Work-related post-traumatic stress disorder: use of exposure therapy in work-simulation activities.

This article was acceptedfor publication March 11, 1997. P ost-traumatic stress disorder (PTSD) occurs in up to 58% of persons exposed to potentially lifethreatening trauma (American Psychiatric Association [APA], 1994). It is characterized by intrusive and distressing thoughts, nightmares, avoidance of and physiological reactivity to trauma-related stimuli, insomnia, and increased startle response (APA, 1994). PTSD can interfere substantially with activities of daily Jiving (ADL), including work performance. Studies in pain rehabilitation settings suggest that PTSD symptoms may be present in many persons with work-related chronic pain and that these symptoms should be addressed if return to work is to be successful (Burgess, Hibler, Keegan, & Everly, 1996; Geisser, Roth, Bachman, & Eckert, 1996). Within the occupational therapy literature, a variety of theoretical models have been applied to the understanding and treatment of PTSD, including object relations theory (Froelich, 1992) and approaches emphasizing therapeutic rituals and emotional catharsis (Short-DeGraff & Engelmann, 1992). Within the clinical psychology literature, the most widely accepted theory of PTSD emphasizes a more behavioral approach, with a focus on learning principles. It proposes that the primary symptoms of PTSD represent a learned association (classical conditioning) between the intense anxiety encountered during the actual trauma and stimuli (e.g., visual, auditory, proprioceptive) present in the traumatic situation (Kilpatrick, Veronen, & Resick, 1979). According to classical conditioning principles, such learned anxiety reactions should diminish over time, with repeated exposure to the stimuli under conditions that are not inherently anxiety provoking (i.e., extinction). However, persons with PTSD tend to avoid stimuli that trigger anxiety, resulting in a failure to extinguish the learned anxiety reactions. Decreased anxiety accompanying avoidance further reinforces the avoidance behavior (operant learning). Persons with PTSD are often treated by occupational therapists in psychiatric settings (Froelich, 1992). Typically, these clients are experiencing PTSD subsequent to sexual abuse or military combat. Despite the relative frequency of PTSD in some occupation therapy settings, a search of the occupational therapy literature revealed no studies that have addressed evaluation and treatment of PTSD subsequent to work-related trauma and no literature that has addressed the role of occupational therapy in achieving rerum to work in persons with work-related PTSD. The most widely used PTSD treatment approac.h in the clinical psychology literature is exposure therapy, which is based on the learning model described previous-