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Secondary psychological injuries and PTSD

Safe Work Month 2019

Dr Andrew Khoo

Presented by: Dr Andrew Khoo

PTSD is a chronic, debilitating and difficult to treat diagnosis which is often associated with physical and psychiatric comorbidity. You’ll receive an overview of the disorder and, using a real case study as a backbone, Dr Khoo will discuss typical presentations, evidence-based medication and psychological treatment approaches and best practices in relating to, communicating with and optimising rehabilitation outcomes in workers with secondary psychological injuries and PTSD.

Run time: 15:34

Download a copy of this podcast (MP3, 14 MB)

Secondary psychological injuries and PTSD

Presented by: Dr Andrew Khoo

[Start of transcript]

Spencer Howsen: Andrew Khoo, Welcome to the podcast. Andrew Khoo:Thanks very much, Spencer. Yeah.

Spencer Howsen: Let's start off with a definition. PTSD, people might think they know what Post-traumatic stress disorder is, but what's your definition of PTSD.

Dr Andrew Khoo: I'm going to go to the safe definition first. The safe definition comes from our psychiatric nosology. In other words, what diagnostic criteria determine that an individual has PTSD, that comes out of the latest diagnostic book, which is DSM, which people might've heard of, Diagnostic And Statistical Manual of Mental Health Illnesses put out by the APA, American Psychiatric Association. New editions, probably every five to 10 years. The latest update is DSM five. What DSM five says about PTSD and I will warn you, it gets longer and longer and longer with every edition.

Dr Andrew Khoo: The main reason behind that is because, lawyers and legal issues have very much come into this particular diagnosis above and beyond all other psychiatric diagnoses because the first thing you have to have, to have PTSD is a trauma or an incident. And if you have to identify a trauma as part of the diagnostic criteria of a condition, then you can blame something. If you can blame something, you can blame someone. If you can blame someone and you've got a chronic, debilitating condition that's going to impact on your ability to work and your quality of life then you're going to get sued.

Dr Andrew Khoo: As a result of that, lawyers have become involved. There is now two major textbooks on PTSD in the law and more DSM five's in fact, were pre-ordered by lawyers than doctors. That's where we're going. But anyway, in a nutshell, PTSD has eight criteria that need to be met in DSM. The first is the trauma. The trauma has to be life threatening or cause serious injury because it has to have a certain cut off threshold. It's experienced or witnessed, but you can only witness a trauma and get PTSD if you are in the same theatre that the person that was injured was in. So, we couldn't, for example, Spencer Howsen, witness or watch September 11 on TV and get PTSD because we weren't there. We weren't really at risk even though it was horrifying to see, we couldn't watch Helmet cam video from Afghanistan and get PTSD because we're not really there. We're not really under risk. Okay? The only time in fact you can witness and get PTSD, there is a one corollary and that is if it's a relative that was killed or injured and you witness it, even away from the scene.

Spencer Howsen: Other than that, you literally have to be there at the scene or in the same theatre as you say?

Dr Andrew Khoo: Exactly. To have ... Because it's all about perceived risk and danger. Okay? A couple of other things were added to that A criteria, which is the trauma and one is that, they added in sexual assault as a specific one because there are a lot of idiots around that felt that you weren't really at risk of life threatening or serious injury if you were sexually assaulted. You are not at no stage under that kind of threat, which is rubbish because it's all about powerlessness and helplessness as a terrible thing unfolds. I can't think of many worst situations in sexual assault.

Dr Andrew Khoo: The last thing, very importantly too that's been added in DSM five, is that it doesn't need to be a personal risk thing anymore. Now you can get PTSD from repetitive exposure to death or circumstances around death. The typical people that we're really talking about there, are scenes of crime officers that have to clean up or see the terrible things that humans can do to other humans. Okay? That also captures a lot of people like our war photographers. A lot of the guys that went on peacekeeping missions and never actually were under necessary risk but had to deal day to day with terrible things that would happen to non-combatants like women and children or deal with the terrible things that humans do to other humans in those kinds of theatres. That's the A criteria.

Dr Andrew Khoo: B criteria is what we call intrusion symptoms or re-experiencing symptoms. They are just quickly intrusive memories, nightmares or flashbacks. The C criteria is avoidance and that is basically avoiding these triggers that are going to cause those intrusive symptoms. The fourth is depressive thoughts and depressive moods. The fifth is physical anxiety symptoms, racing heart, sweating, shaking, abdominal symptoms, all kinds of things that are associated with adrenaline and fight and flight responses. And then psychological anxiety, which involves things like insomnia, irritability, impatience, intolerance, anger, as well as the very important symptoms of PTSD, hypervigilance, which means a greater awareness of the dangerous world around them and checking for contingencies all the time. And an increased startle response. You're more jumpy. Okay?

Dr Andrew Khoo: So they are the four symptom criteria that follow the trauma. And then after that, there are three more criteria in DSM. One is that you can't get PTSD until you've had the symptoms for more than a month. That's a really important criteria because all of us go through a period of psychological adjustment if we go through a very intimidating, confronting, challenging, traumatic experience in our lives. It shows that PTSD ... I don't know whether it should even be seen as an illness or more as the inability to extinguish a normal response.

Dr Andrew Khoo: So basically you can't diagnose it until after a month because everybody needs to go through psychological adjustment and three quarters of us will come out the other side and be okay, but one quarter will go on and get PTSD. Okay.

Spencer Howsen: Can I just pick you up on the timing one?

Dr Andrew Khoo: Yeah.

Spencer Howsen: Is it possible that for some that PTSD, doesn't present until much later? Not everyone's going to be diagnosed after a month, surely.

Dr Andrew Khoo: Yeah. That's actually a very ... That's an insightful question and a question in fact, that had become very topical because of our Vietnam cohort of soldiers who came home from really what was a terrible war in terms of what they experienced but were castigated basically, not come home as heroes. They came home in the middle of the night and they were told to get changed out of their uniform and just blend in.

Dr Andrew Khoo: And so, it was a very difficult return home for them and a lot of them were so ashamed of how they were feeling, ashamed of how they were seen and then ashamed at putting up their hand and saying there was something wrong with them when they were supposedly doing so many terrible things, that they never presented. And then 30 years later, we have this whole cohort of ... When I think mental health became a little bit less stigmatized, PTSD definitely became legitimized as a diagnosis. Then they started to present and often and interestingly, they were presenting when their work lies were finishing, okay? Because they had nothing to do, so they had no more distraction because a lot of them had become workaholic, alcoholic, whatever, to kind of just suppress their symptoms. And then all their symptoms came back and they called that delayed PTSD. Okay?

Dr Andrew Khoo: Personally, I don't think there's any such thing as delayed PTSD, I think it's delayed diagnosis. I think they had PTSD from the start, but they, for whatever reason, didn't access help or weren't diagnosed earlier. Yeah.

Spencer Howsen: Okay. I interrupted you, you were going through the definition. Yeah.

Dr Andrew Khoo: Yeah. The last two parts are, is that it has to have caused a noticeable decline in function academically, vocationally, socially, domestically. Okay? So that I suppose impairment criteria is very important in distinguishing what may be a subclinical illness where they've got the symptoms but it's not impacting them versus a full syndrome condition, which is having the symptoms and then the symptom is just stuffing their life up in all these different areas. Okay? And the last thing is, every DSM criteria has this, is that there isn't another disorder that could better account for the symptoms, but basically they're the eight criteria. A long answer.

Spencer Howsen: No, really interesting. Thank you for picking it and in such detail. So in a workplace, sometimes there'll be staff who have PTSD and the trauma is part of the workplace, the war photographer for example. But for others it's PTSD from a trauma, either historically or contemporaneously, but not from the workplace. Right? Okay. So, what should employers and organizations be looking out for and what's their responsibility in terms of the care of those staff when it comes to PTSD?

Dr Andrew Khoo: Okay. Again, a really ... A question that requires a huge answer really, but quickly, I mean there are certain occupations where there is an expectation that they are going to see or be involved with in a repetitive way, horrible things and will also be at personal risk on a lot ... It's accepted under a lot of situations and they are things like emergency services. So, police, fireys, ambos, military as well. So the AFP for example, so these are situations you expect for that to happen. Now what can those, for those particular places, what they have to be very aware of is that they are logging things like the trauma exposure of their staff. They know they're going to expose this stuff that they're able to log how much, how often and how severe the trauma that an individual is being exposed to is happening. And then sort of making sure that they're touching base with that individual regularly to kind of ... And that that individual is educated about what signs to look for on how to access help if they want it. That's about the most you can do there. Okay?

Dr Andrew Khoo: We do have ... I mean all of these, there is a whole lot of research meant that it's going into this concept of resilience. I'm not sure if you've heard of that. And that is trying to, for PTSD, create a preventative medicine approach. So in other words, what can we do to prevent the onset, which is always the best thing to do for any medical illness. Unfortunately for PTSD, all this resilience work that's going in, all the research, all the money that's going into it in military services, it's very hard to measure if it's actually doing anything. In fact, there isn't any real quality research that's shown that it's made a difference and I think just as much because it's hard to measure.

Dr Andrew Khoo: So why do they keep doing it? They keep doing it because they should, because it's the right thing to do basically. So there's a lot of work going into resilience training too. So I just wanted to quickly touch on that. In terms of a workplace where an individual may be traumatized outside of work contemporaneously but isn't a work related thing, then I think the workplace just has to be aware that this can happen and take on that very important engagement, supportive, responsive, kind of validating type position with regards to the illness. Okay? Step away from the whole sort of judgemental, potentially stigmatizing approach, that you can have when you just focus on productivity and days away and absenteeism and presenteeism and all that kind of stuff. That's the best thing you can do because these things are unfortunately just going to happen.

Dr Andrew Khoo: If it happens as a workplace injury in a workplace, which you don't necessarily expect that this is going to happen a lot. Okay? So that the car accident on the way to work, the liquor land worker that gets held up or something like that, the bank worker that gets held up, then really being aware of the condition, being aware that the big issues around this are engaging the person. Trying to elucidate trust in that therapeutic relationship because they don't trust the world anymore because the world's really slap them and now danger is everywhere and their ability to judge risk is less now. So they're vigilant all the time and they're kind of trying to control and over control their environments, so something like this can never happen again, something unpredictable, something random, something terrible. Engaging them and making sure they get the appropriate treatment, that is individually applied to them but also has a research base behind it that we know works.

Spencer Howsen: And then you've got the return to work of people who have PTSD, whether it's again, acquired through work or otherwise, your advice finally to workplaces. It probably comes back to much of what you've already said around trust and being a human with the people that you're dealing with.

Dr Andrew Khoo: Look, the big thing about that, and again, a really important question, the big thing about that Spencer Howsen is that, I return to meaningful, purposeful, work role, is absolutely key in mediating any chronic psychological condition. Okay? This should be a keystone tenant in anyone with PTSD anyways to vocationally rehabilitate them. It's absolutely key. In fact, we did this research recently on soldiers that had known PTSD and these soldiers that weren't getting any pension and were unemployed. So just not getting any money.

Dr Andrew Khoo: And then we compared them to soldiers that had traversed the whole DVA system and had the maximum amount of pension you could get, a total permanent incapacity pension, gold card, all their treatment, everything. We compared them both and they had the same suicidal behaviours, same frequency of suicidal ideas and behaviours. And it's because they don't have their purposeful, meaningful role in life. There's no reason to get out of bed. There's nothing to ... They hate the fact they don't have anything to talk about when they go to a party and someone asks them what they do or don't do anything. So this is so protective, that's a really important tenant that we've got to have.

Dr Andrew Khoo: So returning them or doing everything we can to successfully return them is just so key. The other things, like you say, all still remain, validating them, supporting them, understanding that they've got a chronic illness and it might take time. Big thing about PTSD is, it doesn't get better in weeks and months. Unfortunately, it's kind of measured more in years. But definitely you could expect that a good outcome could be achieved in two years, definitely.

Spencer Howsen: Andrew, great to have you on the podcast. Thank you so much.

Dr Andrew Khoo: Yeah, thank you very much, Spencer Howsen.

Dr Andrew Khoo: And if you or someone you know, needs support, you can call lifeline on 13, 11, 14 or beyond blue on (1300 224 636).

[End of transcript]