Post-traumatic stress disorder (PTSD) is an anxiety disorder in the same diagnostic category as panic disorder, social phobia and obsessive-compulsive disorder. In 2000, The National Center for PTSD estimated that PTSD affects more than 10 million American children and adults at some point in their lives. This high incidence is because of the wide variety of traumatic events that can cause PTSD. Common causes include motor vehicle accidents, sexual and physical assault, serious illness, being severely injured at work, and witnessing severe workplace injuries or death.
The Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM) published by the American Psychiatric Association provides the internationally accepted diagnostic criteria for PTSD. There are more than 20 signs and symptoms of PTSD, but the DSM groups them into six diagnostic criteria. All of the criteria must be met for a valid diagnosis. Usually, only the first four diagnostic criteria are in dispute in an insurance claim.
Criterion A is what distinguishes PTSD from other anxiety disorders. It requires that the claimant be exposed to a traumatic event in which both of the following are true: (1) There was actual or threatened death or serious injury to self or others; and (2) the claimant’s response involved intense fear, helplessness or horror. Although the development of PTSD can be delayed, an intense response must occur at the time of the trauma to satisfy DSM Criterion A(2).
Criterion B requires re-experiencing the traumatic event. Distressing recollections are common after any upsetting event, even a bad date, and are not sufficient to satisfy the criterion. For claimants with PTSD, these memories intrude upon their daily affairs and their dreams at night. They act or feel as if the event is recurring. They become overwhelmed by intense physical and mental symptoms when confronting reminders of the traumatic event.
Criterion C requires avoidance and numbing. When asked for a statement, affected claimants will try to avoid thinking or talking about the traumatic event or be unable to recall important aspects of it. Discussing other aspects of their lives with them will reveal that they’ve lost interest and stopped participating in previously valued activities. These claimants often present with a restricted range of emotional expression. They often detach from others (e.g., stop attending church or family events) and lose interest in the future.
Criterion D is evidenced as difficulty falling asleep, irritability with outbursts of anger, poor concentration, excessive watchfulness, and an exaggerated startle response. Sleep problems can be assessed by asking questions of the claimant’s spouse. Claims adjusters can note if a claimant is irritable or frequently loses track of his or her thoughts when answering questions or completing forms. These signs are most pronounced when encountering reminders of the traumatic event, an activity often required by the claims adjuster. Consider if the claimant strongly prefers to sit with his or her back to the wall or facing the door or window, or appears to startle at routine environmental noises (e.g., a door slamming down the hall).
Effective Treatment Exists
PTSD is commonly thought of as a permanent mental disorder that haunts a person forever. There are persons for whom that is true, but workers in some professions get PTSD recurrently and recover throughout their careers. Examples include police officers, fire fighters, nurses and physicians.
It is a common mistake to conclude that exposure to a severely traumatic event usually or inevitably results in PTSD. Researchers have determined that up to 60% of the U.S. population is exposed to at least one traumatic event in a lifetime, but the prevalence of PTSD is only about 8%. Untreated, chronic PTSD can be disabling. It is associated with higher odds for school drop-out, teenage pregnancy, marital instability, unemployment, suicidal behavior, and inpatient hospitalization. Fortunately, effective and relatively short-term treatments exist.
When reviewing medical records, claims adjusters can expect to see references to stress inoculation training, cognitive-behavioral therapy, pharmacotherapy (i.e., medications), eye movement desensitization and reprocessing (EMDR), and relaxation training. How can an adjuster know what constitutes effective treatment and what is merely a waste of money and prolongs the claimant’s suffering? Fortunately, we have scientific guidelines for assessing treatment effectiveness to help us sort through all this.
The Agency for Health Care Policy and Research (AHCPR), which is part of the Public Health Service of the U.S. Department of Health and Human Services, has developed six categories to classify the level of evidence for the use of a specific treatment for a medical disorder. Those categories are also used to evaluate treatments for PTSD. The PTSD Treatment Guidelines Task Force established by the board of directors of the International Society for Traumatic Stress Studies evaluated the research literature using the six categories to classify results by research quality and treatment effect size. Their conclusions are conveniently summarized in a single, easily read and affordable book.
The 2008 book, Effective Treatments for PTSD, Second Edition: Practice Guidelines from the International Society for Traumatic Stress Studies is a 658-page definitive reference that summarizes and critiques the rapidly growing evidence base and provides clear guidelines for early intervention and prevention. Unfortunately, many providers continue to select their treatment methods based on personal preference, fads in the field, or their distant graduate school training. The above referenced book can serve as a valuable source of deposition questions to determine the quality of care claimants are receiving from a particular provider. That determination is critical before decisions about permanent injury are reached. Ideally, decisions about permanence of emotional harm are deferred until after the indicated treatment has been completed.
Exposure, Not Avoidance, Is Key
Effective PTSD treatment requires, among other things, repeated exposure of the claimant to the feared situation. This is the opposite of the approach that is typically used by inadequately trained but well intentioned mental health providers and workplace supervisors. Such persons commonly recommend weeks of sick leave, prescribe anti-anxiety medications, and teach relaxation methods. Although those approaches appear logical and compassionate and are often requested by the claimant, they usually delay or obstruct recovery. Avoiding the feared situation or stimulus makes it less likely that the claimant will ever overcome that fear. When the feared situation is the workplace, every day of absence increases the risk of disability.
Repeated exposure to the feared situation in a controlled and supportive manner helps the claimant realize that remembering the situation is not dangerous. It changes the meaning of PTSD symptoms from a sign of personal incompetence to signs of mastery and courage. All of this occurs best when the claimant directly confronts his or her fears both in the imagination and in the real world until the level of anxiety is reduced to a tolerable level. This form of PTSD treatment is called exposure therapy.
The PTSD Treatment Guidelines Task Force examined the evidence for various forms of exposure therapy and determined that several studies on prolonged exposure therapy met the AHCPR Level A rating for research quality and the gold standard for clinical outcome studies. The task force concluded that evidence from many well controlled trials with a mixed variety of trauma survivors indicated that no other treatment modality has stronger evidence of efficacy than prolonged exposure therapy. They strongly recommended the use of prolonged exposure therapy for PTSD treatment.
How to Recognize Proper Treatment
Claims adjusters are often confronted with hundreds of pages of medical records. Fortunately, it is relatively easy to determine if prolonged exposure therapy has been delivered. The main components of prolonged exposure therapy are education about PTSD and trauma, repeated re-living of trauma memories through imagination, and recurrent real-world exposure to avoided situations.
If prolonged exposure therapy is being delivered, progress notes will contain written fear hierarchies with corresponding ratings of subjective units of discomfort next to each step. There will be notes describing the claimant’s progression through those hierarchies both in imagination during the session and in real-life experiences between sessions. The progress notes will indicate that most of each session was spent on re-living the trauma through imagination.
Treatment might include a relaxation component (e.g., breathing training), but the focus will be on directly confronting the feared situation in both imagination and real life. Treatment will usually take about 10 weeks of 90-minute sessions (15 to 30 hours total), depending on the number and severity of traumatic experiences.
If prolonged exposure therapy is being delivered, you will not find a transcript of a compassionate conversation with the therapist repeatedly asking the claimant about how he or she has been feeling the past week. Instead, the discussion will be about how the real-world exposure went, and the session will be spent on imaginary exposure to the feared situation.
Effective treatment benefits the claimant, the insurer, the insured and the larger community. Insurers have little recourse when effective PTSD treatment is not being delivered, but they can make suggestions. Providers can be directed to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania (www.med.upenn.edu/ctsa
) for information on workshops, lectures and practicum opportunities. They can also be given a copy of the 2007 book, Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide
. This brief, practical, 160-page manual with a corresponding patient workbook contains psycho-educational information, forms and worksheets, and homework assignments to keep clients engaged and motivated. The content of the book and workbook can assist in determining if the indicated treatment is being delivered, and it can serve as a source of effective deposition questions.