Trauma in the Workplace: The Need for a Psychology of PTSD in the Workplace W. Criss Lott, Ph.D.

Trauma in the Workplace:The Need for a Psychology of

PTSD in the Workplace

W. Criss Lott, Ph.D.

DSM5 Criteria• PTSD no longer an anxiety

disorder.• A new category of trauma and

stressor-related disorders

Four Phenotypes• Fear-based anxiety • Externalizing Angry/Aggressive• Anhedonic/dysphoric Sxs• Dissociative Sxs

Criterion A• Exposure to actual or

threatened death, serious injury, or sexual violence in one of the following ways:

Criterion A

• 1. Directly experiencing the trauma• 2. Witnessing , in person, events to others• 3. Learning that traumatic event happened to family member or close friend – must have been violent or accidental• 4. Experiencing repeated or extreme exposure

- first time responders /police officers - NOT through electronic media

Criterion B: Intrusion SymptomsOne or more of the following

• 1. Intrusive distressing memories of the traumatic event(s)• 2. Recurrent distressing trauma-

related dreams • 3. Dissociative reactions (e.g.,

flashbacks)

Criterion B: Intrusion Symptoms

• 4. Intense psychological distress when exposed to traumatic reminders • 5. Marked physiological reactions

Criterion C: Avoidance SymptomsOne or both of the following

• 1. Persistent avoidance of thoughts and memories • 2. Persistent avoidance of

external reminders

Criterion D: Negative alterations in cognitions and mood

• 1. Dissociative amnesia of the traumatic event(s)

• 2. Persistent negative expectations • 3. Persistent distorted blame of self or

others about the traumatic event(s) (new)

• 4. Persistent negative emotional state (new)

Criterion D: Negative alterations in cognitions and mood

• 5. Diminished interest or participation in significant activities• 6. Feeling of detachment or

estrangement from others • 7. Persistent inability to experience

positive emotions

Criterion E. Alterations in Arousal and Reactivity – 2 or more

• 1. Irritable behavior or angry outbursts, Reckless or self-destructive behavior

• 2. Hypervigilance • 3. Exaggerated startle response • 4. Problems with concentration • 5. Sleep disturbance

Specifications

• With Dissociative symptoms1. Depersonalization2. Derealization

• With Delayed Exposure (>6 months)

Complex PTSD

• Core symptoms of PTSD plus persistent and pervasive impairments in each of the following:

• Affective functioning: Affect dysregulation, heightened emotional reactivity, violent outbursts, tendency towards dissociative states when under stress

• Self functioning: Persistent beliefs about oneself as diminished, defeated or worthless; pervasive feelings of shame, guilt.

• Relational functioning: Difficulties in sustaining relationships or feeling close to others

Prevalence

• U.S. lifetime risk by age 75 – 8.7%• 12 month prevalence is 3.5%• Rates vary with groups• Higher rates w/Veterans , first

responders• Highest rates – 30-50% Survivors of rape,

Combat veterans, internment & genocide

Development and Course

• PTSD can occur at any age• Sxs begin w/in first 3 months• May be delayed of months or years• Typically seen as Acute Stress Dx• Durations of Sxs vary• Recovery varies – 3 months to 12 months or

longer

Risk and Prognostic Factors

• Pretraumatic factors–Temperamental - emotional problems

by age 6 and prior mental disorders–Environmental – SES, cultural (fatalistic,

self-blaming), lower IQ, racial/ethnic, family hx mental illness–Genetic & physiological

Peritraumatic Factors

• Environmental –- Severity of trauma (the greater the

magnitude the greater the likelihood of PTSD- Perceived life threat- Personal injury- Interpersonal violence - Combatants killing or witnessing atrocities- Dissociation occurring during trauma

Postraumatic Factors

• Temperamental – negative appraisals, poor coping strategies, acute stress disorder

• Environmental – exposure to repeated reminders, later adverse life events, financial or other trauma-related losses

• Social support is protective factor

Culture-Related Issues

• Expression of PTSD can vary depending on – type of traumatic exposure (e.g., genocide)– impact of traumatic event (unable to

perform funerary rites)–ongoing sociocultural context (living with or

near perpetrators)–other cultural factors (acculturative stress)

Gender-Related Issues

• More prevalent with women• Women experience PTSD longer

Differential Diagnoses

• Adjustment Disorders• Acute Stress Disorder (3 days to 1

month)• Anxiety Disorders• OCD (intrusive thoughts not

traumatic)• Major Depressive Disorder

Differential Diagnoses

• Personality Disorders• Dissociative Disorders (non-traumatic)• Conversion Disorders (new sxs post injury

may be PTSD)• Psychotic Disorders• Traumatic Brain Injury (may overlap with

PTSD)

Comorbidity• 80% PTSD meet criteria for one other

disorder

• Substance use disorder and Conduct disorder more common with men

• 48% Military combat veterans have PTSD and TBI-related neurocognitive sxs

Functional Consequences of PTSD

• PTSD is associated with –Poor social and family relationships– Absenteeism from work–Lower income–Lower educational and occupational

success

Symptoms at Work

• Memory problems• Lack of concentration• Difficulty retaining information• Feelings of fear or anxiety• Physical problems

Symptoms at Work

• Poor interactions with coworkers• Unreasonable reactions to situations that

trigger memories• Absenteeism• Interruptions if employee is still in an abusive

relationship, harassing phone calls, etc.• Trouble staying awake• Panic attacks

Treatments for PTSD

Prolonged Exposure Therapy (PE; Foa, Hembree, & Rothbaum, 2007)

Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993)

Eye Movement Desensitization and Reprocessing Therapy (EMDR; Shapiro, 2001)

Prolonged Exposure

9-12 90-minute sessionsEducation and orientationImaginal exposure (exposure to the

memories)In vivo exposure (exposure to avoided

situations and activities)Stress tolerance and cognitive restructuring

throughoutBetween session practice

Cognitive Processing TherapyLargely based on a social-cognitive theory that

suggests trauma alters beliefs in 5 key areas: safety, trust, power/control, esteem, & intimacy

Emphasis on reconciling pre-existing beliefs with new beliefs towards more balanced ways of viewing oneself, others, and the world

Like PE, views activating the “fear network” important

PTSD: Trauma Processing Therapies

Recommended if:Reasonable emotion regulation abilitiesMotivated for treatmentWilling to focus on trauma

Not recommended if:Active substance dependenceHigh HI or SIOther indicators of significant emotion dysregulationFactors that would interfere with adhering to the treatment

Accommodating Workers with PTSD

• Due to the high number of veterans with PTSD, the U.S. Department of Labor created a program called America’s Heroes at Work to help those with combat-related PTSD

• Not all people with PTSD will need accommodation, and many will not ask for help. Examples provided for particular problem areas include the following:

Accommodating Workers with PTSD

• Memory - Provide written instructions - Provide written minutes of each meeting

Lack of Concentration - Reduce distractions in the work environment - Increase natural lighting or increase full spectrum lighting

Accommodating Workers with PTSD

• Coping with Stress - Allow time off for counseling - Assign a supervisor, manager or mentor to answer employee's questions

• Working Effectively with a Supervisor - Provide positive reinforcement - Provide clear expectations and the consequences of not meeting expectations

Accommodating Workers with PTSD

• Dealing with Emotions - Refer to employee assistance programs (EAP) - Allow frequent breaks

Panic Attacks - Allow the employee to take a break and go to a place s/he feels comfortable to use relaxation techniques or contact a support person - Identify and remove environmental triggers such as particular smells or noises

PTSD CASES:

• Betty A. Sibley v Unifirst Bank and Aetna Casualty 699 So.2d 1214 (Miss. Sup. Ct. 1997)

• Claimant was 31-year-old resident of Clinton and branch supervisor/head teller for Unifirst in September 1981 when a robbery occurred at the Metrocenter branch where she worked.

PTSD CASES: Sibley cont.

• Aside from this 6-week period in 1983 and time off work to visit the doctor, Sibley did not miss work due to the robbery between the date of the robbery and the date that her employment was terminated by the bank, December 10, 1990.

PTSD CASES: Sibley cont.

• Three months after the robbery, she was promoted to Asst. Manager of the same branch. In 1982, she was promoted to Branch Manager of a nearby branch. Each year after the 1981 robbery, until 1990, she received merit wage increases.

PTSD CASES: Sibley cont.

• Sibley was terminated in December 1990 because of embezzlement, and she did not return to work in any capacity for any employer.

• In January 1991, Sibley filed a Petition to Controvert against Unifirst, alleging that she sustained a work-connected mental injury on 9-17-81 which had been continuous and ongoing since that time.

PTSD CASES: Sibley cont.

• The AJ noted the MS Supreme Court’s heightened standard of proof in mental-mental cases (mental stimuli/mental injury): (1) evidence of the occurrence of an unusual or untoward event, (2) stress greater than the ordinary incidents of employment, and (3) clear and convincing evidence of causal connection between the work and the mental injury.

PTSD CASES: Sibley cont.

• The AJ found Sibley proved by clear and convincing evidence that the bank robbery was an untoward event or unusual occurrence which exceeded the general stress or normal wear and tear of the workplace.

• Temporary total disability benefits during Claimant’s 6-week LOA in 1983 were awarded, with credit for compensation paid by Employer.

PTSD CASES: Sibley cont.

• The AJ denied the claim for permanent disability benefits. This finding was based on Sibley’s immediate return to work after the robbery, her ability to continue to work until her termination (except for the 6-week period in 1983), and the 4 promotions she earned between 9/1981 and 12/1990, ultimately rising to the position of assistant vice president. It was also based on the opinion that Sibley’s impairment may be attributable to pre-existing characterological issues and to subsequent stressors (marital, family and financial problems) unrelated to the robbery.

• The Commission, Circuit Ct. and Supreme Court affirmed.

PTSD CASES: Adcox

• Mississippi Department of Public Safety, Bureau of Narcotics vs. Elisha Adcox 135 So.3d 194

PTSD CASES: Adcox

• Claimant/MBN agent assisted in the immediate aftermath of Hurricane Katrina on the Gulf Coast – providing security against looters, searching and rescuing survivors, and recovering bodies. She worked 20 hours a day, personally observing many of the dead. Once she inadvertently stepped on a dead body while climbing through the window of a house. She also slept in her car, rather than on the floor of the command station, in fear of rats and snakes.

PTSD CASES: Adcox cont.

• AJ found Claimant proved by clear and convincing evidence that her work during Katrina caused her PTSD and that she was PTD.

• COA Affirmed. COA noted the specifics of Claimant’s service on the Coast which proved her work involved occurrences beyond the ordinary experience of her employment. COA also noted her psychiatrist testified that her Katrina experience qualified as a traumatic event under the DMS-IV. Thus, there was substantial evidence to support the Commission’s decision that Claimant presented clear and convincing evidence that her PTSD was casually connected to her work.

PTSD CASES: Adcox cont.

• COA also noted that although Employer’s psychiatrist opined Claimant did not meet the diagnostic criteria for PTSD because there was “no imminent danger to her or a loved one,” both Claimant’s psychiatrist and therapist testified this was not required to establish a diagnosis of PTSD under the DSM-IV. The DSM-IV criteria for PTSD also includes “witnessing an event that involves...a threat to the physical integrity of another....”