TRAUMA AND STRESS-RELATED DISORDERS

What differentiates trauma/stressor-related disorders from anxiety disorders

They are caused or precipitated by a stressful event

Trauma and Stressor-Related Disorders in DSM-5-TR

1) Reactive Attachment Disorder

2) Disinhibited Social Engagement Disorder

3) PTSD

4) Acute Stress Disorder

5) Adjustment Disorders

6) Prolonged Grief Disorder

Reactive Attachment Disorder (F94.1)

Occurs in some children who have been neglected or separated from their caregiver

Severe trauma (DSM-5-TR)

Experienced, witnessed, learning of violent trauma to a loved one, or repeated/extreme exposure to aversive details (e.g., first responders)

Examples of traumatic events

1) War (especially combat)

2) Natural disasters

3) Personal or societal violence

Group historically among the first diagnosed with PTSD

People returning from military service (returning veterans)

ACEs

Adverse Childhood Experiences: potentially traumatic childhood experiences such as violence or growing up with a family member who has a mental disorder or substance use problem

Prevalence of ACEs

Identified in 61% of adults; females are at greater risk

Effects of ACEs

Impact brain development and stress response; contribute to chronic health conditions, mental disorders, and substance use

Is treating people who have survived trauma within OT scope?

Yes; OT treats people who have survived extreme trauma (abuse, rape, genocide) in all practice areas

Findings from research on people who survived the Holocaust

Most rebuild family and work life but develop psychosocial problems even without PTSD

Lingering problems in people who have survived trauma

Hypervigilance, sleep disturbances, difficulty concentrating, anxiety, obsessive thoughts

Stage 1 of recovery

The person who survived trauma establishes a sense of safety

Stage 2 of recovery

The person integrates the traumatic experience into their personal life

Stage 3 of recovery

The person evolves by helping others or becoming an activist

Does everyone who survives trauma recover through activism?

No; some people heal in more private ways (psychotherapy, relatives, friends, mentors, others who have survived trauma)

Purpose of psychotherapy for people who have experienced trauma

Frames the experience in a specific time and place and encourages acceptance

Why helping others facilitates healing

Restores the person's sense of self and worth; builds a new identity "untouched" by the trauma

How helping others restores power

The person becomes an agent of change; constructive action undoes the damage of victimization

Victimized

Being powerless to stop the traumatic threat

Renewed sense of self

People who survived trauma feel connected to who they were before the trauma but also feel they have evolved

How the OTA may learn a client has survived trauma

Medical chart, interview, or passing references during treatment (often not offered or charted)

OTA responsibility once aware a client has survived trauma

Monitor psychosomatic and psychological complaints and report them in team meetings

OTA approach with a client in early stages of recovery

Don't overwhelm or place stressful demands; progress elsewhere may be sacrificed for the client's well-being

OTA responsibilities when a client who survived trauma begins reaching out

Recognize small acts of consideration; support volunteering and help find resources; validate volunteer work

Most important OTA responsibility with clients who have survived trauma

Treat the person with respect; it reinforces individuality and rights that trauma negates

Trauma-informed: Ask "What happened to you?"

Instead of "What's wrong with you?"

Trauma-informed: pronouns

Ask for preferred pronouns rather than assuming

Trauma-informed: permission

Ask permission for everything; don't assume willingness

Trauma-informed: behaviors

Recognize trauma shows in different ways (flat affect, defensiveness) as communication, not static personality traits

Trauma-informed: historical trauma

Recognize historical trauma and the client's historical context

Trauma-informed: gathering information

Remember that retelling their story may retraumatize a person

Trauma-informed: growth

Foster growth and positivity; don't assume people cannot change after experiencing trauma

Safety (trauma-informed principle)

Treatment and surroundings that consider physical and emotional needs

Trustworthiness and transparency

Clearly stating expectations, treatment details, procedures, and provider information

Peer support

Helping others find inner strength for personal growth rather than "fixing" them

Collaboration and mutuality

Combined work and interaction among clients, families, and staff

Empowerment and choice

Using each person's strengths and informing them of treatment options

Cultural, historical, and gender issues

Continual caring awareness and sensitivity to each person

OTA interventions for clients with PTSD

Stabilizing symptoms and coping; adaptive self-care that avoids triggers; daily routine planning; home modifications; relapse prevention sessions

Triggers to avoid in self-care training for clients with PTSD

Hypersensitivity patterns, dissociation, flashbacks

Settings where veterans may be seen

Military hospitals, VA hospitals, skilled nursing facilities, community

Common conditions among veterans of wars in Iraq/Afghanistan

1) PTSD

2) Substance-related disorders

3) Major depressive disorder

4) TBI

Veteran suicide deaths per year

Approximately 6,500

Top 5 occupational challenges for veterans

1) Leisure/social relationships

2) Student or worker role transition

3) Physical health

4) Sleep and rest

5) Risky or distracted driving

Family members affected by deployment

The service member, spouses, children, parents, siblings

"Broken hero" stereotype

A barrier to community reintegration for veterans, including a returning family member with PTSD

Military culture values

Athleticism and feats of physical and psychological courage

OT approaches that fit military culture

1) Ocean therapy

2) Horticulture/gardening

3) Art and expressive activities

Polytrauma

Two or more injuries to physical regions or organ systems, one possibly life threatening, causing physical, cognitive, psychological, or psychosocial impairment and disability

Causes of polytrauma (WHO)

Falls, traffic accidents, violence, fires; leading cause of death and disability worldwide

Initial emphasis in care for people with polytrauma

Medical management to ensure survivability, then minimizing functional disruption

What is unique to OT for people with polytrauma

Focus on motivation and sense of purpose using activities important to each client

Activity performance (polytrauma)

Progress toward independence in family, social, and professional roles to restore income and economic stability

Cognitive training (polytrauma)

Executive function strategies for problem solving, memory, attention, and self-esteem

Driver rehabilitation (polytrauma)

Helps the person manage anxiety and drive safely in threatening conditions like being "boxed in," loud noises, or unexpected roadside items

Other polytrauma interventions

1) Vision training

2) Coordination/dexterity

3) Adaptations

4) Patient/family education

5) Wound care

6) Therapeutic exercise

Additional polytrauma interventions

1) Sleep hygiene

2) Sense of belonging

3) Leisure and social relationships

4) Emotional expression

5) Reducing substance-related problems

6) Suicide prevention

7) Altruism and service

Where the OT practitioner is most effective for a person with polytrauma

In the moments of everyday life, enabling self-directed change through recovery