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«Work Impairment And Limitations Associated With Posttraumatic Stress Disorder Background It is estimated that 3.6% of adults in the United States ...»

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Work Impairment And Limitations Associated With Posttraumatic Stress Disorder

Background

It is estimated that 3.6% of adults in the United States have PTSD in any given year, with 7.8% developing PTSD during their lifetime (National Comorbidity Survey - Kessler et al., 1995). Oneyear prevalence rates in other countries vary from 0.1% in a German male population to 1.2% in Australia and 1.3% in six European cities combined (Perkonnig et al., 2000; Creamer et al., 2001; Alonso et. al., 2004). In terms of Canadian prevalence rates, two studies have estimated the one-year rate of PTSD in Canada to be 2.7% and 1.0% respectively (Stein et al., 1997;

Sareen et al., 2007). In addition, approximately 3 – 10% of Canadian adults may have a number of symptoms of PTSD without developing the full disorder, sometimes labeled “partial PTSD” (Stein et al., 1997, 2000).

While between 50% and 90% of adults have experienced at least one traumatic event in their life, only 5 – 10% of these actually go on to develop PTSD (Reznick et al., 1993; Breslau et al., 1998, 2002; Kessler et al., 1995, Ozer et al., 2003). In addition, it appears that the majority of individuals recover from trauma in 6 – 16 months without developing any long-term problems, making resiliency the most common outcome after traumatic events (Baum & Fleming, 1993;

Green et al., 1994; La Greca et al., 1996; Bryant, 2003, 2006). A number of factors have been found to increase the risk for developing PTSD (and other mental disorders) including history of mental health problems, previous trauma, poor social support, poor ability to cope with stress, type of traumatic event, severity of injuries, high level of immediate distress, and post-trauma dissociative symptoms (Brewin et al., 2000; Norris et al., 2001, 2002; Ozer et al., 2003).

The following chart outlines the different rates of PTSD associated with various traumatic events (highlighted events are likely to occur in a work setting):

Rape 49% Bombing 34% Severe assault 32% Combat action 30% Plane crash 29% Mass shooting 28% Armed Robbery 24% Serious accident/injury 17% Shooting or stabbing 16% Wi

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al., 2003; Nyberg et al., 2003). Interestingly, in studies that compared work-related accidents to non-work accidents, work-related cases had less severe injuries, more PTSD symptoms, and were more likely to involve litigation (Mason et al., 2002). In addition, research has found that certain types of injuries or incidents are associated with more severe PTSD including upper limb injuries (vs. lower limb amputation), amputations (vs. burns), electrical burns (vs. other burns), high stress (vs. low/med stress incidents), and robberies (vs. work accidents). Factors most likely to affect return to work from PTSD include severity of injury, tendency to blame others, involvement in litigation, physical recovery, and overall mental health functioning (Mason et al., 2002).

In a recent study of WorkSafeBC clients with PTSD (MacDonald et al., 2003), 84% directly experienced a traumatic event (45% robbery, 32% assault, 7% other) and 16% witnessed a traumatic event. In terms of diagnoses, 55% of workers had PTSD only, while 45% had PTSD plus other disorders. Comorbid diagnoses included depressive disorders (27%), anxiety disorders (9%), and mixed depression/anxiety disorders (9%). At a four-year follow-up, 65.9% clients had returned to work while 34.1% had not re-entered the workforce. Of those returning to work, 43.2% returned to the same job, 2.3% returned to a different position with the same employer, 4.5% returned to the same industry, and 34.1% had moved on to a new industry.

Only 1% of workers were assessed with a psychological permanent functional impairment.

Impact of PTSD on work functioning

The relationship between PTSD and work has not been investigated to the same extent as for depression, particularly in relation to reduced productivity and performance on the job (often called “presenteeism”). However, the available research has found that PTSD is associated with impaired occupational functioning, as indicated by absenteeism, unemployment, and work disability (Breslau, 2001; Breslau et al, 2004; Hull et al., 2002; Matthews & Chinnery, 2005). In fact, work impairment associated with PTSD appears to be very similar to the amount of work impairment associated with major depression (Nicoletta et al., 2001).

In addition, PTSD symptom severity has been found to be associated with occupational impairment, even after controlling for the effects of comorbid disorders (Breslau et al., 2004;

Ciechanowski et al., 2004; Momartin et al., 2004; Stein et al., 1997; Zatzick et al., 1997).

However, while work impairment was significantly more pronounced in persons with full PTSD than in those with only partial symptoms, the latter nonetheless exhibited clinically meaningful levels of impairment association with their symptoms (Stein et al., 1997; Zlotnick et al., 2002;

Breslau et al., 2004; Matthews & Chinnery, 2005).

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Work impairments and limitations Below are outlined possible work-related impairments and limitations which may result from symptoms in workers diagnosed with PTSD. As in previous memos, these have been derived from the research literature, clinical experience, and consensus among psychologists working in the workers compensation system. It should be noted that individual limitations will depend on a worker’s circumstances, specific constellation of symptoms, severity of the disorder, and response to treatment.

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Alonso, J., Angermeyer, M.C., Bernert, S., Bruffaerts, R., Brugha, T.S., Bryson, H., de Girolamo, G., Graaf, R., Demyttenaere, K., Gasquet, I., Haro, J.M., Katz, S.J., Kessler, R.C., Kovess, V., Lépine, J.P., Ormel, J., Polidori, G., Russo, L.J., Vilagut, G., Almansa, J., Arbabzadeh-Bouchez, S., Autonell, J., Bernal, M., Buist-Bouwman, M.A., Codony, M., Domingo-Salvany, A., Ferrer, M., Joo, S.S., Martínez-Alonso, M., Matschinger, H., Mazzi, F., Morgan, Z., Morosini, P., Palacín, C.,

Romera, B., Taub, N., & Vollebergh, W.A. (2004). Prevalence of mental disorders in Europe:

results from the European Study of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandanavia Supplement, (420), 21–27.

Asmundson, G.J., Norton, G.R., Allerdings, M.D., Norton, P.J., & Larsen, D.K. (1998).

Posttraumatic stress disorder and work-related injury. Journal of Anxiety Disorders, 12(1), 57Baum, A. & Fleming, I. (1993). Implications of psychological research on stress and technological accidents. American Psychologist, 48, 665-667.

Breslau, N. (2001). Outcomes of PTSD. Journal of Clinical Psychiatry, 62 (suppl.), 55 -59.

Breslau, N., Kessler, R.C., Chilcoat, H.D., Schultz, L.R., Davis, G.C., & Andreski P. (1998).

Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 55, 626-632.

Breslau, N., Lucia, V.C., & Davis, G.C. (2004). Partial PTSD versus full PTSD: an empirical examination of associated impairment. Psychological Medicine, 34, 1205-1214.

Breslau, Naomi (2002). Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. Canadian Journal of Psychiatry, 47(10), 923-929.

Brewin, C.R., Andrews, B., & Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–66.

Brunello, N., Davidson, J.R.T., Deahl, M., Kessler R.C., Mendlewicz, J., Racagni, G., Shalev, A.Y., & Zohar, J. (2001). Posttraumatic Stress Disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment. Neuropsychobiology, 43(3), 150Bryant, R.A. (2003). Predictors of posttraumatic stress disorder. Biological Psychiatry, 53, 789 Bryant, R.A. (2006). Recovery after the tsunami: timeline for rehabilitation. Journal of Clinical Psychiatry, 67 (Suppl 2), 50 - 55.

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Creamer, M., Burgess, P., & McFarlane, A.C. (2001). Post-traumatic stress disorder: findings from the Australian National Survey of mental health and well-being. Psychological Medicine, 31, 1237–1247.

Green, B.L. & Lindy, J.D. (1994). Posttraumatic stress disorder in victims of disasters.

Psychiatric Clinics of North America, 17, 301-309.

Hull, A.M., Alexander, D.A., & Klein, S. (2002). Survivors of the Piper Alpha oil platform disaster:

long-term follow-up study. The British Journal of Psychiatry, 181, 433-438.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M,. & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey, Archives of General Psychiatry, 52(12).) La Greca, A.M., Silverman, W.K., Vernberg, E.M. & Prinstein, M.S. (1996). Symptoms of PostTraumatic Stress in children after Hurricane Andrew: a prospective study. Journal of Consulting and Clinical Psychology, 64, 712-723.

Laposa, J.M., Alden, L.E., & Fullerton, L.M. (2003). Work stress and posttraumatic stress disorder in ED nurses/personnel. Journal of Emergency Nursing, 29(1), 23-8.

MacDonald HA, Colotla V, Flamer S, Karlinsky H. (2003). Posttraumatic stress disorder (PTSD) in the workplace: a descriptive study of workers experiencing PTSD resulting from work injury.

Journal of Occupational Rehabilitation, 13(2), 63-77.

Mason, S., Wardrope, J., Turpin, & G., Rowlands, A. (2002). Outcomes after injury: a comparison of workplace and nonworkplace injury. Journal of Trauma, 53(1), 98-103.

Matthews, L.R. & Chinnery, D. (2005). Prediction of work functioning following accidental injury:

the contribution of PTSD symptom severity and other established risk factors. International Journal of Psychology, 40(5), 339-348.

Momartin, S., Silove, D., Manicavasagar, V., & Steel, Z. (2004). Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. Journal of Affective Disorders, 80(2-3), 231-238.

Norris, F., Friedman, M., & Watson, P. (2002). 60,000 disaster victims speak, Part II: Summary and implications of the disaster mental health research. Psychiatry, 65, 240 – 260.

Norris, F., Friedman, M., Watson, P., Byrne, C., Diaz, E., & Kaniasty, K. (2002). 60,000 disaster victims speak, Part I: an empirical review of the empirical literature, 1981 – 2001. Psychiatry, 65, 207-239.

Nyberg, E., Stieglitz, R.D., Frommberger, U., & Berger, M. (2003). Psychological disorders after severe occupational accidents. Versicherungsmedizin, 55(2):76-81.

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Perkonnigg A., Kessler R.C., Storz S. & Wittchen, H.U. (2000). Traumatic events and posttraumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatrica Scandanavia, 101, 46–59.

Resnick, H.S., Kilpatrick, D.G., Dansky, B.S., Saunders, B.E., & Best, C.L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984-991.

Sareen, J., Cox, B.J., Stein, M.B., Afif,i T.O., Fleet, C., & Asmundson G.J. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine, 69(3), 242-8. (E-pub 2007 Mar 30.) Stein, M.B., McQuaid, J.R., Pedrelli, P., Lenox, R. & McCahill, M.E. (2000). Posttraumatic stress disorder in the primary care medical setting, General Hospital Psychiatry, 22 (4), 261-269.

Stein, M.B., Walker, J.R., Hazen, A.L., & Forde, D.R. (1997). Full and partial Posttraumatic Stress Disorder : Findings from a community survey. The American Journal of Psychiatry, 154 (8), 1114-1119.

Taylor, S., Wald, J., & Asmundson, G.J.G. (2006). Factors associated with occupational impairment in people seeking treatment for Posttraumatic Stress Disorder. Journal of Community Mental Health, 25(2), 289 – 301.



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