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Often gastritis management order line protonix, a key ingredient in the recovery process is first identifying the meaning of the event and the beliefs that changed following the traumatic experience gastritis diet óëûáêà buy protonix 40 mg otc. So when you hear a client say “I will never see life the same gastritis diet ulcer cheap 20 mg protonix overnight delivery,” this expression should trigger further exploration into how life is different gastritis reflux diet cheap protonix 40 mg free shipping, what meaning has been assigned to gastritis diet for gastritis order protonix 20mg overnight delivery the trauma, and how the individual has changed his or her perception of self, others, and the future. In her situation, a random stranger provided a moment that challenged an assumption generated from the trauma. For others, counseling may be helpful in identifying how beliefs and thoughts about self, others, and the world have changed since the event and how to rework them to move beyond the trauma. It is important to understand that the meaning that an individual attaches to the event(s) can either undermine the healing process. The fol­ lowing questions can help behavioral health staff members introduce topics surrounding assump­ tions, beliefs, interpretations, and meanings related to trauma: • In what ways has your life been different since the traumafi Failing to recognize mulative; therefore, a later trauma that out­ that multiple factors aside from individual wardly appears less severe may have more attributes and history influence experiences impact upon an individual than a trauma that during and after trauma can lead to blaming occurred years earlier. People with histories of prior psychological this outcome is often referred to as posttrau­ trauma appear to be the most susceptible to matic growth or psychological growth. Some survi­ may be misunderstood by others in treatment vors who have repressed their experiences de­ and seen as uninterested. Providers need to 54 Part 1, Chapter 2—Trauma Awareness attend to histories, adjust treatment to avoid anxiety disorder, and/or major depression than retraumatization, and steer clear of labeling for those without preexisting mental disorders. Most Demographic variables are not good predic­ individuals are resilient despite experiencing tors of who will experience trauma and subse­ traumatic stress. Gender, age, the trauma is associated with individual factors race and ethnicity, sexual orientation, marital as well as situational and contextual factors. The following sections cover a few specific traits predictive of resilience; instead, it selected variables. Less is stance use disorders, and co-occurring mental known about gender differences with subclini­ disorders are well known. There are also Diagnostic and Statistical Manual of Mental Dis­ other gender differences, such as the types of orders, Fifth Edition (American Psychiatric trauma experienced by men and women. Association, 2013a), traumatic stress reactions Women are more likely to experience physical are linked to higher rates of mood, substance and sexual assault, whereas men are most like­ related, anxiety, trauma, stress-related, and ly to experience combat and crime victimiza­ other mental disorders, each of which can pre­ tion and to witness killings and serious injuries cede, follow, or emerge concurrently with (Breslau, 2002; Kimerling, Ouimette, & trauma itself. Women is a significant determinant of whether an in military service are subject to the same risks individual can successfully address and resolve as men and are also at a greater risk for mili­ trauma as it emerges from the past or occurs tary sexual trauma. Koenen, Stellman, Stellman, in public; women’s are more likely to take and Sommer (2003) found that the risk of place in private settings. Age is not particularly important in yet few studies analyze the relationship of race predicting exposure to trauma, yet at no age is and ethnicity to trauma exposure and/or trau­ one immune to the risk. Some studies show that occurs in the earlier and midlife years appears certain racial and ethnic groups are at greater to have greater impact on people for different risk for specific traumas. For younger individuals, the trauma Americans experienced higher rates of overall can affect developmental processes, attach­ violence, aggravated assault, and robbery than ment, emotional regulation, life assumptions, Whites but were as likely to be victims of rape cognitive interpretations of later experiences, or sexual assault (Catalano, 2004). Literature and so forth (for additional resources, visit the reflects that diverse ethnic, racial, and cultural National Child Traumatic Stress Network; groups are more likely to experience adverse. For adults in midlife, effects from various traumas and to meet crite­ trauma may have a greater impact due to the ria for posttraumatic stress (Bell, 2011). Older adults are as likely as younger viduals are likely to experience various forms adults to recover quickly from trauma, yet they of trauma associated with their sexual orienta­ may have greater vulnerabilities, including tion, including harsh consequences from fami­ their ability to survive without injury and their lies and faith traditions, higher risk of assault ability to address the current trauma without from casual sexual partners, hate crimes, lack psychological interference from earlier stress­ of legal protection, and laws of exclusion ful or traumatic events. Gay and bisexual men as well rally more likely to have had a history of as transgender people are more likely to expe­ trauma because they have lived longer, thus rience victimization than lesbians and bisexual creating greater vulnerability to the effects of women. Research of respondents experienced harassment due to suggests that many women are homeless be­ their sexual orientation. Heterosexual orienta­ cause they are fleeing domestic violence tion is also a risk for women, as women in (National Coalition for the Homeless, 2002). A Homelessness is typically defined as the lack history of physical and/or sexual abuse is even of an adequate or regular dwelling, or having a more common among women who are home­ nighttime dwelling that is a publicly or pri­ less and have a serious mental illness. Two thirds were unaccompa­ from 32 to 63 percent (Administration on nied persons; the other third were people in Children, Youth and Families, 2002). Adults who are homeless and unmar­ tionally, data reflect elevated rates of substance ried are more likely to be male than female. Those who are homeless have higher rates of substance abuse Rates of trauma symptoms are high among (84 percent of men and 58 percent of women), people who are homeless (76 to 100 percent of and substance use disorders, including alcohol women and 67 percent of men; Christensen et and drug abuse/dependence, increase with al. Pro­ viders need to understand how trauma can affect treatment presen­ • Sequence of Trauma tation, engagement, and the outcome of behavioral health services. Reactions this chapter examines common experiences survivors may encoun­ • Common Experiences ter immediately following or long after a traumatic experience. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short and long­ term responses to traumatic experiences in the context of individuals who may seek behavioral health services. Indeed, a past error in trau­ matic stress psychology, particularly regarding Survivors’ immediate reactions in the after­ group or mass traumas, was the assumption math of trauma are quite complicated and are that all survivors need to express emotions affected by their own experiences, the accessi­ associated with trauma and talk about the bility of natural supports and healers, their trauma; more recent research indicates that coping and life skills and those of immediate survivors who choose not to process their family, and the responses of the larger com­ trauma are just as psychologically healthy as munity in which they live. Although reactions range in severity, even the most acute responses Foreshortened future: Trauma can affect are natural responses to manage trauma— one’s beliefs about the future via loss of they are not a sign of psychopathology. Cop­ hope, limited expectations about life, fear ing styles vary from action oriented to reflec­ that life will end abruptly or early, or tive and from emotionally expressive to anticipation that normal life events won’t reticent. The most recent psychological trauma show impairment and symptoms that debriefing approaches emphasize respecting meet criteria for trauma-related stress disor­ the individual’s style of coping and not valuing ders, including mood and anxiety disorders. The following sections focus on some com­ Initial reactions to trauma can include exhaus­ mon reactions across domains (emotional, tion, confusion, sadness, anxiety, agitation, physical, cognitive, behavioral, social, and de­ numbness, dissociation, confusion, physical velopmental) associated with singular, multi­ arousal, and blunted affect. These normal in that they affect most survivors and reactions are often normal responses to trauma are socially acceptable, psychologically effec­ but can still be distressing to experience. Indicators of more se­ responses are not signs of mental illness, nor vere responses include continuous distress do they indicate a mental disorder. Traumatic without periods of relative calm or rest, severe stress-related disorders comprise a specific dissociation symptoms, and intense intrusive constellation of symptoms and criteria. Delayed responses to trauma can in­ Emotional clude persistent fatigue, sleep disorders, Emotional reactions to trauma can vary great­ nightmares, fear of recurrence, anxiety focused ly and are significantly influenced by the indi­ on flashbacks, depression, and avoidance of vidual’s sociocultural history. Beyond the emotions, sensations, or activities that are as­ initial emotional reactions during the event, sociated with the trauma, even remotely. However, individuals may encounter difficulty in identifying any of these Common Experiences and feelings for various reasons. They might lack experience with or prior exposure to emotional Responses to Trauma expression in their family or community. They A variety of reactions are often reported and/or may associate strong feelings with the past observed after trauma. Most survivors exhibit trauma, thus believing that emotional expres­ immediate reactions, yet these typically resolve sion is too dangerous or will lead to feeling out without severe long-term consequences. Still others might deny that they have resilient and develop appropriate coping any feelings associated with their traumatic strategies, including the use of social sup­ experiences and define their reactions as ports, to deal with the aftermath and effects numbness or lack of emotions. Most recover with time, show min­ Emotional dysregulation imal distress, and function effectively across major life areas and developmental stages. In individuals small percentage of people with a history of who are older and functioning well 61 Trauma-Informed Care in Behavioral Health Services Exhibit 1. In treatment, the goal is to tion is usually short lived and represents an help clients learn to regulate their emotions immediate reaction to the trauma, rather than without the use of substances or other unsafe an ongoing pattern. This will likely require learning new substance abuse—is one of the methods that coping skills and how to tolerate distressing traumatized people use in an attempt to regain emotions; some clients may benefit from emotional control, although ultimately it causes mindfulness practices, cognitive restructuring, even further emotional dysregulation. In the following case illustra­ tive, healthy, and industrious ways to manage tion, Sadhanna’s numbing is evidenced by her strong affect generated by trauma, such as limited range of emotions associated with in­ through renewed commitment to physical terpersonal interactions and her inability to activity or by creating an organization to sup­ associate any emotion with her history of port survivors of a particular trauma. Because numbing appropriately experiencing and regulating dif­ 63 Trauma-Informed Care in Behavioral Health Services Case Illustration: Sadhanna Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treat­ ment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admit­ ted that she was drinking at the time of the incident. She also reported severe physical abuse at the hands of her mother’s boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna’s matter-of-fact way of presenting the abuse history. During the interview, she clearly indi­ cated that she did not want to attend group therapy and hear other people talk about their feelings, saying, “I learned long ago not to wear emotions on my sleeve. In Sadhanna’s first weeks in treatment, she reported feeling disconnected from other group members and questioned the purpose of the group. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged. People from health staff to assess levels of traumatic stress certain ethnic and cultural backgrounds may symptoms and the impact of trauma as less initially or solely present emotional distress via severe than they actually are. At times, clients may remain some people who have experienced traumatic resistant to exploring emotional content and stress may present initially with physical remain focused on bodily complaints as a symptoms. Some clients may insist and only door through which these individuals that their primary problems are physical even seek assistance for trauma-related symptoms. In these situations, somatiza­ between trauma, including adverse childhood tion may be a sign of a mental illness. Common physical disorders and distress through the physical realm or view symptoms include somatic complaints; sleep emotional and physical symptoms and well­ disturbances; gastrointestinal, cardiovascular, being as one. It is important not to assume neurological, musculoskeletal, respiratory, and that clients with physical complaints are using dermatological disorders; urological problems; somatization as a means to express emotional and substance use disorders. Somatization Foremost, counselors need to refer for medical Somatization indicates a focus on bodily evaluation. You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho­ tropic medication to address severe symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy. Biology of trauma development and increase a person’s vulnera­ bility to encountering interpersonal violence Trauma biology is an area of burgeoning re­ as an adult and to developing chronic diseases search, with the promise of more complex and and other physical illnesses, mental illnesses, explanatory findings yet to come. Although a substance-related disorders, and impairment thorough presentation on the biological as­ in other life areas (Centers for Disease pects of trauma is beyond the scope of this Control and Prevention, 2012).

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There is level 1b evidence that Desipramine may not improve depression or motor recovery post-stroke gastritis for dogs buy cheap protonix 20 mg on line. There is limited level 2 evidence that Citalopram may improve depression symptomology and functional recovery gastritis omeprazole buy 20mg protonix otc. Mortality and Pharmacologic Treatment of Post-Stroke Depression There is level 1b evidence that early treatment with antidepressants (Nortriptyline or Fluoxetine) post stroke is associated with improved long-term survival gastritis symptoms palpitations buy line protonix. Electroconvulsive Therapy There is limited level 3 evidence that electroconvulsive therapy may be an effective treatment for short term depressive symptoms without worsening existing neurological deficits gastritis gastroenteritis generic 20mg protonix mastercard. There is level 1b evidence that mindfulness may help improve mental fatigue after a stroke gastritis diet 7-up order protonix 40 mg on-line. Combined Therapy There is level 1b evidence that delivery of a brief psychosocial intervention in addition to antidepressant therapy may be more effective than antidepressant therapy alone in terms of depressive symptomatology, functional ability and social participation. There is level 1b evidence that combination therapy of high-intensity light therapy and citalopram is superior over low-intensity light therapy with citalopram at improving post-stroke depression. Music Therapy There is conflicting level 1b and level 2 evidence regarding the effect of music therapy on post-stroke depression. There is level 1b evidence that music-movement therapy may not improve depression however, it may improve upper limb range of motion. Speech Therapy and Emotional Outcomes There is level 1b evidence that speech therapy may not improve depression scores or overall psychological wellbeing. Physical Activity There is level 1a and limited level 2 evidence (one study) that various forms of exercise therapy may not improve depressive symptoms. Ecosystem Focused Therapy There is level 1b evidence that ecosystem focused therapy may not be more effective than education in reducing depressive symptoms post-stroke. Acupuncture There is level 1b evidence that acupuncture may not improve post-stroke depression however, it may improve neurological status. There is limited level 2 evidence that electro-acupuncture may help improve post-stroke depression. Reiki Treatment There is level 1b evidence that Reiki treatment may not improve functional recovery or depression symptomology post-stroke. Meridian Acupressure There is limited level 2 evidence that meridian acupressure may improve depression and independent functioning. Massage Therapy There is limited level 2 evidence that anxiety may be improved following massage therapy. Relaxation Therapy There is limited level 2 evidence that relaxing unilateral nostril breathing may not improve anxiety or depressive symptoms in aphasic compared to non-aphasic individuals. Community Reintegration Social Support and Functional Status High levels of social support may facilitate improved functional gains, mood, and social interactions. Moderate amounts of instrumental support and high amounts of emotional support may appear to be most beneficial to stroke patients. The presence and size of social support networks as well as the perceived effectiveness of social support networks have a positive influence on physical recovery, psychological distress and quality of life post stroke. Higher levels of support are associated with greater functional gains, less depression and improved mood and social interaction. The size and perceived effectiveness of social support networks are important predictors of discharge destination. Having a pet was found to facilitate physical, psychological and social recovery after a stroke. Social Work Interventions There is level 1a evidence that social work interventions providing counselling along with information and education for stroke patients and their families may not be associated with improvements on measures of independence or social activity. Specialized Social Support Network Interventions There is level 1b and limited level 2 evidence that a specialized social support intervention that includes the stroke patient’s social support network may not be effective in improving perceived social support or functional recovery. Subgroup analyses suggest that there may be some benefit in terms of physical performance and instrumental activities of daily living for healthier, non-frail stroke survivors. Day Services There is level 1b evidence that early attendance (within 6 months of stroke) at a day service is associated with improved participation in leisure activities. Home-Based Support and Care Management There is level 1a evidence that home-based support and care management interventions are not associated with improved social activity, mood, quality of life or physical independence. However, there is level 1b evidence that participation in a social worker led program of care coordination featuring frequent, regularly-scheduled contact may result in improved mental health. There is level 1a evidence that involvement with a stroke liaison worker or case manager is associated with increased knowledge about stroke and satisfaction with services. There is inconclusive level 1b evidence regarding the efficacy of occupational therapist led home-visits on mental health and hospital readmission. Active Case Management There is level 1a evidence that active case management may result in improved social activity and mood however, it may not be more effective than the comparator control treatment. Discharge Planning Programs There is limited level 2 evidence that individualised, caregiver-oriented discharge planning may improve both preparedness and quality of care. Education Programs There is limited and inconclusive level 2 evidence regarding the effect of caregiver training programs on the patients’ and caregivers’ well-being. There is limited level 2 evidence that community-based nurse-led education programs for patients may improve stroke knowledge. There is limited and inconclusive level 2 evidence regarding the effect of providing re-integration guidelines to patients. Community Based Rehabilitation Programs There is limited level 1b evidence that community walking programs are more efficient than usual care at improving walking performance and the impact of stroke on the patient. Self-Management Education Programs There is level 1b evidence that self-management programs are not superior to usual care for improving quality of life of patients with stroke. Effects of Caregiving Post stroke Commonly identified effects of caregiving on the caregiver include increasing psychological distress, increased financial burden, decreased social contact and activity, increased risk for depression, increased carer stress, strain or burden and an overall decrease in quality of life. Decreased social contact and activity in itself may contribute to increased carer strain, increased risk of depression and decreased life satisfaction. Reports concerning the influence of patient characteristics vary with the effect in question. However, age, severity of stroke and stroke-related impairments, functional status and cognitive status have been reported as influencing caregiver outcomes. Positive consequences of caregiving include improved appreciation of life, feeling needed or appreciated and development of a more positive outlook. Maintaining a positive attitude has been identified as an important coping strategy. Social Support Interventions for the Caregiver Support provided by caregiving peers may have a positive effect on the caregiver. However, access to web-based information may be associated with reductions in healthcare utilization. There is level 1a evidence that group-based programs and support may improve stroke-related knowledge and family structure however, it may not have an impact on psychological health. There is level 1b evidence that interactive educational resources and professional support accessed via online chat sessions, message boards and educational videos may reduce depression in caregivers but has no impact on mastery or self-esteem. There is level 1b evidence that a caregiver-mediated home-based program may improve the physical impairments of stroke patients. Family Interactions and Stroke: Perceived family dysfunction is common post stroke. Effective communication, good problem solving or adaptive coping, and strong emotional interest in each other characterize well-functioning families. Information Provision and Education Interventions: There is level 1a evidence from a meta-analysis that psychoeducational interventions have no significant effect on the burden or health of caregivers but may benefit family functioning. There is level 1a evidence of a positive benefit, associated with the provision of information and education through a variety of intervention types. Education sessions may have a greater effect on outcome than the provision of information materials alone. There is level 1a evidence that skills training is associated with a reduction in depression. There is level 1b evidence that a problem-solving intervention for caregivers is associated with a reduction in depression, life changes, and health. Perceived Need for Information, Education and Training Although the receipt of information is of great importance to stroke patients and their families/caregivers, relatively few receive adequate information about topics they perceive to be important. Caregivers rarely receive adequate training in skills they require to care for the stroke survivor. Healthcare professionals involved in stroke care may acknowledge the importance of education for patients and carers; however, relatively few provide adequate information based upon the information needs of the recipients. In addition, written materials should be suited to the educational/reading level of the intended recipient. Leisure Activities Post-Stroke Deterioration in social and leisure activities is common post-stroke and is greatest in women, the young and those who are better educated. Perceptions about how others view their disabilities and perceptions about how they will be able to cope post-stroke may influence the degree of social isolation experienced. There is level 1b evidence that participation in a leisure education program focused on awareness and competency development is associated with improvement in number and duration of activities and reduction in depressive symptoms. There is level 1a evidence that participation in group education and exercise programs result in improved physical outcomes, but not social/leisure participation outcomes. Sexual Activity Post-Stroke A decrease in sexual activity is very common post-stroke. There is general agreement that sexual drive is still present and the main barriers to sexual activity are physical impairments and psychological factors, in particular a changed body image and lack of communication. There may be an association between inappropriate sexual behaviour and the presence of right frontal lobe stroke and cognitive impairment. There is level 3 evidence that sexual issues should be discussed during rehabilitation and addressed again after transition to the community when the stroke survivor and significant other are ready. Assessment of Driving Ability Patients for whom there is concern about their ability to drive need to be identified and proper assessment and treatment initiated. Determination of ability to drive should not rely solely on neuropsychologic testing or road test evaluation. Rather, a 2-step process is recommended in which the patient is first screened for readiness to participate in an on-road evaluation. In addition, provision of contextual driving therapy may be associated successful on-road evaluation. Driving Ability Treatment Interventions Post-Stroke There is level 1b evidence that a visual attention-retraining program is no more effective than traditional visuoperception retraining in improving the driving performance of patients with stroke. There is level 1b evidence that a simulator training program involving use of appropriate adaptations and driving through complex scenarios similar to real life is associated with improvement in driving fitness and successful on road evaluation. There is level 1b evidence that Dynavision training is not effective in improving the results of on-road assessments in individuals with stroke. Return to Work Post-Stroke A substantial proportion of stroke survivors who were employed prior to the stroke event do not return to work. Factors influencing return to work include the severity of functional limitations, age and type of pre-stroke employment. There is level 3 evidence that stroke survivors who worked prior to their stroke should, if their condition permits, be encouraged to be evaluated for their potential to return to work. Accepting and adapting to a post-stroke status can mitigate the negative effects that come as a result of stroke. The individual characteristics of stroke patients such as optimism, determination, competitiveness, resilience and initiative can facilitate community reintegration.

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In exceptional circumstances gastritis green stool order genuine protonix, where there are issues of risk of harm to gastritis diet 5 bites purchase genuine protonix on line self or others gastritis best diet trusted protonix 40 mg, family involvement may need to gastritis beans generic 40 mg protonix amex occur without the person’s consent gastritis diet mayo clinic purchase protonix on line. A lack of understanding can contribute to partners inadvertently undermining treatment efforts. It is often useful to invite the partner to a session early in the treatment process to discuss the rationale for subsequent interventions and to clarify the partner’s role – usually simply one of support and gentle encouragement (but not one of co-therapist). The partner’s own need for mental healthcare or support should be considered and, where appropriate, referral made to another provider for assessment and possible treatment. In effect, this means that individual practitioners should not deliver interventions that are beyond their level of expertise. In most cases, the specialist symptom-focussed interventions will be undertaken by psychiatrists, psychologists and other mental health practitioners specifcally trained in recommended treatments, while occupational therapists, rehabilitation counsellors and social workers are more likely to address family, social and occupational recovery, and rehabilitation issues. Ideally, the general practitioner will have an existing relationship with the individual that allows provision of holistic care and support to the person and family over time. The individual, their family and carers also play a critical role in support and recovery. Unfortunately, this ideal circumstance is not always possible, most notably in rural and remote parts of Australia where a visiting nurse or general practitioner may be the sole health professional in the region. Their role is more likely to involve screening, assessment, pharmacotherapy, and possibly general psychological interventions such as psychoeducation and simple arousal management. Wherever possible the person should be referred to an appropriately trained mental health practitioner who can provide time-limited specialist psychological treatment and ongoing consultation to the primary care practitioner. In some cases, it may be possible to achieve this through telemedicine or even telephone consultations. Repeated exposure to the traumatic experiences of others, combined with the high levels of distress often seen when people recount their experiences, can take a toll on the practitioner. Often referred to as ‘compassion fatigue’, health professionals can be at risk of general stress or adverse psychological reactions such as depression, substance abuse and professional burnout. For these practitioners, routine training and support may need to be addressed remotely (for example, via the internet and teleconferencing). For general practitioners who are geographically isolated, Balint groups offering peer support operate in some areas of Australia. Post-traumatic stress disorder: Findings from the Australian National Survey of Mental Health and Well-being. Acute stress disorder as a predictor of posttraumatic stress disorder: A systematic review. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women. Dissociation: An insuffciently recognized major feature of complex posttraumatic stress disorder. The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder. The epidemiology of posttraumatic stress disorder: What is the extent of the problemfi Epidemiology of anxiety disorders in the Australian general population: Findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Posttraumatic stress disorder in primary care with special reference to personality disorder comorbidity. Prevalence of personality disorders among combat veterans with posttraumatic stress disorder. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster. The construct of resilience: A critical evaluation and guidelines for future work. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. The relation of perceived and received social support to mental health among frst responders: A meta-analytic review. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Standardized self-report measures of civilian trauma and posttraumatic stress disorder. Trauma Symptom Inventory – Psychometrics and association with childhood and adult victimisation in clinical samples. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. The impact of fear activation and anger on the effcacy of exposure treatment for posttraumatic stress disorder. Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder. Hazardous alcohol use and treatment outcome in male combat veterans with posttraumatic stress disorder. Social support moderates outcome in a randomized controlled trial of exposure therapy and (or) cognitive restructuring for chronic posttraumatic stress disorder. Comparison of treatment outcomes for veterans with posttraumatic stress disorder with and without comorbid substance use/dependence. Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: A systematic review of the evidence. Pain and post traumatic stress disorder: Review of clinical and experimental evidence. Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic painfi Patients’ view of the alliance in psychotherapy: Exploratory factor analysis of three alliance measures. Outcome expectancy as a predictor of treatment response in cognitive behavioral therapy for public speaking fears within social anxiety disorder. Treatment expectancy affects the outcome of cognitive behavioral interventions in chronic pain. Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Posttraumatic stress disorder treatment in correctional settings: A brief review of the empirical literature and suggestions for future research. Do all psychological treatments really work the same in posttraumatic stress disorderfi Evidence-based practices for services to families of people with psychiatric disabilities. Trauma and Trauma Reactions 50 General Considerations when Working 3 with Children and Adolescents Although most principles that underpin good clinical practice apply equally when working across various age groups, some differences will inevitably apply when working with children and adolescents. The following considerations should inform every aspect of the way in which clinicians think about, assess, and treat posttraumatic mental health problems in children and adolescents. Children and adolescents are typically dependent upon an adult to present them for treatment in the frst instance and to ensure that they attend subsequent appointments. This means that it is as important to engage with, and maintain, the relevant adult’s motivation to pursue treatment, as it is to do these things with the child or adolescent client. In line with the frst two considerations, common sense suggests that involving parents/caregivers in children’s treatment should be helpful. However, as will be discussed below, there are many reasons why parents/ caregivers may be unwilling or unable to participate in their child’s treatment in a helpful manner. The rate of agreement between parents/caregivers and children in relation to internalising symptoms (and especially posttraumatic mental health problems) is very low. Never rely solely on an adult’s report of a child’s internalising symptoms – even if the child is of preschool age. For instance, a 40-year-old who is assaulted physically is less likely than a three-year-old to develop attachment problems. In other words, children and adolescents have a much greater potential to be rendered either ‘stuck’ or developmentally regressed by trauma. Depending on their age and developmental stage, children have less well-developed linguistic, affect regulation, cognitive and perceptual capacities than adults. Naturally, these developmental limitations will infuence the nature of treatment and the manner in which it is delivered. Note: For the purposes of this chapter, the term ‘pre-schoolers’ or ‘preschool-aged children’ is used to refer to children aged birth to 5 years. The term ‘primary school-aged children’ is used to refer to children aged 6 to 11 years, and the term ‘adolescents’ is used to refer to youth aged 12 to 17 years. General Considerations when Working with Children and Adolescents 52 Trauma and trauma reactions Trauma, traumatic event and potentially traumatic event As noted in the previous chapter, the terms trauma, traumatic event, and potentially traumatic event are used in a variety of ways. By no means do all young people exposed to such events develop signifcant psychological problems. Increasingly, however, in the feld of children and adolescents (especially preschool-aged children) this focus is broadening to include behavioural and attentional problems (such as oppositional defant disorder and attention defcit hyperactivity disorder). Clinical presentations in children and adolescents following potentially traumatic events Yule6 described the manifestation of traumatic stress responses in children and adolescents in a manner that has withstood the test of time and burgeoning research. He noted that, while the majority of children are bothered almost immediately by repetitive, intrusive thoughts about the event, dissociative fashbacks are not common. As in adults, irritability, anger and aggression are common, often manifested as temper tantrums in preschool-aged children. Many primary school-aged children and adolescents are able to articulate a desire to talk about their experiences, but also note that they fnd it diffcult to speak about what happened with their parents and peers. Hypervigilance to danger in their environment (including increased awareness of trauma related reminders in the media) is typical. The development of increased general anxiety, as well as specifc fears related to aspects of their trauma experience, is common – although often the link between the feared stimulus and the trauma experience is not always immediately obvious (for instance, a child who develops a fear of helicopters after being involved in a natural disaster where helicopters were used to rescue people). Other important aspects of clinical presentation in preschool-aged children that were not explicitly described by Yule include new oppositional behaviour, regression in, or loss of, previously mastered developmental skills. Rather, the clinician is required to apply the same criteria as those used for adults, albeit sometimes with minor adjustments. Thus, the full adult-centric diagnostic criteria will not be reviewed here (see previous chapter for the diagnostic criteria). B1 – ‘In young children, repetitive play may occur in which themes or aspects of the trauma are expressed’. The studies that have been conducted have focussed on samples of youth involved in motor vehicle accidents and single assaults, with relatively low prevalence rates reported: 8 per cent;23 19 per cent;24 and 9 per cent. A wide range of adverse health consequences for pre-schoolers through to adolescents has been identifed,e.

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To provide an effective incentive for the implementation of a risk control intervention gastritis diet îäíîêëàñíèêè discount protonix 20 mg with visa, costs must be economic gastritis diet handout order protonix online, internal gastritis diet ÷àòðóëåòêà purchase protonix american express, variable gastritis diet ùåëêóí÷èê order 20mg protonix otc, and visible (Dorman gastritis diet en espanol order protonix on line, 2000). The second step is to calculate the economic costs for the types of injuries and illnesses selected, based on the definition criteria established in the first step. A more comprehensive economic cost analysis including multiple data sources will create a more complete, accurate picture of the current problem. Finally, applying a proposed risk control investment based on projected costs and benefits to a financial model that predicts the cost-effectiveness of implementation and can be measured against other business 26 investment opportunities allows decision-makers to anticipate the maximum rate of return (Kuchler and Golan, 1999). The methodology to achieve this objective can be categorized into four general sections: (a) identifying and quantifying the historical cost of occupational injury and illness, (b) translating related costs into business-based economic measurement criteria to effectively define the impact on profitability, (c) projecting the estimated costs associated with an ergonomic program intervention, and (d) proposing a cost-benefit financial model to estimate the return on a risk control initiative. The Review of Literature helped to determine the scope of this study by analyzing the types of related costs to be considered, reviewing methods of translating costs into business terms, researching cost and benefit statistics associated with ergonomic interventions, and identifying various financial models to translate costs and benefits into business terms. The Uniprise business segment of UnitedHealth Group was chosen as a target population for this study based on its size, employee population and contribution to UnitedHealth Group’s overall workers’ compensation experience. The costs of occupational injuries and illnesses were limited to developed, direct costs associated with workers’ compensation claims as well as additional administrative costs to associated with managing and maintaining the workers compensation program. Data collection and analysis was limited to occupational injury and illness data from January 1, 1999 through April 30, 2002. More current data was chosen to more accurately reflect the organizational changes that have occurred since 1998. Data was collected from two primary databases linked to two third party administrators that managed claims during the specified time period. Analyzed data was specific to the Uniprise business segment with some comparison to UnitedHealth Group overall experience. Key indicators included incidence data, severity measured in terms of lost time and overall financial impact, and descriptive data. Overhead costs associated with the administration of the workers’ compensation program including claims processing and administration fees, payment for the waiting period prior to the onset of workers’ compensation coverage, and internal risk management salaries. A portion of the measured costs was attributed to the Uniprise business segment based on historical claims experience. The direct cost of occupational injuries and illnesses were translated into impact on profitability within Uniprise using 2001 as the most recent, complete year. Impact on profitability was calculated by using the profit margin to determine the actual cost of injuries in terms of the additional 29 revenue needed to pay for the injury during a specified time period. Average medical-only claim cost, average lost time claim cost, and average cost for cumulative trauma disorder were considered. The UnitedHealth Group cost-benefit analysis model was used to estimate the return on investment of a risk control program. Key components of the combination net present value/internal rate of return model included project cost estimation, assumptions, estimated savings associated with the project and return on investment calculations. The cost of a risk control intervention related to the prevention of cumulative trauma injuries was estimated by quantifying required resources including personnel, training, and furniture and equipment needs. The general procedure used to estimate the costs for the intervention was modeled after the Cost Benefit Analysis of the Ergonomic Standard conducted by the Washington Department of Labor and Industries in May 2002. Estimates were based on Uniprise Production and Service division population and were not considered to be indicative of a comprehensive program but rather an initial, three-year phase of implementation. Estimated projected savings were quantified in terms of the reduction in the number of related injuries and illnesses. The average cost of medical claims and average cost 30 of lost time claims were used as baseline expenditures. The projected internal rate of return was calculated to determine the interest rate that is equivalent to the monetary return or savings expected from the risk control intervention. The internal rate of return was compared with current investment rates to determine if the intervention as defined in the cost-benefit analysis would be considered acceptable in financial terms. First, a target population was chosen, based on the size of the business segment and the overall contribution to UnitedHealth Group workers’ compensation costs. Next, the types of costs associated with occupational injury and illness were selected and analyzed, based on their ability to be isolated and monetarily quantified. Total costs were then translated to impact on productivity and profitability within the Uniprise business segment, focusing on key production standards within the Production and Service divisions. Finally, the estimated costs and benefits of an ergonomic program were applied to a financial model to determine the internal rate of return. Target Population UnitedHealth Group has approximately 29,845 employees throughout the United States, housed in six business segments, each operating as independent companies with separate financials. Uniprise is the largest business segment of UnitedHealth Group with approximately 10,152 employees nation-wide. As the largest business segment, Uniprise also significantly contributes to overall workers’ compensation costs on an annual basis. Of the total Uniprise population, 6192 or 61% of the employees currently reside in two divisions, Production and Service. Correspondingly, Uniprise Production and Service divisions have contributed 44% of reported claims and 58% of the total cost of Uniprise occupational injuries and illnesses since 1999, accounting for $3,548,769 in related costs which represents over 35% of UnitedHealth Group’s total cost. Based on the large employee population as well as the contribution to overall workers’ compensation costs, Uniprise was chosen as the target population for this study, with special emphasis on the Production and Service divisions. Information from both databases was cross-referenced with the UnitedHealth Group human resources database to obtain specific business segment, unit, function, and job classification information. The intent of the analysis was to determine the total number of claims that have incurred cost, total cost and distribution of claims and injury types as they relate to the Uniprise business segment. The goal was to quantify the costs associated with workers’ compensation claims and determine predominant injury types by functional division. Table I represents the annual number of Uniprise workers’ compensation claims that resulted in incurred cost and the total cost of claims through 4/30/02 as of 5/21/02. Costs reflect the total amount incurred including paid and reserved medical expenses, indemnity expenses and ancillary expenses such as legal fees charged to the claims files. Claims reported in 2002 were annualized and industry development factors were applied to each year to project the ultimate cost of claims. The number of reported claims has decreased by a greater margin each year from 5% in 2000, 10% in 2001 to a projected 27% in 2002 while the cost of claims has fluctuated since 1999 with a high projected in 2002 of $2,151,803. Table I Uniprise Annual Number and Cost of Injuries Fiscal Year 1999 2000 2001 2002 196 187 168 165 Number Total Cost $1,296,372 $1,650,770 $1,011,827 $2,151,804 Recordable 1. The six divisions represented account for over 87% of the total number of reported injuries and illnesses. Combined, the Production and Service divisions account for 44% of reported occupational injury and illness and 58% of the total cost after development. The Operations division has contributed 21% of reported claims and 18% of the total cost of injuries, however losses have been trending dramatically downward since 1999 with 80% of the claims occurring in 1999 and 2000. The number and cost of injuries and illnesses within the Production and Service divisions have been steadily increasing since 1999 with 70% of claims occurring in 2001 and 2002. Cumulative trauma disorders alone contributed over 61% of the total cost of claims. Occurrence and cost data for 2002 was annualized and industry development factors were used to project the ultimate cost of claims. Slips, trips and falls and cumulative trauma disorders account for 75% 36 of total claims and almost 78% of the cost. Cumulative trauma disorders alone account for 45% of the cost of occupational injuries and illnesses, averaging $16,904 per claim. Table V represents the average cost of medical, indemnity and cumulative trauma disorders by year. The average cost of medical claims had increased by 26% from 1999 to 2000 and 2000 to 2001. Based the annualized and developed claims in 2002, the cost is anticipated to increase even more substantially. Average cost of indemnity claims has fluctuated since 1999, as has the average cost of cumulative trauma disorders with highs projected in 2002. Administrative Cost Assessment UnitedHealth Group maintains a self-insured workers’ compensation program and currently contracts with a third party administrator to manage related claims. While the costs presented in the workers’ compensation database contribute to a substantial portion of the total direct cost of occupational injury and illness, there are additional administrative costs associated with maintaining the workers’ compensation program that are not reflected in the database and are billed separately. These additional administrative costs include employee salary to manage the program, payment of the waiting period before workers’ compensation benefits ensue as well as unallocated costs charged by the third party administrator for various administrative services and expenses. UnitedHealth Group employs one person to oversee the workers’ compensation program at a salary of $67,500. At a 33 % allocation rate based on the number of occupational injuries and illnesses, $22,275 can be attributed to the Uniprise business segment on an annual basis. In addition to the salary devoted to managing claims, 38 UnitedHealth Group also incurs the expense associated with the waiting period before indemnity benefits are allocated to the claim file. The waiting period varies by state however an average of three days was used to project associated costs based on the number of indemnity claims. At an average daily wage of $100, projected lost time costs associated with the waiting period were conservatively estimated at $13,800. Lastly, there are three flat-rate fees associated with claims administration including a $20 per claim intake fee, a $90 per medical only claim fee, a $925 per indemnity claim fee, and an annual $9,600 general administrative fee. Using the 2001 fiscal year as an example, ancillary fees contributed an additional $13,420 to the total cost of medical claims, $44,712 to the total cost of indemnity claims and $3,168 to general claims administration. Overall, an estimated $97,375 in additional total administrative costs were added to the 2001 loss year to project ultimate claim costs at $1,109,202. To translate the loss to Uniprise into business terms, the direct costs of occupational injuries and illnesses for the 2001 fiscal year were applied to the operating margin for 2001. Cost-Benefit Analysis Based on the number and cost of injuries within the Uniprise business segment, an ergonomic program was chosen as the proposed risk control intervention. The UnitedHealth Group cost-benefit analysis model was used to estimate the return on 39 investment of the ergonomic program by estimating the cost of the intervention, the savings associated with the intervention and calculating the internal rate of return. The general procedure used to estimate the costs for the intervention was modeled after the Cost Benefit Analysis of the Ergonomic Standard prepared by the Washington Department of Labor and Industries (2002). Based on the number and cost of cumulative trauma disorders, the Production and Service divisions of Uniprise were chosen as the target population for the risk control intervention, representing 6,192 employees. The Washington State analysis calculated the unit control cost by standard industrial code for each component of the program. Training costs were estimated to occur in the first year and every three years thereafter. Job analysis costs were applied over three years as were managerial and administrative costs. Engineering controls and protective equipment costs were allocated over three years with heavy emphasis on the first year of implementation. In addition to the 41 $204,643 associated with the specific components of the intervention, it was assumed that training would be provided internally by UnitedHealth Group Risk Management, adding $9,250 to the total cost of intervention (see Appendix A for project cost estimation). Estimated savings or benefits associated with an ergonomic risk control intervention were also modeled in part after the Cost Benefit Analysis of the Ergonomic Standard conducted by the Washington Department of Labor and Industries in May, 2002. Projected savings were based on the impact on direct workers’ compensation claim costs associated with the decrease in cumulative trauma disorders that are anticipated to follow the reduction or elimination of related hazards in the workplace.

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