1 PTSD in the Railway Industry –A mental Health ApproachBrian Klassen, phD National Association of Railroad Referees Chicago, il 2016
2 What is a psychologist doing here?Let me get to the first question… Not here to hypnotize anybody...or talk about mothers... Brian was kind enough to clue me in on this question... The railroad industry employs a lot of veterans Sometimes your work calls you away from home for long periods of time A lot of your work occurs in small, tightly knit groups The railroad industry has a heirarchical structure High risk for violence, accidents, exposure to grissly details / guilt about what happened BUT I am here to talk about PTSD –both because I understand that the railroad industry is hard AND because there are a lot of misconceptions about PTSD. Basically, I hope the information I present today clears some things up about PTSD, and (I’m tipping my hand here) that, although PTSD is a serious public health issue, it is very treatable. It need not be a perminantly disabiling condition.
3 Please text questions to Brian Claus (847) 814-1322
4 About 60% of Americans have experienced at least one trauma…I want to start with a fact that’s pretty counter-intuitive, but I think it can enlighten us and help us figure out what the heck PTSD is. So, we have very good data to show that the majority of Americans, 60%, experience at least one trauma in their lifetime. Trauma here means direct contact with loss of life, serious injury or sexual violence. This can encompass a lot of things like work accidents, natural disasters, combat, and rape. But…only 7% of those people exposed to trauma ever develop PTSD. but only about 7% develop PTSD
5 Let’s dig a little deeper here…So if you were to go an interview a group of people after they had been traumatized, say in an ER or in a combat theatre, you’d find that nearly everyone (95%) would describe things like intrusive thoughts, nightmares, irritability, anxiety, poor sleep, and on and on. You’d also find that the more time passes from a trauma, the less and less people describe having these symptoms. This is very interesting because it tells me that stress reactions –that involve being “wound up” (fight or flight response) is pretty normal. Nearly everyone has this. I tell my combat veterans that many of the symptoms of PTSD are actually good things in a combat zone. Think about it... So, these post-traumatic stress responses are actually a normal or even good thing. So, what makes it a disorder then? I like to think of PTSD as a natural response that gets stuck. So, post-traumatic responses might be OK or even a good thing in combat zones, right? Well, they aren’t so good when you’re at home with your wife and kids, they aren’t so good at school, they aren’t so good at work. Its like the body and mind are frozen in time, so to speak, and can’t re-calibrate to the safe environment anymore. Literally, you can think of PTSD as a broken bone that hasn’t set right...or a wound that became infected and didn’t fully heal.
6 If you read between the lines of what I’m saying, you’ll notice that post-traumatic stress reactions are nothing to be ashamed of. They are normal, and even a good thing in some circumstances. It is how we are wired, and that’s all there is to it. But here’s another way to think about it… So down here we have resiliency… And over here is stress... This is saying that even among highly resilent people, there still is a “breaking point”. There still is a level of trauma that could affect them. A quick example: I’ve treated one green beret, a handful of Army rangers, and a member of Marine recon. Also, several CPD officers. IF you want to call them sissies, be my guest.
7 Who develops ptsd? Pre-Trauma Trauma Post-Trauma History of traumaTraumas caused by others Guilt/Shame Personality style Perpetration of violence on others Lacking Social Support Family history of mental health problems Lacking Meaning in Life So there is this imbalance between trauma exposure and the development of PTSD. Basically, in any group you look at there will always be a higher rate of trauma exposure than PTSD. What explains why some people develop PTSD while some people don’t? Well…I wish I could say that it is easy, but it isn’t. Very complicated. I’ve distilled it down here, so you get a sense of how this works… There are certain factors that make people more vulnerable to developing PTSD after trauma exposure. The first is no suprise...the more trauma you experience the more likely you are to develop PTSD. Think of it like being constaintly exposed to germs... There are certain people who are PTSD and other mental health problems tend to run in families as well, so there is evidence that there is a genetic component as well. Holocaust survivors, vietnam veterans. There’s been some interesting work done saying that the type of trauma matters as well. Traumas inflicted by others (abuse, rape, violence) tend to be worst than other kinds (work accidents, natural disasters, etc). Actually pereprating violence can be a predictor of PTSD severity. Actually wounding or killing another person in combat predicts PTSD severity greater than being wounded yourself. After the dust settles, so to speak –what are the things that make PTSD more likely? -when people feel guilt and shame, it makes seeking help hard. People are very sensitive to stigma or being judged or misunderstood. They tend to lock things away and never mention them again, even though this creates problems. -When you ask patients “Do you have someone in your life who is interested in you and would help you if you needed it?” –the ones who are all alone or estranged from family and friends are at a high risk for a range of problems. Same way with PTSD. Relationships help people heal. -One of the things that makes trauma so traumatic is that it can shatter our assumptions about how the world works. Nothing is guarenteed, etc. People that have a system (religious or spiritual, but not neccesarily that alone) tend to do better.
8 Signs and symptoms DSM symptom What you may see Intrusive thoughtsPoor concentration; “zoning out”; frustration during difficult tasks Nightmares Efforts to avoid sleep Emotional/Physiological reactivity to reminders Efforts to avoid public places; isolation; mood can change “out of the blue”; Avoidance of external reminders Avoidance of thoughts/feelings “I don’t want to talk about it” Negative beliefs about self/others “I’m a monster/ I can’t trust anybody” Hyper-vigilance Frequently “keyed up”; defensive body language; Anger Poor sleep Frequently appears tired, worn out; not paying attention, makes many mistakes I tried very hard to make this a non-technical talk, so this is not even a full list of PTSD criteria, but I wanted to cover what are the things that others might notice… Typically, what drives people into treatment is sleep deprivation and feeling like they have lost control of their anger. As an employer or co-worker, the anger and unstable mood is certainly a problem, but so is the inability to concentrate and complete detailed tasks...
9 What else? Depression Alcohol / Drugs Legal Problems IsolationDisability / Sick role PTSD I’d be remiss in a talk on PTSD not to mention the fact that PTSD is a complicated disorder to treat for a lot of reasons, but it also entails so many other problems that aren’t even part of the diagnosis. The word for this is co-morbidity. PTSD and Depression co-occur about 80% of the time. PTSD and alcohol problems occur in about 50% of men and 30% of women Not part of the diagnosis, but these other problems can compound the severity of the diagnosis Divorce and the added stress of broken relationships and loss of a support network Legal problems (particularly credit and DUIs) can impair a person’s ability to fend for themselves and maintain employment, etc Isolation can increase the feelings of guilt and shame, which basically blocks the healing process from happening Some experiences of trauma can really threaten a person’s sense of meaning in life –that the universe makes sense, etc People with chronic PTSD can take on a view that they are broken and have nothing to contribute to society. Feelings of being stuck can really impede treatment
10 What can we do about this?
11 Now, that I’ve bummed everybody out… let’s get to my favorite part.I know that therapy has a bad rap, for a lot of reasons Maybe it is a place to feel good about yourself but not make any substantive change Maybe it is more a “lifestyle” of navel gazing, new-age kind of stuff
12 Treatment options PRESENT-FOCUSED Coping with difficult emotions Exercise, Yoga, Mindfulness Medication TRAUMA-FOCUSED Exploring the memories in depth New information can surface Break the connection between the past/present There are many effective and worthwhile treatments for PTSD, way too many to name here. A helpful way to think about it is that treatments are divided into two camps –either present focused, dealing with the here-and-now OR treatments that deal with the memories of the trauma. Present focused treatments deal with coping, ways to relax, sleeping better, how to communicate better with your spouse, etc. Medications are included in this. I’ll be glossing over medications. They are effective and safe –plenty of my patients use them. But, all the practice guidelines that I know of emphasize talk therapy as the front line intervention…why is that? For the simple reason that talk therapy helps people find new ways of living with these memories, new ways to see their role in what happened –there is no pill that can do that. Trauma focused treatment is mostly what I do, and it is hands-down the most effective way to treat trauma. Rather than get too technical, I’ll tell a couple stories. Story #1 –”If my rifle was six inches to the left, my friends would be alive today” Story #2 – “I’m a monster because of what I’ve done”
13 OK –GREAT! BUT, DOES IT WORK?86% of individuals with PTSD improve with therapy Psychotherapy is more effective than _____________ Aspirin for preventing heart attacks NSAIDs for pain Nicotine replacement therapy for quitting smoking Viagra for erectile dysfunction Maybe some of you think I’m cherrypicking and only talking about the successful cases. There was a study in 2010 that compiled all the major studies of a particular method of treating trauma, and it showed that 86% of patients improved significantly as the result of therapy. Think about that. What other clinic or area of medicine can boast that much success? Here’s some more… Interesting, isn’t it?
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15 OK –GREAT! BUT, DOES IT WORK?PTSD among returning veterans cost the US economy between 4-6 billion over two years PTSD costs each individual about 7k per year Treating PTSD costs between 1-4k OK…OK so you can improve people’s lives with therapy, but what about the money? I’ve seen it time and time again...you can very quickly improve people’s lives with therapy and get them back on a healthy trajectory
16 QUESTIONS? Please e-mail me: [email protected]Thanks for listening QUESTIONS? Please me: