Timely and effective return-to-work is the goal of all workers’ comp professionals. Yet, despite the growing concern of post-traumatic stress disorder in the industry, too many injured employees at risk for PTSD are not being properly assessed for the disorder. This can have a significant impact on delayed RTW, as Genex’s Mariellen Blue tells us in today’s Inside Workers’ Comp. In this podcast, she offers suggestions on how to spot PTSD in injured employees and give them the help they need to return to function.
Tom Kerr (TK): PTSD is a medical term that has entered the mainstream vernacular as mass shootings and other catastrophic events dominate our news feeds. What many may not realize, however, is trauma associated with workplace injury can also have a strong impact on injured employees and delay return to work. Mariellen Blue, Genex national director of case management services, joins us to talk more about this issue in today’s Inside Workers’ Comp. Mariellen, welcome to the podcast.
Mariellen Blue (MB): Thank you, Tom.
TK: Mariellen, can you start by helping us better understand what PTSD is and why it’s sometimes an issue in workers' comp?
MB: Post‑traumatic stress disorder, also referred to as PTSD, is really a mental health condition that can develop when a person experiences or witnesses a traumatic event such as a natural disaster, a serious accident, terrorist attack — things that are very common, unfortunately, today — mass shootings, war combat, rape, or other types of really violent personal assault. And these symptoms that can occur include things like flashbacks, severe anxiety, nightmares, and even uncontrollable thoughts about the specific traumatic event that can last long after the event is really over.
PTSD was first referred to as shellshock or combat fatigue during World Wars I and II, and we really started to use the term post‑traumatic stress disorder in the 1970s, really in large part due to the diagnosis of US military veterans during the Vietnam War. It was officially recognized by the American Psychiatric Association in 1980. According to the National Center for PTSD, seven to eight percent of the US population will suffer from PTSD during their lifetime. It affects 5.2 million American adults each year, and women are twice as likely as men to have PTSD.
So, looking at the workplace today, there are violent situations in the workplace, there are individuals that are exposed to catastrophic events, and PTSD, unfortunately, is a disorder that can go along with these types of events.
TK: Are PTSD factors something case managers always look for following a catastrophic event, or is it more of a case‑by‑case basis?
MB: Most people who experience or witness a traumatic or catastrophic event will have some degree of difficulty coping, as well as experience feelings such as shock, denial, fear, nervousness, anger, hopelessness, and even guilt. These are really common symptoms which typically will get better with time, but unfortunately for individuals with PTSD, these feelings don't get better, and even become worse, typically lasting for months or even years.
And these interfere with their ability to perform their normal day‑to‑day activities, including functioning in relationships and work. And it's really important for case managers to always be alert for signs of PTSD in cases that they manage, because the symptoms of PTSD most often begin within three months of the traumatic event, but may not appear until years after the event.
Once the symptoms develop, evaluation by a mental health professional and treatment is really critical to reduce the symptoms and improve functioning. Case managers are in a really unique position to recognize risk factors and symptoms of PTSD in the individuals that they're working with and to assist them with getting the right diagnosis and the proper treatment.
TK: What are some symptoms of PTSD to be aware of after a catastrophic incident?
MB: Symptoms of PTSD are typically grouped into four categories; these include intrusive memories, avoidance, hyperarousal, and negative alterations in cognition and mood. I'll just give you a little more background about each of those.
The first is intrusive memories and this really refers to the individual reliving or re‑experiencing the tragic event through involuntary memories, hallucinations, nightmares, and flashbacks. They might also experience severe physical and emotional distress when they're exposed to triggers that remind them of that traumatic event. For example, the anniversary of the event, passing the site of the event, and even things such as sights, sounds, or smells that were associated with that particular event.
The next is avoidance. Avoidance is characterized by the person avoiding people, places, situations, or activities that remind them of the traumatic event. They try to avoid remembering or thinking about the trauma they experienced. They resist talking about it to others. This often leads them to feelings of isolation, detachment from family and friends, as well as a lack of interest in all the people, places, and activities they used to enjoy prior to the event.
Next is hyperarousal and this refers to changes in that person's physical and emotional reactions that result in their body being in almost a constant state of high alert when they're thinking about the trauma even though they're not currently in any type of danger. Symptoms of hyperarousal can include things such as chronic anxiety, being easily startled or frightened, difficulty concentrating and sleeping, irritability, angry outbursts, aggressive behavior, panic attacks, and even self‑destructive behavior such as excessive drinking, drugs, and reckless driving.
The last category is negative alterations in cognition and mood and this is really manifested through ongoing negative thoughts and feelings about themselves and others related to blame, fear, even horror, anger, guilt, and detachment from others and ongoing memories of the trauma that they experienced.
TK: How do case managers help target those at risk of PTSD?
MB: When a case manager's working with an individual who's lived through a traumatic event, it's really important to remember that not everyone is going to develop PTSD. Most individuals are going to recover. They're not going to need any intense intervention.
While many people who are exposed to a traumatic event are going to experience symptoms that could be associated with PTSD such as what I just mentioned, intrusive thoughts, avoidance, hyperarousal, and negative thoughts and feelings, for symptoms to be considered PTSD they must last more than a month and be severe enough to interfere with functioning in relationships or work.
According to the Institute of Mental Health, there are many factors that play a role in whether a person will develop PTSD. These include both risk factors that make a person more likely to develop PTSD as well as resilience factors that can help reduce the risk of developing the disorder. Some of these risk and resilience factors are present before the trauma in the individual and others become important during and after a traumatic event occurs.
Some of the risk factors for PTSD that could assist a case manager in identifying their patients that might be most at risk would be:
- Having a history of living through dangerous events and traumas
- Getting hurt during a traumatic event
- Seeing other people hurt or killed during the event
- Having a job that increases the risk of being exposed to traumatic events — this is particularly evident in military personnel and first responders
- Having history of childhood trauma or abuse
- Experiencing feelings of horror, helplessness, or extreme fear above and beyond what you might normally expect
- Lacking a good support system of family and friends
- Dealing with the extra stress after the event such as a loss of a loved one, pain, injury, loss of home, or loss of job
- Having a personal or family history of mental health issues including anxiety and depression, or a history of substance abuse such as excessive drinking or drug use.
Some of the resilience factors that might help reduce the risk of PTSD include:
- Seeking support from other people such as their family and friends
- Engaging in support groups after the traumatic event
- Learning to feel good about their own actions in the face of danger
- Having a coping strategy or way of getting through the bad event and learning from it
- Being able to act and respond effectively despite feeling afraid
TK: So, if PTSD is evident, what's the protocol to helping the injured worker get the treatment he or she needs?
MB: It's really critical that case managers working with individuals who have experienced or witnessed a catastrophic or traumatic event be educated in risk factors, symptoms, and treatment of post‑traumatic stress disorder. PTSD is not diagnosed, as I mentioned before, until at least one month has passed since the time a traumatic event occurred.
If symptoms of PTSD are present, the treating physician is going to typically perform a complete medical history and physical exam to rule out any physical causes that could be causing the problems. Once a physical cause for the symptoms is ruled out, the patient is typically evaluated by a psychiatrist, a psychologist, or other mental health care professional who can diagnose PTSD and assist in developing an individualized treatment plan for that person.
The goal of treatment for PTSD is to reduce the physical and emotional symptoms, improve daily functioning, and help that individual better cope with the traumatic event that triggered the disorder. The main treatments for PTSD include psychotherapy such as cognitive behavioral therapy, medications such as antidepressants, or a combination of both.
It's important to remember that everyone is different and PTSD affects people differently, so a treatment plan that works for one person may not work for everybody. The case manager can work with the patient and their mental health care professional to find and coordinate the best treatment for their symptoms as well as provide that ongoing education and support to that individual.
TK: How does PTSD affect return to work and activities of daily living?
MB: According to the American Psychologic Society, the symptoms of PTSD cause significant distress for the individual, which could impact their social and occupational participation to a degree that is clinically significant. Difficulties are frequently seen in the person's ability to engage in their selfcare and home care activities, education and work roles as well as any of their usual social and leisure activities.
For them, doing normal, ordinary tasks can become quite overwhelming, and the ability to develop and maintain relationships is often negatively impacted and there's also an increased risk of self‑injury behaviors, again, such as substance abuse, self‑mutilation, and even a high risk of suicide.
Because one of the primary symptoms of PTSD is avoidance of places and situations associated with the traumatic event, for employees who experienced or witnessed a catastrophic injury or event at work, they can have an extremely difficult time returning to work.
Unfortunately, research has shown that employees who are unable to return to work also experience more persistent PTSD symptoms. Without clear strategies in place to assist in developing and facilitating a successful return-to-work plan, that individual can remain in a cycle where their PTSD symptoms are preventing them from returning to work, but their absence from work is negatively impacting their ability to overcome the PTSD symptoms.
Now, symptoms of PTSD can interfere with the individual's ability to work in numerous ways. These include memory problems, lack of concentration, poor relationships with coworkers, trouble staying awake, fear, anxiety, panic attacks, emotional outbursts while at work, flashbacks, and absenteeism.
TK: What are some effective strategies to reintegrate the worker with PTSD back to the workplace?
MB: One of the most important strategies that a case manager can implement is really making the patient feel comfortable in discussing what their fears and concerns are relative to returning to work. This is particularly evident if the injury or the traumatic event occurred at that particular workplace.
Once an employee has been released to safely return to work by their treating physician, the case manager can assist in helping both the employee and employer through the process including discussion of any workplace accommodations that might be needed. For the returning employee, the experiencing of symptoms related to PTSD might be unavoidable, but there are actions and safeguards that can be taken to avoid exacerbating the symptoms.
Workplace accommodations can help the individual with PTSD better manage any physical, cognitive, or emotional limitations. It's important for the case manager to allow the injured employee to feel comfortable talking about any fears or concerns that they have with returning to work.
Some strategies that might be able to be used initially are enabling them to go back to work on a part‑time basis, even having visits to the workplace in advance of an actual return to work. In terms of workplace accommodations, each person will have specific needs, and you really have to look at accommodations based on that individual.
- Providing instructions or job related responsibilities in writing as well as verbal instructions
- Offering additional training or refreshers to assist that individual with some of the memory difficulties
- Allowing workers to maintain more flexible schedules and being able to take time off for any treatment or appointments that they have to attend
- Permitting time to complete non-urgent tasks
- Letting employees wear noise canceling headphones to reduce distractions while they're working
- Increasing the amount of light in the work environment to help maintain alertness and help them improve concentration
- Removing any emotional triggers that remind the employee of the trauma that are upsetting (when possible)
- Making sure parking areas are well lit or that security personnel is available to accompany them when walking to a car or unsafe locations in the dark
Again, these are just some examples but it's really working with what are the things that are most concerning to that individual — what are their triggers, and what can be done at the workplace to assist them in their coping mechanisms.
TK: With PTSD becoming more recognized, is there still a stigma associated with it?
MB: Yes, unfortunately, there is a stigma with PTSD, and the best way I can describe it is that people tend to fear what they don't understand. And educating employees about PTSD is another strategy that can be used in the workplace.
So, again, it's facilitating a work environment of understanding what that individual is going through and trying to help the other employees cope in addition to that particular employee.
TK: How can listeners find out more on PTSD?
MB: There are resources that can assist with understanding and education related to PTSD, which include the National Center for PTSD, the American Psychiatric Association, the American Psychological Association, the National Institute of Mental Health, and the US Department of Veterans Affairs.
These can be significant resources not only for the patient who is suffering from PTSD, but to others who are interested in more information as well as case managers who are working with these individuals.