June is National Post Traumatic Stress Disorder (PTSD) Month!

The Statistics

  • The prevalence rate of lifetime PTSD in Canada was estimated to be 9.2%, with a rate of current (1-month) PTSD of 2.4%. PTSD is a common psychiatric disorder in Canada. The results are surprising, given the comparably low rates of violent crime, a small military and few natural disasters. (NCBI)
  • A Canadian Forces survey estimates that 11.1% of regular personnel have experienced PTSD at some time, and 5.3 per cent met the case definition at the time of the survey or in the previous year.
  • A recent report says 36% of male corrections officers suffer PTSD.
  • Canada leads the world with 9.2% lifetime PTSD prevalence and a vulnerability score of 31.02.
  • First responders are at least twice as likely to suffer from PTSD.
  • In Canada, there are provinces that have developed workers compensation policies for Traumatic Stress that include presumptive clauses – for example, if the individual is a first responder and is diagnosed with PTSD, then it is presumed that it is related to the employment.

What is PTSD?

Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop after experiencing or witnessing a traumatic event, or learning that a traumatic event has happened to a loved one. The DSM5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) defines a traumatic event as exposure to actual or threatened death, serious injury, or sexual violence. Examples include:

  • Being involved in, or witnessing, a car accident
  • Undergoing major surgery (bone marrow transplant, extensive hospitalization, or severe burns)
  • Experiencing or witnessing natural disasters (earthquakes, hurricanes, floods, or fire)
  • Violent crimes (kidnapping, physical assault, or assault or murder of a parent or loved one)
  • Community violence (attacks at school, or suicide of a friend, family member, or a child in the same-age group)
  • Chronic physical or sexual abuse (AnxietyBC, 2018)

Signs and Symptoms (adaa.org)

The disorder is characterized by three main types of symptoms:

  • Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
  • Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
  • Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.

Treatment 

There are recent guidelines for health care providers in the intervention for Anxiety-Related Disorders and PTSD.  It is advisable that these treatment guidelines be implemented as soon as possible when symptoms are noted and a proper diagnosis is in place.

Katzman et al ; Canadian Clinical Practice Guidelines for the Management of Anxiety, Post Traumatic Stress Disorder and Obsessive Compulsive Disorders;   BMC Psychiatry 2014, 14 (Suppl 1)

Most Effective Therapies for PTSD

Anxiety Management (stress inoculation training): teaching a set of skills that will help patients cope with stress

  • Relaxation training: teaching patients to control fear and anxiety through the systematic relaxation of the major muscle groups
  • Breathing retraining: teaching slow, abdominal breathing to help the patient relax and/or avoid hyperventilation with its unpleasant and often frightening physical sensations.
  • Positive thinking and self-talk: Teaching the person how to replace negative thoughts (e.g., “I’m going to lose control”) with positive thoughts (e.g., “I did it before and I can do it again”) when anticipating or confronting stressors.
  • Assertiveness training: teaching the person how to express wishes, opinions, and emotions appropriately and without alienating others.
  • Thought stopping: distraction techniques to overcome distressing thoughts by inwardly “shouting stop.”

Cognitive therapy: helping to modify unrealistic assumptions, beliefs, and automatic thoughts that lead to disturbing emotions and impaired functioning. For example, trauma victims often have unrealistic guilt related to the trauma: a rape victim may blame herself for the rape; a war veteran may feel it was his fault that his best friend was killed. The goal of cognitive therapy is to teach patients to identify their own particular dysfunctional cognitions, weigh the evidence for and against them, and adopt more realistic thoughts that will generate more balanced emotions.

Exposure therapy: helping the person to confront specific situations, people, objects, memories, or emotions that have become associated with the stressor and now evoke an unrealistically intense fear.

This can be done in two ways:

  • Imaginal exposure: the repeated emotional recounting of the traumatic memories until they no longer evoke high levels of distress.
  • In vivo exposure: confrontation with situations that are now safe, but which the person avoids because they have become associated with the trauma and trigger strong fear (e.g., driving a car again after being involved in an accident; using elevators again after being assaulted in an elevator). Repeated exposures help the person realize that the feared situation is no longer dangerous and that the fear will dissipate if the person remains in the situation long enough rather than escaping it.

Psychoeducation: educating patients and their families about the symptoms of PTSD and the various treatments that are available for it. Reassurance is given that PTSD symptoms are normal and expectable shortly after a trauma and can be overcome with time and treatment. Also includes education about the symptoms and treatment of any comorbid disorders.

What can an employer do to prevent PTSD? (www.firstrespondersfirst.ca)

What can an employer do to support stay at work and return to work planning?

As an employer it is important to recognize the signs and symptoms of PTSD in an employee.  There are a number of screening tools available but the manager will notice behavioural changes and performance changes in the employee.  When you recognize these changes it is important to meet with the employee and discuss what is observed and offer support.

Prepare for the Conversation:

  • Consider all factors before reacting to the change in behaviours. Think about your concern.  Are you seeing someone who is having a bad day or someone in distress?  You can respond to both but the way you respond to an employee having a bad day is different than to one showing longer term behaviour changes.
  • Gather information and note new changes in behaviour.
  • Consider what your role is to be in this situation.
  • Look at possible assistance and supports that could be offered, not just the concern.
  • Consider the effects of the concerns on others.
  • What assistance can be offered for the employee to be successful at work.
  • It is not necessary to provide a solution, rather offer support and assistance, such as EAP
  • Do not dismiss, minimize or rationalize your observations and concerns thinking someone else will deal with them.
  • Allow appropriate amount of time for the conversation.
  • Contact union supports or company supports to discuss your concerns.

 Respond to the Distress:

  • Remain respectful, calm, and patient.
  • Approach your concern about the changes in behaviour.
  • Listen to the distressed employee.
  • Preserve the dignity of the individual during the meeting.
  • Find out if the employee has a support system in place to assist them (i.e. – family physician, family and friends).
  • Involve yourself only as far as you can go given the limits of your role.
  • Adequately address the concerns others have raised.

Confidentiality:

  • Recognize there is a stigma. Be careful about your conversations with the employee and about the employee.
  • Need to know basis – only those in the employment setting that require the personal information shall have access. Communicate with the employee how the information is stored, shared and with whom.
  • Maintenance of records – secure, protected – keep your records in a locked cabinet away from others’ access. Any health or medical information should not be in your files.  All medical related information should be forwarded to Health or Disability Management Services.

Offer Support and Assistance: 

  • Ask if there is something we can consider to assist them in their job.
  • Consider possible work adjustments if needed, for example flexibility with procedures like deadlines.
  • Provide access to the EAP provider. There are many services through EAP that can assist employees.  (legal, financial, nutritional, elder care, child care, resources for a variety of life stressors in addition to counselling).
  • Consider if the Corporation can assist the employee in accessing medical assistance. Various medical supports can sometimes be accessed.
  • Suggest the individual make an appointment with their health care provider to seek assistance.
  • Offer assistance and support but also encourage the employee to take control and responsibility for their own wellbeing.

 Identify Possible Risks of Suicide or Harm: 

  • If you are concerned about your safety, or if a one-on-one conversation is not appropriate, invite an appropriate support person along to meet with the employee.
  • In critical situations, call 911. They are prepared for critical situations.
  • If concerns of safety of distressed employee or yourself, alert Corporate Security and Return to Work Services of your concerns.

Actions and Follow Up: 

  • Confirm details discussed at meeting.
  • Review the return to work plan and any accommodations if applicable.
  • Contact Return to Work Services if assistance is required.
  • Set a time to meet again to review the employee’s circumstance.
  • Determine how frequent you will meet with the employee.
  • Frequently check in with employee to see how things are going.
  • Document details of meeting.
  • Recognize that helping/supporting an emotionally distressed employee can be trying, stressful and isolating. There are resources available for you as well.

Return to Work Accommodations:

When developing accommodations in the workplace ensure that you individualize the accommodations to the employee’s level of function and the job demands.  A proper Occupational Therapy assessment can assist the employer and employee in discussing suitable adjustments to the work and safety in return to work.

Some accommodations may include:

  • gradual exposure back into the workplace and work duties
  • implementation of tools to help with memory and concentration such as use of checklists, electronic reminders, removal of distractions
  • strategies to manage hyper arousal symptoms such as grounding and mindfulness
  • use of mentoring and training tools in the workplace
  • communication training and support for difficult situations

The Occupational Therapist can develop a suitable plan with your workplace stakeholders and health care team to ensure that the employee is safe and productive and the plan is well monitored.

Contact Gowan Consulting to arrange for your Occupational Therapy assessment or discuss how you can have Cognitive Demands Analyses completed on your jobs to identify the cognitive and behavioural risks and factors that may impact the employee on return to work.

Resources

www.firstrespondersfirst.ca

www.adaa.org

www.anxietyBC

NCBI, 2018

Gowan Consulting Manager Mental Health Training Manual. 2017

Katzman et al ; Canadian Clinical Practice Guidelines for the Management of Anxiety, Post Traumatic Stress Disorder and Obsessive Compulsive Disorders;   BMC Psychiatry 2014, 14 (Suppl 1)

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