Medical Unit - Post-traumatic stress disorder
(Adopted February 24, 1997)
I. Introduction:
The Industrial Medical Council and supporting advisory committees were established in 1989 as part of workers' compensation reform. The Psychiatric Advisory Committee followed a legislative mandate to revise the disability evaluation protocols for psychiatric injury which were accepted into law by the Office of Administrative Law on December 7, 1993. The legislature also mandated the IMC to develop guidelines for common industrial injuries.
Violent encounters and exposure to life threatening events are common occurrences in the workers' compensation system. According to the Bureau of Labor Statistics for the calendar year 1992, 1,004 homicides took place at the work site and 22, 400 attacks occurred in the national workforce. The IMC and the Psychiatric Advisory Committee have thus selected post-traumatic stress disorder (PTSD) as the focus for establishment of treatment guidelines.
The California legislature made subsequent changes to the workers' compensation system including a higher threshold of compensability for psychiatric injuries. For injuries that occur after July 17, 1993, an injured worker must prove that the "actual events of employment" were the "predominant cause" (at least 51 percent) among all of the combined causes of the psychiatric injury.
However, if the psychiatric injury results from a violent act, or from direct exposure to a significant violent act, the actual events of employment must have been a "substantial cause" (at least 35 percent) of the injury (Lab. Code _ 3208.3).
The Psychiatric Advisory Committee, composed of psychiatrists and psychologists from different geographic locations in California, developed these guidelines following committee deliberations, a review of the clinical literature of PATS, and input from national experts.
Scope of this guideline:
This guideline does not deal with legal issue of causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed in these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the official medical fee schedule.
A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the physician is necessary to monitor and explain the use of variances.
The physician may wish to advise the parties of the availability of the Cal/OSHA guidelines for workplace security from the Division of Occupational Safety and Health.
II. Background on the concepts of post-traumatic stress disorder (PTSD):
The diagnosis of post-traumatic stress disorder was first established in the Diagnostic & Statistical Manual, 3rd Edition (DSM-III) by the American Psychiatric Association in 1980. The earlier DSM-I (1952) listed a diagnostic category entitled stressors resulted in a state of fearfulness. More recently DSM-IV (1994) has added the category called Acute Stress Disorder for individuals who experience a brief episode of symptoms that resemble those that occur in PTSD following exposure to an extreme stressor.
The medical literature details the phenomenon of post-traumatic stress disorder dating back well before this century. DaCosta published a paper in the "American Journal of Medical Science" (1871) regarding "irritable heart" found in Civil War soldiers who complained of chest pain, palpitations and dizziness subsequent to exposure to battle scenes. "Shell shock" is a concept that came forth in the medical literature that relates to the description of front line soldiers' emotional states during World War I. In World War II a number of papers were published concerning the concept of "traumatic neurosis" again addressing the emotional response on the part of soldiers to witnessing and experiencing serious trauma. Over the past two decades, numerous publications have described similar post-traumatic stress reactions among civilians exposed to catastrophic violence, disaster and traumatic injury. This literature has also documented that the witnessing of life threat, injury or traumatic death to another may result in the full spectrum of post-traumatic symptoms.
The anxious response in patients diagnosed as having PTSD may well relate to increased catecholamine excretion. Studies of Vietnam veterans have found increased levels of noradrenergic metabolites compared to the normal population. Psychological theories point toward the breakdown of the individual's normal defenses such as the use of denial in coping with anxiety related to one's own mortality. Mardi Horowitz (1986) described several stages that patients experience in treatment for PTSD including the traumatic event, outcry, denial, intrusive symptoms, working through and completion. Research involving psychological and biological factors is consistent with PTSD as a separate and distinct disorder from patients with a clinical depressions.
It should be noted that not all those exposed to serious trauma develop symptoms of PTSD. Not all those diagnosed with PTSD go on to become disabled. Symptomatology should not be equated with functional impairment. The lifetime prevalence of PTSD is somewhere between 1.3 to 9 percent of the general population (Breslau, 1991) and 15 percent in psychiatric inpatients (Saxe, 1993). The majority of victims of the Buffalo Creek Flood and the Coconut Grove Fire were noted to have post-traumatic symptomatology. Fifteen percent of Vietnam Theater veterans twenty years after the war were diagnosed with PTSD according to the National Vietnam Veterans Readjustment Study (1990). Thus, the diagnosis is by no means uncommon. Studies to date indicate that the severity of exposure to direct life-threat and the witnessing of mutilating injury or death is strongly positively associated with severity of post-traumatic stress reaction. PTSD varies with type, intensity and duration of trauma.
III. Diagnosis:
Post-traumatic stress disorder and acute stress disorder fall within the anxiety disorders category according to the current Diagnostic and Statistical Manual (DSM-IV). Certain criteria must be met for the diagnosis of PTSD to be made. It is essential that the individual experience, witness or be confronted by an event(s) that involve actual or threatened death, serious injury or threat to the physical integrity of oneself or others. The individual must respond by experiencing intense fear, helplessness or horror. There are three symptom categories of PTSD: reexperiencing, avoidance and arousal. The individual goes on to re-experience the event through such things as intrusive recollections and disturbing dreams. Prominent symptoms include avoidance and numbing. Increased arousal is manifest through disturbance of sleep, hypervigilance, exaggerated startle responses and other symptoms. For acute stress disorder the disturbance lasts at least two days and for a maximum of four weeks whereas for PTSD the diagnosis can be made where symptoms are present for more than one month. The disorder causes distress or impairment in social, occupational or other areas of functioning. If the duration of symptoms is less than three months the condition is deemed acute. If three months or longer, then the descriptor of chronic is appropriate. Delayed onset PTSD occurs when symptoms make their appearance six months or longer after the recognizable stressor.
Examples of traumatic exposures provided in DSM-IV include but are not limited to exposure to combat, violent personal assault, kidnapping, hostage situations, terrorist attacks, torture, concentration camp incarceration, disaster situations, severe automobile accidents or diagnosis with a life-threatening illness. It should be noted that the stressors can be sudden, circumscribed and singular or they may be cumulative and repetitive. Either an individual can be responding to a single hold-up or a series of bank robberies, for example. Natural as well as man-made and intentional trauma can result in features of PTSD. Guilt amongst survivors of serious trauma situations may be a predominant theme. A pre-existing psychiatric disorder or a history of significant trauma, whether related to the current event or not, has been associated with risk of a more severe reaction to a current traumatic exposure.
There is some debate about the extent to which PTSD symptoms overlap with those of depression, substance abuse and other anxiety disorders, which commonly occur with it. There is also some controversy about the type of traumatic events and required levels of intensity that qualify for meeting the diagnostic criteria. The change in the stressor criterion from DSM-III-R to DSM-IV was prompted by the recognition that many extremely traumatic experiences are common enough among the general population not to be deemed "outside the range of usual human experience." The stressor criterion now includes meeting criteria for both objective features, e.g., life-threat or witnessing injury, and subjective features, e.g. horror, terror, intense fear or helplessness. Whereas the inclusion of subjective reactions may appear to some clinicians to broaden the potential range of events that may qualify for the diagnosis, the objective features do not differ from those mentioned in DSM-III-R.
Some clinicians may use diagnostic terms such as a typical PTSD or diagnose PTSD when only secondary symptomatic criteria are met without the initial stressor criteria. Some clinicians make reference to a psychologically "toxic work environment" as sufficient for the diagnosis for PTSD. There are also instances in which corroboration cannot be consistent with malingered or factitious presentations. Where all of the criteria are not met for PTSD or acute stress disorder, the differential diagnosis should include other considerations such as an adjustment disorder, other anxiety disorders, mood disorders, personality disorders, and even psychotic decompensation with this listing not being all-inclusive.
In order to make a correct psychiatric diagnosis treating and evaluating clinicians need to take a thorough history, review all appropriate medical and administrative records, and consider other sources of corroborating data. In making an assessment of whether a patient meets the criteria for PTSD, inquiry should be made about the objective features of the referent traumatic event. The patient's subjective experience should be ascertained in such detail as to determine the patient's appraisal of the threat(s) and severity of subjective reactions. Just as in the assessment of other psychiatric disability situations, there is an appropriate role for psychometric testing that can add additional data concerning the veracity of the applicant's reporting, the severity of symptomatology experienced and the style of coping for that individual.
IV. Treatment considerations:
Most clinicians and researchers agree that early intervention is called for in cases of acute stress disorder and in cases of post-traumatic stress disorder when later identified. Critical incident stress debriefing at times can be brought about at the worksite, allowing employees to discuss their joint experience of a workplace trauma such as a bank robbery. This type of group intervention can provide psycho-education and reassurance about the range of normal expected reactions to serious traumatic situations. It also gives clinicians the opportunity to suggest ways of coping with secondary stresses, traumatic reminders and losses. It must be kept in mind that a group of employees may have a wide range of exposures to the same incident. For those employees with the most severe levels exposure, critical incident debriefing alone is likely to be insufficient. In the aftermath, individuals with more serious symptoms or those at greater risk need to be identified and provided with further symptomatic assessment and intervention.
A. There are different models of psychotherapy for PTSD that are appropriate. Some take a supportive approach that is consoling. Others use a group approach allowing patients to develop a shared experience. Some clinicians use short-term individual treatment such as that developed by Horowitz and Marmar at UC San Francisco, or short-term group psychotherapy. Additional approaches involve a more long-term working through of the trauma. Recovery from PTSD may have a phasic course, in part, due to expected traumatic reminders such as physical rehabilitation, criminal proceedings, return to the worksite where violence or disaster occurred, and anniversary reactions, as well as unexpected reminders. Short-term psychotherapy, therefore, may need augmentation by periodic follow-up brief psychotherapy sessions in preparation for, during and after such occasions. Treatment should be targeted and focused on symptom removal rather than on uncovering pre-existing psychopathology and addressing personality change.
Cognitive behavioral therapy employing exposure-related techniques to address painful memories of the original experience can be very effective in reducing the fear that often times accompanies the PTSD syndrome. Cognitive approaches may also be used to restructure the meaning attributed to the experience. These techniques can utilize the therapeutic assignments outside the office. In vivo exposure at the work site following discussion in the therapy setting can also be a powerful adjunct to treatment. More general behavioral interventions can also be useful, for example, the use of relaxation techniques to reduce reactivity to trauma-related cues or reminders, desensitization for phobic symptoms, and sleep induction.
B. Psychotropic medication is a common component of treatment. Anti-anxiety medication, especially for acute stress disorder, and tricyclic antidepressants have been shown to assist with sleep induction and can suppress the REM component of sleep in which disturbing dreams can come forth. Imipramine can reduce intrusive symptomatology through action on noradrogernic receptor sites in the brain. Amitriptyline and selective serotonin re-uptake inhibitors (SSRI's) such as fluoxetine can reduce numbing and hyperarousal through serotonergic sites. The SSRI's tend to be well tolerated. There is also a rationale for other types of antidepressants such as the MAO inhibitors, mood stabilizing agents such as lithium and valproic acid, adrenergic blockers such as propanolol and clonidine, antipsychotic agents for agitation and paranoia, as well as other psychotropics depending on the severity of symptoms and their duration.
The Advisory Committee recommends treatment be placed into three categories for establishing treatment based upon DSM-IV criteria .
Certain general treatment principles apply. Early clinical intervention soon after the identified workplace trauma can reduce morbidity and disability. An increased frequency in sessions beyond weekly on a short term basis can be appropriate, particularly, early in treatment. Treatment may be appropriate and necessary that exceeds the following guidelines when complicating factors influencing the frequency and duration of treatment are present and documented. There are cases where maintenance treatment may be necessary, especially utilizing supportive psychotherapy and psychopharmacologic approaches for individuals who have experienced extreme trauma and/or present with ongoing symptoms that justify such measures. Psychopharmacologic management visits can be separate from the psychotherapeutic sessions and should not reduce the total number of psychotherapy sessions made available to PTSD patients.
1) Acute stress disorder. This condition is present when symptoms have a duration of up to one month subsequent to the traumatic event. The treatment should involve a brief psychoeducational approach lasting one to eight psychotherapy sessions. Positive outcome expectations should be fostered. The patient should be assured that his/her responses are a normal reaction and that they usually disappear in a short time. The use of illicit substances or alcohol as a means of coping should be discouraged. Psychotropic medication is generally restricted to the occasional use of anxiolytics, antidepressants, or hypnotics to assist sleep. The major goals of this treatment approach are normalization, positive expectation, catharsis and desensitization.
2) Acute PTSD. The duration of symptoms is from one to three months subsequent to the industrial trauma. Typically for this type of case where the individual responds to a recognizable stressor, short-term psychotherapeutic treatment, which may be accompanied by the use of medication, is provided for approximately 12 to 16 psychotherapy sessions.
3) Chronic or delayed PTSD. (The committee suggests that this category be considered for cases of complicated or protracted PTSD.) The duration of symptoms is beyond a period of three months following the trauma. Persistent and significant symptomatology may continue in certain individuals who have received short-term treatment. Complicating factors may include the nature of the initial stressor, prior psychiatric treatment or prior history of trauma/abuse. In such instances treatment beyond the short-term intervention model is appropriate and necessary. Treatment may require 35 to 55 psychotherapy sessions in such instances with justification by the treating clinician. (More frequent therapy and the ongoing use of medication may be warranted.) There are cases where additional treatment may be necessary beyond a period of one year. When treatment is to extend beyond a period of one year, justification by the treating clinician is warranted. Reevaluations by non-treating clinicians at periodic intervals to address the efficacy of treatment can be useful. An opinion from a psychiatrist or psychologist is necessary to amend or discontinue treatment. That opinion must be based upon medical evidence in the case being reviewed.
Factors influencing the frequency and duration of treatment in complicated PTSD. Risk factors which may complicate treatment and the course of the clinical presentation include: a childhood history of trauma, poor social supports, a history of alcohol and drug abuse, lasting physical injury, and disruption of marital and family functioning. As noted above, a history of prior psychiatric treatment can complicate the treatment for the more recent traumatic event. Furthermore, a co-morbid diagnosis with an additional psychiatric condition such as a major depression or a psychotic disorder can add to the complexity and prolong the course of treatment. Personality disorders can also result in resistance to treatment requiring more skill on the part of the treating clinician and at times more treatment resources. Some of the types of maladaptive traits that are intensified by traumatic exposure include paranoia, dependency and avoidance. While treatment for a pre-existing personality disorder or other pre-existing psychiatric condition may not be caused by the traumatic event, complicating maladaptive traits or symptoms may need to be recognized and treated to the extent necessary to provide maximum PTSD treatment efficacy. The influence of legal and administrative factors is significant for injured workers within the workers' compensation system. Symptom prolongation can come about as the result of an inability to resolve the applicant's claim, thus drawing out the need for supportive psychotherapy or counseling. Symptom exacerbation can also occur as a result of repeated examinations, depositions, and court testimony, at times related to other legal matters such as criminal proceedings. In extreme cases patients may present with concomitant syndromes such as major depression which can require inpatient treatment. While acknowledging complicating factors that can prolong treatment and disability, clinicians should be mindful for the potential for secondary gain. Reducing symptomatology, improving functional ability and returning the injured worker to the work force should be the achievable goal of treatment in most cases.
V. Clinical intervention / recommendations beyond treatment:
While not under the rubric of clinical treatment, other types of interventions can be extremely helpful in assisting the employee to return to a more functional status and ultimately to some type of employment whether with the employer of record or at an alternative worksite. In some cases of PTSD, treating or clinicians will issue recommendations for measures in addition to treatment. These include recommendations for accommodations at the worksite. For example, a bank teller may have to be taken off the teller line following a bank robbery for a period of time. Certain individuals can be accommodated by being placed in positions where they do not handle money subsequent to a robbery event. Clinicians may recommend improving security measures at the worksite. The treating doctor may indicate that it is appropriate for his/her patient to take a self-defense class as a means of empowering the individual in addition to teaching the person how to protect himself or herself in a potential similar situation in the future. Also during the treatment phase a treating doctor may collaborate with the vocational counselor about the worker taking incremental steps toward venturing out into the public, taking on the challenge of retraining or returning to the work site. Where appropriate the employer can facilitate the early return to work by the incremental resumption of duties, e. g. part time employment . Success in regard to the goals of returning the employee to work and increasing functionality can actually reduce the duration of treatment and at times the level of permanent disability.