Diagnosis and treatment of posttraumatic stress disorder

Issue: BCMJ, vol. 50 , No. 5 , June 2008 , Pages 264 WorkSafeBC

Psychological trauma injuries can oc­cur in the workplace after a variety of disturbing events: industrial accidents resulting in severe physical injuries, assault, robbery, serious automobile accidents, or witnessing the death or injury of a co-worker. 

Following the event, a worker may develop one of a number of psychological conditions, but the most commonly diagnosed is posttraumatic stress disorder (PTSD). In the WorkSafeBC context, these conditions are referred to as mental stress. 

Emotional upset due to other workplace stresses—such as high workload or conflict with co-workers—is not considered a workplace injury.

DSM-IV diagnostic criteria
The event
PTSD is an anxiety disorder that may develop after exposure to an extreme traumatic stressor. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the traumatic event in­volves “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.”

It’s important to note that not all upsetting events meet this diagnostic criterion. There are many events that may be described as traumatic (for example, divorce, loss of a job, death of an aging parent, or job stress), which can result in significant psycho­logical dysfunction. It is important to differentiate these conditions from PTSD because the expected course and appropriate treatment will vary.

For those individuals who manifest the signs and symptoms of PTSD and are diagnosed with this condition, the following typically occurs.

The reaction
At the time of the event, “the person’s response involved intense fear, helplessness, or horror.” In essence, the person’s ability to cope with the event at that moment was exceeded.

Re-experiencing
Following the initial reaction, the person’s behavior is characterized by a persistent re-experiencing of the traumatic event. 

This can take the form of:
• Recurrent and intrusive recollections of the event.
• Nightmares.
• Psychological distress or physio­logical reactivity to reminders of the event.
• In severe situations, dissociative episodes in which the person be­lieves and acts as though the event is occurring again.

Avoidance
The person tries to avoid thoughts, feelings, and reminders of the event and may:
• Avoid activities, people, and places that remind them of the event.
• Disengage from and feel detached from others.
• Feel emotionally numb.
• See no future for themselves.

Arousal
The person experiences a continuing state of anxiety characterized by:
• Difficulty falling or staying asleep.
• Uncharacteristic irritability or anger.
• Difficulty concentrating.
• Extreme wariness and being easily startled.

Recovery
Many people who experience a traumatic event recover and resume normal functioning in a matter of hours or days. Because of this rapid recovery rate, a diagnosis of PTSD is not made until the symptoms have been present for at least 1 month. 

For those who meet the criteria for the event and initial reaction, and are experiencing significant dysfunction, a diagnosis of acute stress disorder may be appropriate during the first month of symptoms. Symptom remission for PTSD varies, with half of the patients recovering completely in 3 months and some still experiencing symptoms after 1 year.

Treatment of choice is a cognitive-behavioral approach that includes de­sensitization to the triggering stimuli.

How WorkSafeBC can help
At the time of the initial attending physician consultation, the worker may not present with a fully diagnosable psychological condition, or the psychological distress may not be the major focus of intervention where there are significant physical injuries. 

In either situation, it is helpful for the attending physician to highlight the presenting psychological symptoms in his or her reports to WorkSafeBC and request consultation with the Work­SafeBC psychology advisor. Work­SafeBC can then arrange for psy­chological assessment to assist in diagnosis and adjudication and provide appropriate clinical intervention when supported.

If you have questions about a PTSD diagnosis for an injured worker patient, please consult the WorkSafeBC psychology advisor or call Dr Greg Meloche, WorkSafeBC manager of Psychology Services, at 604 279-7654.

—Greg Meloche, PhD, R Psych
WorkSafeBC Manager of Psychology Services

Greg Meloche, PhD, RPsych. Diagnosis and treatment of posttraumatic stress disorder. BCMJ, Vol. 50, No. 5, June, 2008, Page(s) 264 - WorkSafeBC.



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