An Overview Of Post- Traumatic Stress Disorder: What Vocational Rehabilitation Specialists Need to Know Jennifer Olson-Madden, PhD VISN 19 Eastern Colorado.

An Overview Of Post-An Overview Of Post-Traumatic Stress Traumatic Stress Disorder: What Disorder: What

Vocational Vocational Rehabilitation Rehabilitation

Specialists Need to Specialists Need to KnowKnow

Jennifer Olson-Madden, PhDJennifer Olson-Madden, PhD

VISN 19 Eastern Colorado Healthcare VISN 19 Eastern Colorado Healthcare SystemSystem

Mental Illness Research, Education and Mental Illness Research, Education and Clinical CenterClinical Center

Synopsis of PresentationSynopsis of Presentation

Overview of PTSD and other Stress Overview of PTSD and other Stress DisordersDisorders

Comorbid/Coexisting IssuesComorbid/Coexisting Issues

Implications of PTSD on Vocational Implications of PTSD on Vocational StatusStatus

Therapeutic Assessment and Therapeutic Assessment and InterventionIntervention

Referral ConsiderationReferral Consideration

Relevance of the TopicRelevance of the Topic

Operation Enduring Operation Enduring Freedom/Operation Iraqi FreedomFreedom/Operation Iraqi Freedom

Particular impact of combatParticular impact of combat

Impact manifests across the Impact manifests across the lifespanlifespan

Individualized and personal Individualized and personal accounts of traumaaccounts of trauma

Each veteran will have unique set Each veteran will have unique set of social, psychological, and of social, psychological, and psychiatric difficultiespsychiatric difficulties

www.ncptsd.va.govwww.ncptsd.va.gov

National Center for Post National Center for Post Traumatic Stress Disorder Traumatic Stress Disorder

StatisticsStatistics

7.8% of Americans experience PTSD 7.8% of Americans experience PTSD (Keane et al., 2006)(Keane et al., 2006)

Women = 2X riskWomen = 2X risk

30% of combat veterans experience 30% of combat veterans experience PTSDPTSD

• Approximately 50% of Vietnam veterans Approximately 50% of Vietnam veterans experience experience symptomssymptoms

• Approximately 8% of Gulf War veterans Approximately 8% of Gulf War veterans have have demonstrated symptoms demonstrated symptoms (Duke and (Duke and

Vasterling, 2005)Vasterling, 2005)

Relevance for Relevance for Vocational Rehabilitation Vocational Rehabilitation

SpecialistsSpecialists Individuals with Individuals with

traumatic stress traumatic stress reactions may not reactions may not seek mental health seek mental health care but do seek out care but do seek out other health related other health related servicesservices

Only 1/3 of Iraq war Only 1/3 of Iraq war veterans accessed veterans accessed mental health mental health services first year of services first year of post-deployment post-deployment (Hoge, (Hoge, Auchterloine & Milliken, 2006)Auchterloine & Milliken, 2006)

Recognition of PTSD or Recognition of PTSD or other trauma-related other trauma-related symptoms can:symptoms can: Optimize clients’ overall Optimize clients’ overall

healthcare and treatment healthcare and treatment through referral and triagethrough referral and triage

Aid in understanding and Aid in understanding and taking action around taking action around clients’ difficulties in the clients’ difficulties in the work settingwork setting

DisclaimerDisclaimer

Information during this Information during this presentation is for educational presentation is for educational purposes only – it is not a purposes only – it is not a substitute for informed medical substitute for informed medical advice or training. You should not advice or training. You should not use this information to diagnose use this information to diagnose or treat a mental health problem or treat a mental health problem without consulting a qualified without consulting a qualified professional/providerprofessional/provider


Definition of PTSDDefinition of PTSD

An anxiety disorder An anxiety disorder resulting from exposure resulting from exposure to an experience to an experience involving direct or involving direct or indirect threat of serious indirect threat of serious harm or death; may be harm or death; may be experienced alone experienced alone (rape/assault) or in (rape/assault) or in company of others company of others (military combat)(military combat)

PTSD StressorsPTSD Stressors

Violent human assaultViolent human assault

Natural catastrophesNatural catastrophes

AccidentsAccidents

Deliberate man-made disastersDeliberate man-made disasters


Signs and SymptomsSigns and Symptoms

Depends on a variety of Depends on a variety of individual, contextual, and individual, contextual, and cultural factorscultural factors

ImmediateImmediate

AcuteAcute

ChronicChronic

APA, 1994APA, 1994

““Combat Fatigue”Combat Fatigue”

Immediate psychological and functional Immediate psychological and functional impairment that occurs in war-zone/battle impairment that occurs in war-zone/battle or during other severe stressors during or during other severe stressors during combatcombat

Caused by stress hormonesCaused by stress hormones

Features of the stress reaction include:Features of the stress reaction include: RestlessnessRestlessness Psychomotor deficiencies Psychomotor deficiencies WithdrawalWithdrawal StutteringStuttering ConfusionConfusion NauseaNausea VomitingVomiting Severe suspiciousness and distrustSevere suspiciousness and distrust

APA, 1994APA, 1994

Acute Stress DisorderAcute Stress Disorder

Anxiety occurring within one Anxiety occurring within one month after month after exposureexposure to to extreme traumatic stressorextreme traumatic stressor

Total duration of disturbance is Total duration of disturbance is two days to a maximum of four two days to a maximum of four weeks (i.e., occurs and resolves weeks (i.e., occurs and resolves within one month)within one month)

APA, 1994APA, 1994

Symptoms of ASD include:Symptoms of ASD include:

One re-experiencing symptomOne re-experiencing symptom Marked avoidanceMarked avoidance Marked anxiety or increased arousalMarked anxiety or increased arousal Evidence of significant distress or impairmentEvidence of significant distress or impairment Three dissociative symptoms: a subjective Three dissociative symptoms: a subjective

sense of numbing/detachment, reduced sense of numbing/detachment, reduced awareness of one’s surroundings, awareness of one’s surroundings, derealization, depersonalization, or derealization, depersonalization, or dissociative amnesiadissociative amnesia

ASD is considered a predictor or PTSD, though not a necessary precondition

APA, 1994APA, 1994

Post Traumatic Stress Post Traumatic Stress DisorderDisorder

• Chronic phase of adjustment to Chronic phase of adjustment to stressor across lifespanstressor across lifespan

APA, 1994APA, 1994

Symptoms of PTSD

Recurrent thoughts of the eventRecurrent thoughts of the event

Flashbacks/bad dreamsFlashbacks/bad dreams

Emotional numbness (“it don’t matter”); reduced interest or Emotional numbness (“it don’t matter”); reduced interest or involvement in work our outside activitiesinvolvement in work our outside activities

Intense guilt or worry/anxietyIntense guilt or worry/anxiety

Angry outbursts and irritabilityAngry outbursts and irritability

Feeling “on edge,” hyperarousal/ hyper-alertnessFeeling “on edge,” hyperarousal/ hyper-alertness

Avoidance of thoughts/situations that remind person of the Avoidance of thoughts/situations that remind person of the traumatrauma

APA, 2000APA, 2000

DSM-IV CriteriaDSM-IV Criteria

Essential Clusters of PTSD:

1. Re-experiencing symptoms (nightmares, intrusive thoughts)

2. Avoidance of trauma cues and Numbing/detachment from others

3. Hyperarousal (i.e. increased startle, hypervigilance)

APA, 1994APA, 1994

Duration of PTSDDuration of PTSD

- To meet criteria for PTSD, symptom - To meet criteria for PTSD, symptom duration must be at least one month duration must be at least one month

AcuteAcute PTSD: duration of symptoms PTSD: duration of symptoms is less than 3 monthsis less than 3 months

ChronicChronic PTSD: duration of PTSD: duration of symptoms is 3 months or moresymptoms is 3 months or more

- Often, the disorder is more severe - Often, the disorder is more severe and lasts longer when the stress is of and lasts longer when the stress is of human design (i.e., war-related human design (i.e., war-related trauma)trauma)


Potential Consequences of Potential Consequences of PTSDPTSD

Physiological ConcernsPhysiological Concerns

Physical complaints are often treated Physical complaints are often treated symptomatically rather than as an symptomatically rather than as an indication of PTSDindication of PTSD



Social and InterpersonalSocial and Interpersonal

Problems:Problems:- - Relationship issuesRelationship issues

- Low self-esteem- Low self-esteem

- Alcohol and substance - Alcohol and substance abuse abuse

- Employment problems- Employment problems

- Homelessness- Homelessness

- Trouble with the law- Trouble with the law

- Isolation- Isolation



Self-Destructive/DangerousSelf-Destructive/Dangerous

Behaviors:Behaviors:- - Substance useSubstance use

- Suicidal attempts- Suicidal attempts

- Risky sexual behavior- Risky sexual behavior

- Reckless driving- Reckless driving

- Self-injury- Self-injury

APA, 1994APA, 1994

““Complex PTSD”/DESNOSComplex PTSD”/DESNOS

Long-term, prolonged (months or years), Long-term, prolonged (months or years), repeated trauma or total physical or repeated trauma or total physical or emotional control by anotheremotional control by another

- Concentration camps - Prisoner of war- Prostitution brothels - Childhood abuse

- Long-term, severe domestic or physical abuse

APA, 1994; 2000APA, 1994; 2000

““Complex PTSD”Complex PTSD”

Symptoms includeSymptoms include: :

• Alterations in emotional regulationAlterations in emotional regulation• Alterations in consciousness Alterations in consciousness • Changes in self-perception Changes in self-perception • Alterations in interpersonal relationshipsAlterations in interpersonal relationships• Changes in one’s system of meaningsChanges in one’s system of meanings

Issues with misdiagnoses (i.e., “Borderline”)Issues with misdiagnoses (i.e., “Borderline”)Ongoing research regarding its efficacy in Ongoing research regarding its efficacy in

categorizing symptoms of prolonged traumacategorizing symptoms of prolonged trauma


Comorbid/Coexisting Comorbid/Coexisting ProblemsProblems

Veterans with PTSD are also at risk for: Veterans with PTSD are also at risk for: Depression and AnxietyDepression and Anxiety Substance abuseSubstance abuse Spectrum of severe mental illnesses Spectrum of severe mental illnesses Aggressive behavior problemsAggressive behavior problems Sleep problems like nightmares, insomnia or Sleep problems like nightmares, insomnia or

irregular sleep schedulesirregular sleep schedules Acquired Brain Injury Acquired Brain Injury

- - Traumatic Brain InjuryTraumatic Brain Injury

It can be difficult for healthcare providers to prioritize It can be difficult for healthcare providers to prioritize target treatment areas given the range of symptoms target treatment areas given the range of symptoms and difficulties seen among veteransand difficulties seen among veterans

TBI ComorbidityTBI Comorbidity

Head injury is damage to any Head injury is damage to any part of the headpart of the head

TBI is damage to the brain TBI is damage to the brain triggered by externally acting triggered by externally acting forces (i.e., direct penetration, forces (i.e., direct penetration, sustained forces, etc.)sustained forces, etc.)

A significant portion of soldiers A significant portion of soldiers from OEF/OIF have sustained a from OEF/OIF have sustained a brain injury brain injury Blast injuries are the Blast injuries are the leading cause of injury in the leading cause of injury in the current conflict current conflict

(DVBIC, 2005)(DVBIC, 2005)

dvbic.orgdvbic.org

Blast injuriesBlast injuries

• Blast injuries are injuries that result from the Blast injuries are injuries that result from the complex pressure wave generated by an explosioncomplex pressure wave generated by an explosion

• Ears, lungs, and GI tract, brain and spine are Ears, lungs, and GI tract, brain and spine are especially susceptible to primary blast injuryespecially susceptible to primary blast injury

• Those closest to the explosion suffer from the Those closest to the explosion suffer from the greatest risk of injury greatest risk of injury

• Additional means of impact:Additional means of impact:Being thrown, debris, burnsBeing thrown, debris, burns

DVBIC, 2005DVBIC, 2005

Why blast injuries are of Why blast injuries are of interest nowinterest now

Armed forces are sustaining Armed forces are sustaining attacks by rocket-propelled attacks by rocket-propelled grenades, improvised explosive grenades, improvised explosive devices, and land mines almost devices, and land mines almost daily in Iraq and Afghanistandaily in Iraq and Afghanistan

Injured soldiers require specialized Injured soldiers require specialized care acutely and over timecare acutely and over time

Enduring sequelae post TBI can result in:

– Motor and sensory deficitsMotor and sensory deficits

– Thinking, memory and Thinking, memory and learning difficultieslearning difficulties

– Behavioral issuesBehavioral issues

– Higher rates of suicidal Higher rates of suicidal behaviorsbehaviors

– Psychiatric problemsPsychiatric problems

PTSD and TBI symptom PTSD and TBI symptom overlap:overlap:

Emotional lability Emotional lability

Difficulty with attention and concentrationDifficulty with attention and concentration

Amnesia for the eventAmnesia for the event

Irritability and angerIrritability and anger

Difficulty with over-stimulationDifficulty with over-stimulation

Social isolation/difficulty in social situationsSocial isolation/difficulty in social situations

dvbic.orgdvbic.org

TBI TBI PTSD PTSD

Research shows that Research shows that among TBI patients among TBI patients who have a memory who have a memory for the event, they for the event, they were more likely to were more likely to develop PTSD than develop PTSD than those with no those with no memorymemory

Harvey & Bryant, 1998; 2000Harvey & Bryant, 1998; 2000

Among TBI patients, Among TBI patients, greater risk for PTSD if:greater risk for PTSD if:

• History of ASD History of ASD

• Memory of trauma that Memory of trauma that resulted in TBIresulted in TBI

• Co-morbid psychiatric Co-morbid psychiatric disorders disorders

• Avoidant coping styleAvoidant coping style

Difficulties with PTSD Difficulties with PTSD DiagnosisDiagnosis

Onset of symptoms may not occur Onset of symptoms may not occur for months to years after traumafor months to years after trauma

Professionals may misdiagnose or Professionals may misdiagnose or not recognize symptomsnot recognize symptoms

Individual psychosocial factors may Individual psychosocial factors may interfere with individuals seeking interfere with individuals seeking helphelp

Avoidant behaviors may result in Avoidant behaviors may result in an inability for others to recognize an inability for others to recognize the need for treatmentthe need for treatment

Vocational ImplicationsVocational Implications

• Impact on well-beingImpact on well-being• EmployabilityEmployability• Challenges for reservistsChallenges for reservists• Military vs. civilian life issuesMilitary vs. civilian life issues• Job turnover and maintenanceJob turnover and maintenance

Steady employment is one predictor of better long-term functioning

Work Accommodation Work Accommodation ConsiderationsConsiderations

Lack of concentration Lack of concentration

• Reduce distractionsReduce distractions• Provide private Provide private

spacespace• Music via headsetMusic via headset• LightingLighting• Divide large Divide large

assignmentsassignments• Plan uninterrupted Plan uninterrupted

work timework time

Work Accommodation Considerations

Effective supervision Effective supervision

• Give information in writingGive information in writing• Provide detailed, daily Provide detailed, daily

feedback and guidancefeedback and guidance• Provide positive Provide positive

reinforcementreinforcement• Provide clear expectations Provide clear expectations

and consequencesand consequences• Develop strategies Develop strategies

together for dealing with together for dealing with conflictconflict

Work Accommodation Work Accommodation ConsiderationsConsiderations

Coping with stress Coping with stress

• Longer/frequent Longer/frequent breaksbreaks

• Backup coverageBackup coverage• Additional time for Additional time for

new responsibilitiesnew responsibilities• Restructure duties Restructure duties

during times of stressduring times of stress• Time off for therapyTime off for therapy• Assign one mentor, Assign one mentor,

manager, supervisormanager, supervisor


Interacting with Interacting with

co-workers co-workers

• Encourage the employee Encourage the employee to walk awayto walk away

• Allow employee to work Allow employee to work from home part-timefrom home part-time

• Provide partitions or Provide partitions or closed doors for privacyclosed doors for privacy

• Provide disability Provide disability awareness training to awareness training to coworkers/ supervisorscoworkers/ supervisors


Dealing with Emotions Dealing with Emotions

• Refer to EAPs and vet Refer to EAPs and vet centerscenters

• Use stress Use stress management management techniquestechniques

• Allow for a support Allow for a support animalanimal

• Allow telephone calls Allow telephone calls during work hours to during work hours to doctors, counselorsdoctors, counselors

• Allow frequent breaksAllow frequent breaks


Sleep disturbance Sleep disturbance

• Allow employee one Allow employee one consistent scheduleconsistent schedule

• Allow for flexible start Allow for flexible start timetime

• Combine regularly Combine regularly scheduled breaks into scheduled breaks into one longer breakone longer break

• Provide place for Provide place for employee to sleep employee to sleep during breakduring break


AbsenteeismAbsenteeism

• Allow for flex timeAllow for flex time• Allow for work at homeAllow for work at home• Provide straight shift or Provide straight shift or

permanent schedulepermanent schedule• Count one occurrence for Count one occurrence for

all PTSD-related all PTSD-related absencesabsences

• Allow the employee to Allow the employee to make up time missedmake up time missed


Panic Attacks Panic Attacks

• Allow for a break or Allow for a break or place to go to use place to go to use relaxation techniques relaxation techniques or contact a support or contact a support personperson

• Identify and remove Identify and remove environmental triggersenvironmental triggers

• Allow presence of a Allow presence of a support animalsupport animal

Managing Treatment Managing Treatment ReferralReferral

Identify at-risk individuals History of psychiatric problems Poor coping resources or capacities Past history of trauma/mistreatment ASD Isolated Financially burdened Limited or no respite from work, family and social

demands Stigma or faulty belief systems around seeking help

Care providers’ play a big role

Likelihood of interacting with individuals with chronic PTSD is high

Early assessment and intervention is crucial

Understanding the presentation of PTSD is important

Your role in the process of identification and referral will be key

Cozza et. al., 2004Cozza et. al., 2004

Considerations for Comprehensive Assessment

of OIF/OEF veterans Work functioning

Interpersonal functioning

Recreation and Self-care (i.e. sleep hygiene

Physical functioning

Psychological symptoms

Past distress and coping

Previous traumatic events

Deployment-related experiences

Prins, et.al., 2004Prins, et.al., 2004

Primary Care PTSD screen (PC-PTSD)*

“In your life, have you had any experiences that were so frightening, horrible, or upsetting that in the past month you..”

a) Have had nightmares about it or think about it when you did not want to?

b) Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

c) Were constantly on guard, watchful, or easily startled?

d) Felt numb or detached from others, activities, or your surroundings?

* Endorsement of three items suggests that PTSD follow-up is warranted for a formal diagnosis

Identifying PTSD Identifying PTSD consultants/specialistsconsultants/specialists

Expert therapists Psychiatrists (MD/DO) Clinical Psychologists (Ph.D./Psy.D.) Social Workers (LCSW/MSW) Psychiatric Nurse

VA Medical Centers/ VA PTSD programs/ VA Vet centers/ VA Community Based Outpatient Clinics (CBOCs)

Phone Book

Hospital/Medical Clinic Affiliation

Local and National Psychological Association

Keane, et.al., 2006Keane, et.al., 2006

Therapeutic Therapeutic Approaches/TechniquesApproaches/Techniques

Recovery plan and process

Empirically Supported Psychotherapies:

Exposure Therapies Anxiety Management Training

Medications: SSRIs

Connecting and Networking

Specific procedures to follow Specific procedures to follow if a client demonstrates PTSD if a client demonstrates PTSD

symptoms during your symptoms during your meeting:meeting:

Display calmness Provide reassurance Orient to place Make periodic “check-ins” with the

client Take a break Guide Implement an appropriate referral

Dealing with Dealing with anger/irritabilityanger/irritability

Anger is often the most troublesome problem

Attempt to understand anger from the individual’s perspective

Intervene Recognition Establish boundaries/ “rules” Using “time outs” Follow emergency procedures if

necessary

Preemptively discuss the advantages and disadvantages of anger expression (i.e. in the workplace)

Seek consultation

Refer for therapy and psycho-educational groups/trainings

Helpful Tips for Dealing Helpful Tips for Dealing with Angry Clientswith Angry Clients

RESOURCES

• Veteran’s Affairs services: www.va.gov

• National Centers for PTSD www.ncptsd.va.gov or www.ncptsd.org

• VA Health Benefits Service Center 1.877.222.VETS or 1.800.827.1000

• Vet Centers’ national number 1.800.905.4675

• PTSD support groups can be located through VA, National Alliance for Mental Illness (NAMI), or About.com’s trauma resource page

• Department of Health Services- in the blue government pages of the phone book

The Center for Mental Health Services Locator http://www.mentalhealh.samhsa.gov/databases/

Anxiety Disorders Association of America (ADAA)

Association for Advancement of Behavioral and Cognitive Therapies (database for CBT therapists)

http://www.alcoholanddrugabuse.com

National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nij.gov/faq/faq.htm

Substance Abuse Treatment Facility Locator http://findtreatment.samhsa.gov/

http://www.alcoholics-anonymous.org/

Stanford University Center for Excellence in the Diagnosis and Treatment of Sleep Disorders: www.med.stanford.edu/school/psychiatry/coe/

See www.mentalhealth.samhsa.gov/hotlines/ for list of phone numbers

National Mental Health Hotline 1.800.969.NMHA (6642)

National Resource Center on Homelessness and Mental Illness 1.800.444.7415

National Suicide Prevention Lifeline 1.800.273.TALK (8255)

SAMHSA’s Center for Substance Abuse Treatment 1.800.662.HELP

Su Familia (Office of Minority Health Resources) 1.866.783.2645

Blast Injury: www.dvbic.org/blastinjury.html

Projects for Assistance in Transition from Homelessness (PATH) – 1.800.795.5486

Job Accommodation Network: www.jan.wvu.edu

Iraq War Clinician Guide, 2nd Edition; wwwIraq War Clinician Guide, 2nd Edition; www.ncptsd.va.gov.ncptsd.va.gov

Resources for Families

• ““Warzone-Related Stress Reactions: What Families Warzone-Related Stress Reactions: What Families Need to Know”Need to Know”

• ““Families in the Military”Families in the Military”

• ““Homecoming: Dealing with Changes and Homecoming: Dealing with Changes and Expectations”Expectations”

• ““Homecoming: Tips for Reunion”Homecoming: Tips for Reunion”

Take Home Points

Essential Features of PTSD Re-experiencing symptoms (nightmares,

intrusive thoughts) Avoidance of trauma cues Numbing/detachment from others Hyperarousal (i.e. increased startle,

hypervigilance)

A variety of factors including personal, cultural, and social characteristics, coping abilities,

experiences in war, and the post-deployment/civilian environment all contribute to the level, severity and duration of stress reactions

““Courage is learning Courage is learning to ask for help”to ask for help”

Thank You

[email protected]

References

American Psychiatric Association (1994). American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth EditionDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American . American Psychiatric Association: Washington, D.C. Psychiatric Association: Washington, D.C.

American Psychiatric Association (2000). American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised. American Psychiatric Association: Washington, D.C.American Psychiatric Association: Washington, D.C.

Cozza, S.J., Benedek, D.M., Bradley, J.C., Grieger, T.A. (2004). Topics specific to the psychiatric treatment of military personnel. Cozza, S.J., Benedek, D.M., Bradley, J.C., Grieger, T.A. (2004). Topics specific to the psychiatric treatment of military personnel. In In Iraq War Clinician’s Guide (2Iraq War Clinician’s Guide (2ndnd Ed.). Ed.). http://www.ncptsd.va.gov/war/guide/index.html http://www.ncptsd.va.gov/war/guide/index.html

Defense and of Veteran Brain Injury Center. Defense and of Veteran Brain Injury Center. http://www.dvbic.org/blastinjury.htmlhttp://www.dvbic.org/blastinjury.html. Downloaded 09/15/2007.. Downloaded 09/15/2007.

Duke, L.M. & Vasterling, J.J. Epidemiological and methodological issues in neuropsychological research on PTSD. In Duke, L.M. & Vasterling, J.J. Epidemiological and methodological issues in neuropsychological research on PTSD. In Neuropsychology of PTSD: Biological, Cognitive and Clinical PerspectivesNeuropsychology of PTSD: Biological, Cognitive and Clinical Perspectives . . Vasterling & Brewin, Eds. The Guilford Press: 2005.Vasterling & Brewin, Eds. The Guilford Press: 2005.

Harvey, A.G., & Bryant, R.A. (1998). Predictors of acute stress following mild traumatic brain injury. Harvey, A.G., & Bryant, R.A. (1998). Predictors of acute stress following mild traumatic brain injury. Brain InjuryBrain Injury, 12, (2): 147-, 12, (2): 147-154.154.

Harvey, A.G. & Bryant, R.A. (2000). Two-year prospective evaluation of the relationship between acute stress disorder and Harvey, A.G. & Bryant, R.A. (2000). Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following traumatic brain injury. posttraumatic stress disorder following traumatic brain injury. The American Journal of PsychiatryThe American Journal of Psychiatry, 157, (4): 626-628., 157, (4): 626-628.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D. (2004). Combat duty in Iraq and Afghanistan, mental health problems and Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D. (2004). Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. barriers to care. The New England Journal of MedicineThe New England Journal of Medicine, 35, (1): 13-22., 35, (1): 13-22.

Hoge, C.W., Auchterloine, J.L., Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from Hoge, C.W., Auchterloine, J.L., Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deplloyment to Iraq or Afghanistan. military service after returning from deplloyment to Iraq or Afghanistan. Journal of the American Medical Association, Journal of the American Medical Association, 295, 1023-295, 1023-1032.1032.

Insurance Information Institute. Insurance Information Institute. http://www.iii.orghttp://www.iii.org. .

National Center for PTSD. National Center for PTSD. http://www.ncptsd.va.govhttp://www.ncptsd.va.gov

Prins, A., Ouimette, P., Kimerling, R., Camerond, R.P., Hugelshofer, D.S., Shaw-Hegwar, J., Thraikill, A., Gusman, F.D., Sheikh, J.I. Prins, A., Ouimette, P., Kimerling, R., Camerond, R.P., Hugelshofer, D.S., Shaw-Hegwar, J., Thraikill, A., Gusman, F.D., Sheikh, J.I. (2004). The primary care PTSD screen (PC-PTSD): development and operating characteristics. (2004). The primary care PTSD screen (PC-PTSD): development and operating characteristics. Primary Care PsychiatryPrimary Care Psychiatry, 9 (1), , 9 (1), January 2004, 9-14.January 2004, 9-14.

An Overview Of Post- Traumatic Stress Disorder: What Vocational Rehabilitation Specialists Need to Know Jennifer Olson-Madden, PhD VISN 19 Eastern Colorado.

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