By Cheryl Gulasa RN, CPHM, CCM – Vice President, AmeriSys
Beginning October 1st of this year, due to enacted Florida legislation, first responders under certain circumstances will be provided workers’ compensation benefits for Post-Traumatic Stress Disorder absent of a physical injury. These benefits are not subject to a certain apportionment or limitation providing a time for notice of injury or death.
The PTSD diagnosis will not be limited to a 1 percent impairment rating as are mental health disorders currently.
The new legislation is requiring mental health training for first responders, inclusive of mental health awareness, prevention, mitigation and treatment.
The legislation requires the PTSD diagnosis to be based on the Diagnostic and Statistical Manual for Mental Disorders, 5th Edition, published by the American Psychiatric Association.
The following is the DSM-5 definition of PTSD:
Under DSM-5, post-traumatic stress disorder (PTSD) is an anxiety disorder that develops in relation to an event which creates psychological trauma in response to actual or threatened death, serious injury, or sexual violation. The exposure must involve directly experiencing the event, witnessing the event in person, learning of an actual or threatened death of a close family member or friend, or repeated first-hand, extreme exposure to the details of the event. Traumas experienced may involve war, natural disasters, car accidents, sexual abuse and/or domestic violence.
A formal diagnosis of PTSD is made when the symptoms cause clinically significant distress or impairment in social and/or occupational dysfunction for a period of at least one month. The symptoms cannot be due to a medical condition, medication, or drugs or alcohol. 1 (Criterion A)
Not every employee who lives through or witnesses a traumatic event will develop PTSD. There are multiple risk factors that increase an employee’s chance of developing PTSD.
Those factors include, but are not limited to getting physically hurt, a childhood trauma, or having little or no social support after the incident.
To quantify the PTSD diagnosis, the injured employee will have to be experiencing one of the following intrusion symptoms (Criterion B):
• Unwanted upsetting memories
• Emotional distress after exposure to traumatic reminders
• Physical reactivity after exposure to traumatic reminders
The injured employee should also be avoiding trauma-related stimuli after the incident in either trauma related thoughts or feelings. This can also be trauma-related external reminders (Criterion C).
Negative thoughts or feelings that begin or worsen after the trauma will present in at least two of the following ways (Criterion D):
• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect
Trauma related arousal and reactivity that begins or worsens will present itself in the following ways (Criterion E)
• Irritability or aggression
• Risky or destructive behavior
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping
These symptoms last for more than one month (Criterion F). The correct diagnosis prior to one month of symptomduration is Acute Stress Disorder.
The symptoms create a level of distress or functional impairment. This impairment could be either social or occupational (Criterion G).
The symptoms are not due to medication, substance use, or other illness (Criterion H).
In addition to meeting the criteria for a PTSD diagnosis, an injured employee will be experiencing high levels of either of the following in reaction to trauma-related stimuli (Dissociative Specification):
• Experience of being an outside observer or detached from oneself (Depersonalization)
• Experience of unreality, distance, or distortion (Derealization)
Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately (Delayed Specification).
With PTSD, the Amygdala, the area in the brain where flight, fright or freeze signals originate, sends signals to the adrenal glands that begin a stress response. The Hippocampus is the area in the brain where memories are stored in the right place. In situations of PTSD, the memories are stored in the wrong place making the injured employee feel like the incident is happening again instead of being a memory.
In making a diagnosis of PTSD, the authorized psychiatrist will also be ruling out other similar diagnoses. For example, acute stress disorder has the same symptoms as PSTD but with shorter duration. There are multiple anxiety and depressive disorders that have similar symptomology as PTSD.
Substance abuse is a frequent complication of PTSD, and determining if substance abuse is the root cause must be determined. Finally, various personality disorders have a close resemblance to PTSD as well.
The goals for intervention include stabilization, a reduction of symptoms, return to functionality, and facilitation of continued care for the injured employee.
During the stabilization phase, the injured employee must be assessed to ensure all immediate medical and physical needs are being met. This will involve establishing a sense of safety and security. At this time, it is essential to identify if there is social support available.
To facilitate a reduction of the injured employee’s symptoms, it is necessary to initiate psychological therapies. The amount of sessions required will vary by individual, but the average number of therapy sessions range between 12 and 16. The two types of therapy most frequently utilized are Cognitive Behavioral Therapy and Exposure/ Desensitization Therapy.
Cognitive Behavioral Therapy, which utilizes the principles of learning and conditioning to treat the disorder, has been proven to have the best response.
Exposure/Desensitization is a therapy which includes imaginal exposure and/or “in vivo” therapy. The injured employee would confront the actual scene of the incident or a similar trauma event.
If medication management is required, usually Anti-Depressants are utilized. The treatment must be designed to move the injured employee’s memories where they are supposed to be and stop the stress response from occurring. In doing so, there is a defusing of the effect the trauma memory has over the injured employee.3
By understanding the PTSD disease process we will be better able to comply with the new legislation and implement a claims protocol that will best serve our customers and their injured employees.
Clinical oversight will be essential for the management of this program. AmeriSys is partnering with Dr. Michael Coupland, RPsych (AB), the Network Medical Director for Integrated Medical Case Solutions (IMCS Group) to assist with development of the PTSD component of the BADGE program. Dr. Coupland and his team of psychiatrists and psychologists bring a wealth of experience in dealings with PTSD for municipalities, along with proven outcomes for their patients.
A psychiatrist will be required to make a PTSD diagnosis, assign a work status or functional limitations, if necessary prescribe medications, and make Maximum Medical Improvement and Permanent Impairment Rating determinations. All other therapies can be provided by a psychologist.
Any time Workers’ Compensation is faced with new legislation; there are multiple challenges for both the claims handlers and defense counsel. This time will be no different.
There will be challenges related to the time frames for a PTSD diagnosis, which by evidence-based guidelines cannot be given prior to 30 days. The handling of the “acute stress disorder” in the first 30 days will need to be investigated. Another issue will be apportionment related to any pre-existing mental health conditions. Finally, and the most significant, as it is currently with presumption claims, the 1996 Florida Impairment Guidelines are very outdated and are not written to address this issue either.
As your claims and medical management partner, we are committed to ensuring compliance with the new legislation, providing the highest quality of mental health care to your injured employees and staying current with any case law that may affect the processing of these complicated claims.
3 Dr. Michael Coupland, RPsych (AB) Network Medical Director, Integrated Medical Case Solutions (IMCS Group)
Cheryl is the Vice President for AmeriSys. Her primary responsibilities include overseeing the professional operations of AmeriSys which includes Telephonic Case Management, Field Case Management, Provider Relations and Utilization Management, including Bill Review. Cheryl has over 34 years’ experience in nursing, the last 16 years in workers’ compensation case management and utilization management. She has successfully implemented and handles large public entity programs. Cheryl’s experience, coupled with her energy and leadership skills, brings valuable assets to our organization.