management commitment to PTSD prevention and management and considers it a vital component of OHS Management JHSC/HSR are involved in development and implementation of the Prevention Management Plan Organization is focused on leading or best practices Workers at high risk for injury are routinely screened All personnel regularly talk about the importance of self-care and assessment as it relates to identifying PTSD and reducing stigma Surveys are provided to staff so that they can selfassess/self-screen Workplace assessments have been completed to identify gaps in PTSD prevention and management plan Organizations have active engagement of broader family/community members to support recovery and return to work of workers 32

33 USING #FIRSTRESPONDERSFIRST PTSD RESOURCE TOOLKIT 1. Explore the Website 2. Complete the Online Assessment 3. Receive and Review your Action Plan 4. Use Your Action Plan to Develop the PTSD Prevention Plan 33

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35 FEATURES OF #FIRSTRESONDERSFIRST. Provides all of the site content in a downloadable guide so that the information can be read and viewed off of the site Content is also provided as downloadable sections Sections online are colour coded to match the triangle 35

36 #FIRSTRESPONDERSFIRST PTSD TOOLKIT FEATURES elearning, training, mental health first aid Signs and Symptoms self assessment, when to see a doctor How to respond to signs and symptoms Sample policies Sample screening protocol Key Messages for Workers who have experienced Trauma Getting started with peer support Accessing Treatment and Support Strengths and Limitation of EAP Community Support Legislative requirements Return to Work coordination, tips for accommodating workers and supportive management techniques 36

37 ONLINE ASSESSMENT AND ACTION PLAN User Completes Online Assessment User Downloads an Action Plan that Outlines Steps to Building their Customized Prevention Plan and Program 37

38 CUSTOMIZABLE PREVENTION PLAN RESOURCES Users have access to templates that will assist them in building their own customized PTSD Prevention Plan The templates provide direction on how to customize your prevention plan. 38