PTSD: Armed Security Officers and Licensed Operators. Peter Oropeza, PsyD Consulting Psychologist

Transcription

1 PTSD: Armed Security Officers and Licensed Operators Peter Oropeza, PsyD Consulting Psychologist

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3 History of PTSD 1678 Swiss physician Johannes Hofer coins the term nostalgia. to describe symptoms seen in Swiss Troops Symptoms of Nostalgia Melancholy Incessant thinking of home Disturbed sleep or insomnia Loss of appetite Anxiety Cardiac palpitations Anspach, C. K. (1934). Medical Dissertation on Nostalgia by Johannes Hofer. Bulletin of the Institute of the History of Medicine, 2(6),

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5 History of PTSD 1871 Jacob Mendez Da Costa (internist) noted the following symptoms in soldiers: Chest-thumping (tachycardia) Anxiety Breathlessness (hyper-arousal) Referred to as Soldier s Heart and later as Da Costa Syndrome Jones, F. D. (1995). Psychiatric Lessons of War in War Psychiatry. In Zajtchuk, R. (eds.), The Textbooks of Military Medicine (1-35). Washington, DC: Office of The Surgeon General.

6 History of PTSD WWI: Symptoms of Shell Shock Staring eyes Violent tremors Blue, cold extremities Unexplained deafness, blindness, or paralysis Hitchcock, F. C. (1937). Stand To: A Diary of the Trenches London: Hurst & Blackett.

7 History of PTSD 1917: U.S. Army Surgeon General s office creates a comprehensive treatment program for shell shock Placing psychiatrists in combat units Pols, H., & Oak, S. (2007). War & military mental health. The US psychiatric response in the 20 th century. American Journal of Public Health, 97(12),

8 History of PTSD WWII: Unit cohesion recognized as a factor in resilience to combat fatigue Understanding that intensity and duration of combat exposure increased risk for combat fatigue Pols, H., & Oak, S. (2007). War & military mental health. The US psychiatric response in the 20 th century. American Journal of Public Health, 97(12),

9 DSM-I (1952) Recognized both civilian and military experiences could cause PTSD Described as a brief reaction rather than a potentially long-term disorder, stress response syndrome caused by gross stress reaction

10 DSM-II (1968) Vietnam War Veteran s treated for Stress Response Syndrome DSM-II combined PTSD with adjustment disorders and placed in the Transient Situational Disturbances category

11 DSM-III (1980) PTSD became a separate diagnosis PTSD could now be diagnosed in someone with an existing personality disorder More likely to occur in someone with a pre-existing mental disorder Traumatic events described as outside the range of usual human experience Risk of PTSD varied with the type of trauma

12 DSM-III (1980) Trauma triggers leading to worsening symptoms Situations or activities that resemble or symbolize the original trauma Possible complications Interpersonal relationship caused by emotional numbing Self-defeating behavior or suicidal actions" Other disorders that could develop after PTSD: Anxiety Depression Substance Use Disorders (e.g., alcoholism) Organic Mental Disorder

13 DSM-III-R (1987) Increased emphasis on avoidance symptoms New types of trauma: Witnessing another person's trauma, Learning about a serious threat or harm to a close friend or relative, e.g., that one s child has been kidnapped, tortured, or killed" but this does not include "simple bereavement Effect of a trauma anniversary Forgetting an important part of the trauma (psychogenic amnesia, trauma-related hallucinations, and a sense of a foreshortened future)

14 DSM-IV (2000) Introduction of Acute Stress Disorder (symptoms lasting more than 2 days and up to 4 weeks) Added criterion A2 Required the person to report feeling intense fear, helplessness, or horror during rather than after the trauma(s) Added criterion F Required either significant distress or impairment resulting from the PTSD symptoms

15 DSM-IV-TR Criteria for PTSD The person has been exposed to a traumatic event in which both of the following were present: (1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. (2) The person s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

16 DSM-V (2013) Criterion A: stressor (one required) The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure Witnessing the trauma Learning that a relative or close friend was exposed to a trauma Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

17 DSM-V Criterion B: intrusion symptoms (one required) The traumatic event is persistently re-experienced in the following way(s): Unwanted upsetting memories Nightmares Flashbacks Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders

18 DSM-V Criterion C: avoidance (one required) Avoidance of trauma-related stimuli after the trauma, in the following way(s): Trauma-related thoughts or feelings Trauma-related external reminders

19 DSM-V Criterion D: negative alterations in cognitions and mood (two required) Negative thoughts or feelings that began or worsened after the trauma, in the following way(s): Inability to recall key features of the trauma Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Negative affect Decreased interest in activities Feeling isolated Difficulty experiencing positive affect

20 DSM-V Criterion E: alterations in arousal and reactivity Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s): Irritability or aggression Risky or destructive behavior Hypervigilance Heightened startle reaction Difficulty concentrating Difficulty sleeping

21 DSM-V Criterion F: duration (required) Symptoms last for more than 1 month Criterion G: functional significance (required) Symptoms create distress or functional impairment (e.g., social, occupational) Criterion H: exclusion (required) Symptoms are not due to medication, substance use, or other illness

22 DSM-V Dissociative Specification In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream) Derealization. Experience of unreality, distance, or distortion (e.g., "things are not real ) Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately

23 Prevalence National Comorbidity Study 7-8% of U.S. population meet criteria for PTSD About 4 % of men and 10% of women Operations Iraqi Freedom and Enduring Freedom 11-20% meet criteria Gulf War (Desert Storm) 12% meet criteria Vietnam War 15-30% meet criteria

24 Assessing PTSD PTSD Screening instruments: Brief Trauma Questionnaire (BTQ) Trauma History Questionnaire (THQ) PTSD Checklist for DSMI-5 (PCL-5) Semi-structured interview: Clinician Administered PTSD Scale for DSM-5 (CAPS-5)

25 VA Assessment of PTSD The VA has a standard practice that deployed service members are screened for PTSD In cases where PTSD is suspected, or a service member selfrefers for assessment, the VA has psychologists and/or psychiatrists assess in more detail In terms of ratings, the VA rates PTSD disability based on the level of assessed occupational and social impairment E.g. 50 percent is occupational and social impairment with reduced reliability and productivity Disability ratings range upward to 100%, numberically, but in descriptive terms can be from meets criteria debut able to function without limitations to total incapacitation

26 Commercial Nuclear Employment of all personnel requires reliability and trustworthiness, and by implication, stability. The NRC requires nuclear facilities to have fitness-for-duty programs: To provide reasonable assurance that nuclear facility personnel are trustworthy, will perform their tasks in a reliable manner, are not under the influence of any substance, legal or illegal, that may impair their ability to perform their duties, and are not mentally or physically impaired from any cause that can adversely affect their ability to safely and competently perform their duties.

27 Things to consider What is reasonable assurance? What is trustworthy? Will perform their tasks in a reliable manner? Are not mentally or physically impaired from any cause that can adversely affect their ability to safely and competently perform their duties.

28 Where does PTSD come in? Remember Criterion G: functional significance (required) Symptoms create distress or functional impairment (e.g., social, occupational) By the very nature of the diagnosis, there must be significant impairment or distress So what is significant? And what are the impairments and /or distress specifically?

29 Focus on behavior and symptoms A diagnosis in and of itself does NOT define current level of functioning, stability/instability, or one s current ability to be reliable. At the time of diagnosis What were the symptoms? The three key areas of inquiry: Frequency Severity Duration Recent and current: Symptoms present plus the three key areas of FREQUENCY, SEVERITY, and DURATION How much stock should we place in the ratings from the VA?

30 Fluid, Not Static PTSD (and most MH disorders) are fluid and not static Symptoms can improve despite a disability rating from the VA being high Symptoms can also resurface due to a number of triggers despite the disability rating from the VA being low Periodic reassessment is key (be it by BOP or mandatory 5 year reassessments) Other notable/peripheral symptoms or behavior can have their roots based in PTSD (e.g. a mood or anxiety disorder that stems from an undiagnosed PTSD such as increased irritability and short temper or being stressed out or a substance abuse disorder that is rooted in PTSD)

31 Rubber meets the road Appropriate personnel in the nuclear industry are consulted when there is a known diagnosis of PTSD Assessment and consultation should include testing when appropriate (i.e. PAI and/or MMPI) and there should be an interview by the MRO and/or psychologist VA records, when warranted, should be obtained and reveiwed by the MRO and/or psychologist The MRO and/or psychologist should contact and speak with the treating psychiatrist and/or psychologist when warranted Any discrepancies (from what the applicant/employee reports versus what is documented in the VA (or other) records should be discussed with the appropriate site UAA supervisor Based on the above, a plan and determination is made

32 Questions?