Litigation on Accommodating Teachers With Disabilities

Cancer as a trauma? Predictors of development of posttraumatic stress disorder (PTSD) in patients with cancer

Research is limited regarding the role of high-risk behaviors, trauma, and posttraumatic stress disorder (PTSD) symptoms in people with severe mental illnesses (SMI).The current survey of 276 community mental health clients diagnosed with either a schizophrenia spectrum disorder or a major mood disorder examined the mediating role of lifetime high-risk behaviors with regard to lifetime traumatic events and PTSD symptom severity measured by the PTSD Symptom Scale-Interview version. Structural equation modeling revealed that lifetime high-risk behaviors had significant direct effects on PTSD symptom severity, and high-risk behaviors partially mediated the relationship between lifetime trauma and PTSD symptom severity. Lifetime trauma had the greatest total effect on PTSD symptoms, followed by primary Axis I diagnosis and lifetime high-risk behaviors. Implications for practice with people with SMI include more thorough assessments of trauma, PTSD, and high-risk behaviors and use of coping skills approaches to reduce high-risk behaviors. Limitations of the study include the cross-sectional nature of the data. KEY WORDS: high-risk behaviors; major mood disorders; posttraumatic stress disorder; schizophrenia; severe mental illness ********** People with severe mental illnesses (SMIs), including schizophrenia spectrum disorders (SSDs) and major mood disorders (MMDs), experience higher rates of trauma, such as physical and sexual abuse and exposure to violence, than do people in the general public (Mueser et al., 1998; Resnick, Bond, & Mueser, 2003), and they show rates of posttraumatic stress disorder (PTSD) four to five times greater (between 33% and 43%) than do people in the general population (about 8%) (Mueser et al., 1998; O'Hare, Sherrer, & Shen, 2006). People with SMI are also more likely to engage in high-risk behaviors--such as suicide attempts, substance abuse, drug overdoses, unprotected sex, and self-mutilation--and to demonstrate behaviors associated with more severe psychiatric symptoms, have more frequent hospitalizations, be at increased risk of trauma, and have poorer treatment outcomes (Gearon, Kaltman, Brown, & Bellack, 2003; Mueser et al., 1998; O'Hare et al., 2006). Few research investigations have focused on the relationship of high-risk behaviors to trauma and PTSD. Given that the consequences of high-risk behaviors can be retraumatizing, the current study tests whether high-risk behaviors mediate the relationship between lifetime trauma and PTSD symptom severity. AIMS OF THE CURRENT STUDY The relationships among traumatic events, high-risk behaviors, and PTSD remain poorly understood in the SMI population (Butler, Mueser, Sprock, & Braff, 1996; Mueser, Rosenberg, Goodman, & Trumbetta, 2002; O'Hare et al., 2006). Although PTSD symptoms in this population have been shown to be positively related to other measures of emotional distress (O'Hare et al. 2006; Resnick et al., 2003), there is only limited research on the linkages between the frequency of lifetime trauma and PTSD. In addition, the relationship between lifetime trauma and high-risk behaviors is even less understood. Although a recent study of clients, most of whom participated in the current investigation, showed that subjective distress from highrisk behaviors--that is, overdosing on medication, self-mutilation, and suicide attempts--mediated the connection between trauma-related subjective distress and PTSD symptoms (O'Hare et al., 2006), it is not known if high-risk events mediate the relationship between lifetime traumatic events and PTSD symptoms. Discovery of such a link could help improve our understanding of the mediating role of high-risk behaviors with regard to traumatic events and PTSD symptom severity. Gender is a key factor to consider when examining trauma, high-risk events, and PTSD. Women with serious psychiatric disorders appear to be at greater risk for certain stressors, including sexual abuse and interpersonal violence as adults, and men are more likely to witness serious acts of violence (Goodman et al. …

ObjectivesDespite evidence of high rates of diagnosable mental health difficulties in children in care, there remains ongoing debate around the appropriateness of traditional diagnoses and treatments. The aim of this study was to quantitatively explore whether mental health diagnosis and treatment decision‐making differed when a young person was identified as being in care, specifically focused on post‐traumatic stress disorder (PTSD). PTSD is a trauma‐specific mental health disorder with rates substantially higher in children in care versus their peers.MethodsParticipants were 270 UK mental health professionals who completed an online survey. Participants were randomized to receive one of two vignettes, which were identical in their description of a teenage boy experiencing PTSD symptoms, except in one he was in foster care and in the other he lived with his mother. Participants were asked to select a primary diagnosis, treatment approach, and potential secondary diagnosis.ResultsProfessionals were twice as likely to choose a primary diagnosis of PTSD and a National Institute for Clinical Excellence (NICE)‐recommended PTSD treatment when randomized to the mother vignette versus the foster carer vignette. Selecting PTSD as the primary diagnosis made clinicians three times more likely to select a NICE‐recommended treatment for PTSD. Developmental trauma was the most common ‘diagnosis’ for both groups, although this led to different treatment decisions.ConclusionsIn the context of PTSD, we found children in care face diagnosis and treatment decision‐making biases. Practice implications are discussed.

Treatment Rationale: Exposure to repeated sexual trauma, particularly during childhood, often leads to protracted mental health problems. Childhood adversity is specifically associated with complex posttraumatic stress disorder (PTSD) presentation, which is particularly tenacious and treatment refractory, and features severe emotion dysregulation. Augmentation approaches have been suggested to enhance treatment efficacy in PTSD thus integrating first-line psychotherapy with mechanistically informed self-neuromodulation procedures (i.e. neurofeedback) may pave the way to enhanced clinical outcomes. A central neural mechanism of PTSD and emotion dysregulation involves amygdala hyperactivity that can be volitionally regulated by neurofeedback. We outline a treatment rationale that includes a detailed justification for the potential of combining psychotherapy and NF and delineate mechanisms of change. We illustrate key processes of reciprocal interactions between neurofeedback engagement and therapeutic goals. Case Study: We describe a clinical case of a woman with complex PTSD due to early and repetitive childhood sexual abuse using adjunctive neurofeedback as an augmentation to an ongoing, stable, traditional treatment plan. The woman participated in (a) ten sessions of neurofeedback by the use of an fMRI-inspired EEG model of limbic related activity (Amygdala Electrical-Finger-Print; AmygEFP-NF), (b) traditional weekly individual psychotherapy, (c) skills group. Before and after NF training period patient was blindly assessed for PTSD symptoms, followed by a 1, 3- and 6-months self-report follow-up. We demonstrate mechanisms of change as well as the clinical effectiveness of adjunctive treatment as indicated by reduced PTSD symptoms and improved daily functioning within this single case. Conclusions: We outline an integrative neuropsychological framework for understanding the unique mechanisms of change conferring value to conjoining NF applications with trauma-focused psychotherapy in complex PTSD.

ABSTRACTBackground and Objectives: The aim of this study was to further understanding of the relationship between social support, internalized and perceived stigma, and mental health among women who experienced sexual violence in the eastern Democratic Republic of Congo (DRC).Methods: Drawing from baseline survey data collected in eastern DRC, researchers conducted a secondary cross-sectional analysis using data from 744 participants. Regression and moderation analyses were conducted to examine associations between social support variables, felt stigma, and depression, anxiety and posttraumatic stress disorder (PTSD).Results: Emotional support seeking and felt stigma were positively associated with increased symptom severity across all three mental health variables. Stigma modified associations between emotional support seeking and depression (t = −2.49, p = .013), anxiety (t = −3.08, p = .002), and PTSD (t = −2.94, p = .003). Increased frequency of emotional support seeking was associated with higher mental health symptoms of anxiety and PTSD among women experiencing all levels of stigma.Conclusions: Enhancing understanding of social support and stigma may inform research and intervention among Congolese forced migrant populations across circumstances and geographic locations. Implications for practice and research are discussed.

INTRODUCTION In this chapter, it is argued that there is no reason why the duty to make reasonable accommodation for people with disabilities, which exists in European Union (EU) law, could not be extended to include religious people and people with other characteristics which attract protection under antidiscrimination law. However, even if this duty is not extended, it is suggested that something which comes close to such a duty is part of the provision of indirect discrimination. This chapter specifically focuses on the accommodation of religious manifestations and practices, but the duty could be expanded to include all grounds of discrimination covered by EU law (sex, race, religion or belief, age and sexual orientation). It can be said that EU law itself makes certain accommodations in relation to sex, for example, in the regulations protecting pregnant and breast-feeding women, and in relation to age, where it protects younger workers. EXISTING DUTIES OF REASONABLE ACCOMMODATION In EU law, a duty of reasonable accommodation in relation to disabled people is laid down in Article 5 of Directive 2000/78/EC. Employers must ‘take appropriate measures, where needed in a particular case, to enable a person with a disability to have access to, participate in, or advance in employment, or to undergo training, unless such measures would impose a disproportionate burden on the employer’. The first sentence of Article 5 provides that reasonable accommodation must be made ‘in order to guarantee compliance with the principle of equal treatment’, so this duty is clearly placed within a discrimination context and a failure to provide accommodation can thus be seen as a form of discrimination. However, this duty applies only in relation to disability and does not extend to any of the other grounds covered by Directive 2000/78/EC (religion or belief, age and sexual orientation), nor does it extend beyond the employment field. In contrast, in the USA, a duty of reasonable accommodation short of ‘undue hardship’ was first laid down in law for cases of discrimination on the ground of religion and then later extended to cases of disability discrimination.

WHAT IS KNOWN ON THE SUBJECT?: Trauma among psychiatric nurses and other healthcare workers is related to workplace violence, but other risk factors may also contribute, including those occurring before, during or after workplace violence. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Most previously identified PTSD risk factors were not tested or supported in research with psychiatric nurses, although there is promising evidence for risk factors including severe or injurious assault, cumulative exposure, burnout, and other worker characteristics. We identify directions for research needed to improve knowledge, including collecting data before nurses experience workplace violence, defining workplace risk factors consistently and conducting and reporting qualitative analysis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Provide training in risk assessment and violence prevention to psychiatric nurses. Offer mental health support to those exposed to violence, especially with cumulative exposure. ABSTRACT: Introduction Psychiatric nurses are at risk of workplace violence and post-traumatic stress disorder (PTSD). There is limited understanding of pre-trauma and post-trauma risk factors. Aim Our aim was to review factors associated with workplace PTSD in psychiatric nurses. Method We searched quantitative and qualitative studies from 1980 to 2019 in 23 databases plus abstracts for studies on psychiatric hospital nursing staff, potentially traumatic workplace events, workplace factors and PTSD. Following duplicate abstract (n=10,064) and full-text (n=199) screening, data were extracted in duplicate from 19studies. Using best-fit framework synthesis, we identified workplace violence, pre-trauma and post-trauma risk factors. Results Six variables yielded evidence in at least two empirical studies scoring at least 6/8 on a quality measure, or one such study plus more than one other study ("promising": severe/injurious assault, cumulative exposure, burnout, poor mental health, low compassion satisfaction, neuroticism). Four were supported by at least one better quality study or at least two others ("suggestive": gender, poor training, any physical aggression exposure, compassion fatigue). Discussion Pre-trauma measures, consistent definitions of workplace exposures and thorough reporting of quantitative results are needed to improve research. Implications for Practice Violence prevention and mental health care for exposed nurses appear the most promising targets for PTSD prevention. Therefore, it is particularly important to understand workplace violence and mental health among nurses working in psychiatric hospitals.

Exposure to potentially traumatic events is a global health problem, especially in low- and middle-income countries. Assessments for symptoms resulting from trauma exposure rely heavily on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for post-traumatic stress disorder (PTSD), which may not be relevant in all regions of the globe. We examined posttrauma symptoms that were not limited to Western constructs of mental health (i.e., PTSD). In a systematic review, we searched nine databases to identify posttrauma symptoms arising in qualitative literature published before July 17, 2017. A total of 17,938 records were identified and 392 met inclusion criteria. The 392 studies represented data on 400 study populations from 71 different nationalities/ethnicities. The presence and frequency of posttrauma symptoms were examined across all regions. Fisher’s exact tests were also conducted to compare frequencies in posttrauma symptoms across region and gender. Based on a weighted analysis across regions, a list of global posttrauma symptoms (N = 85) was compiled into an item bank. We found that the majority of DSM-5 PTSD symptoms were mentioned across regions (with the exception of inability to recall specific aspects of the trauma and blame of self or others for the event). Across all regions, we also found a number of symptoms mentioned that were not part of PTSD and its associated features. Findings suggest that assessing posttrauma symptoms solely based on PTSD may be limiting to global populations. Research, policy, and practice implications are discussed.

Adverse childhood experiences (ACE) are associated with increased risk for psychopathology over the life course. However, few studies have examined the differential impact of ACE and posttraumatic stress disorder (PTSD) for racially and ethnically diverse adolescent populations. The findings from the few studies that examine differential effects are contradictory. This study uses data from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative adolescent sample (N = 10,123) to examine the impact of race/ethnicity on the association between ACE and PTSD among youth in a nationally representative sample in the United States. A multivariate logistic regression model was used to examine the main effects of ACE and race/ethnicity on PTSD, as well as the moderating role of race/ethnicity adjusting for socio-demographic variables. Findings suggest that race/ethnicity moderates the association between ACE and PTSD. Higher ACE score increased probability of lifetime PTSD for White non-Hispanic, Black, and Hispanic adolescents with White non-Hispanic adolescents presenting with a much higher probability of lifetime PTSD compared to their Hispanic and Black peers. Implications for future research and practice are discussed, specifically trauma informed strategies and culturally inclusive/specific practices that address the structural, interpersonal, and intrapersonal influences adolescent outcomes.

BackgroundOur research arises from anticipated increases in demand for psychological trauma services in the UK, with particular reference to armed forces veterans with post-traumatic stress disorder (PTSD). Commissioning and service provider activity to improve veterans’ health is evolving.ObjectivesTo explore what UK services exist and establish potentially effective models of care and effective treatments for armed forces veterans with PTSD.DesignA four-stage rapid evidence synthesis comprising information gathering on UK service provision; an evidence review on models of care; a metareview on treatment effectiveness; and a synthesis highlighting research priorities.SettingFor the evidence reviews, any setting that was relevant to the UK health and social care system.ParticipantsUK armed forces veterans with PTSD following repeated exposure to traumatic events.InterventionsAny model of care or treatment.Main outcome measuresAny relevant outcome.Data sourcesInformation about current UK practice. Searches of databases [including MEDLINE, PsycINFO and PILOTS (Published International Literature on Traumatic Stress)], guidelines and relevant websites, up to November 2016.Review methodsWe screened titles and abstracts using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, UK) and EndNote X7 [Clarivate Analytics (formerly Thomson Reuters), Philadelphia, PA, USA]. Decisions to include papers were made by two reviewers independently. We conducted a narrative synthesis of research literature on models of care and on treatments, guided by information from UK practice. In our evidence reviews, we assessed (when appropriate) the quality of included studies using established criteria. To help interpret our findings, we consulted recently published public and patient involvement data, a veteran service user and experts with academic, military and commissioning backgrounds.ResultsWe gathered information about current UK practice. Sixty-one studies were included in the rapid evidence review on models of care and seven systematic reviews in the rapid metareview of treatments. The quality of evidence in both evidence reviews was limited. Promising models of care from more robust studies (three randomised controlled trials and one qualitative study) were collaborative arrangements and community outreach for improving intervention access and uptake; integrated mental health services and behavioural intervention on increased smoking abstinence; and peer support as an acceptable complement to PTSD treatment. A poor fit was noted between the research literature and UK service provision. Promising treatments were psychosocial interventions (eye movement desensitisation and reprocessing, cognitive processing therapy, trauma-focused and exposure-based intervention) and pharmacotherapy (selective serotonin reuptake inhibitors, antidepressants, anticonvulsants, antipsychotics) for improving PTSD and mental health symptoms.LimitationsThe literature pool was larger than anticipated. Evidence for potentially effective models of care and potentially effective treatments is limited in quality and quantity. Although we aimed for a comprehensive evidence synthesis, pragmatic decisions in searching, screening and inclusion of studies may mean that relevant studies were overlooked.ConclusionsThere is tentative support for the effectiveness of some models of care and certain treatments currently delivered in UK practice. Our findings are timely for commissioners and service providers when developing present activity in veterans’ health care.Future workWe report potential implications for future health-care practice, including early intervention for veterans transitioning from military life, improving general practitioners’ knowledge about services, implementing needs-based service design and tackling wider-system challenges. Regarding potential areas of future research, we have identified the need for more-robust (and longer) evaluative studies in the UK setting.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background: Emotional memory is an adaptive process that improves the memorization of emotional events or stimuli. In Post-Traumatic Stress Disorder (PTSD), emotional memory may be altered, which in turn may affect symptoms. Having a clearer view of the processes of interaction between memory and emotional stimuli in PTSD may improve our knowledge of this disorder, and could create new therapeutic management tools. Thus, we performed a systematic review of the evidence of specific emotional memory in PTSD patients.Method: Following PRISMA guidelines, a systematic review of MEDLINE, PsycInfo, and ScienceDirect was undertaken to identify controlled studies on emotional memory that used cognitive tasks on PTSD patients. The initial research was conducted from June 2017 to July 2017, and search terms included: Post-Traumatic Stress Disorder; PTSD; emotional memory; emotion; emotional; memory; and episodic memory.Results: Eighteen studies reporting on 387 PTSD patients met the eligibility criteria. Among the studies selected, 11 observed specific memory processing in PTSD patients, such as a greater memorization of negative information, or a trend to false recognition of negative information. In addition, attentional and inhibition processing seem to play an important role in emotional memory in PTSD sufferers. Furthermore, other studies that did not find behavioral differences between PTSD and control groups nevertheless showed differences in both specific cerebral activities and neurohormone levels during emotional memory tasks.Conclusion: This review has several limitations, including a limited number of controlled studies, small sample sizes, different tasks and methods. Nevertheless, the results of this systematic review provide interesting information on emotional memory for clinicians and researchers, as they seem to highlight facilitated memory processing for negative information in PTSD patients. This topic needs further controlled studies with sensitive behavioral tasks. Also, future studies may evaluate emotional memory after symptom amelioration.

Young children from impoverished backgrounds experience high levels of family and environmental stress, adversely impacting developmental functioning. Early identification provides a pathway to solutions, but many children are never assessed. In addition, the child-serving workforce lacks resources and expertise to use traditional measures. Furthermore, existing measures do not account for the substantial influence of a child's ecology. To bridge these gaps, we developed the Neurodevelopmental Ecological Screening Tool (NEST) and conducted a pilot study (n=60) to test its feasibility for use with caregivers of children ages 3-5 in low-resource settings. We developed an item pool across three domains (child, caregiver, environment), vetted it with experts, and conducted cognitive interviewing with parents (n=15) and case managers (n-10). Simultaneously, we built an online, user-friendly delivery platform. We used a one parameter Item Response Model and a Rasch-based Rating Scale Model (RSM) and fit confirmatory factor analytic (CFA) models to test for unidimensional and construct validity. The results support the feasibility of screening children from low SES populations within low-resource settings using an ecological perspective and supports the work of child-serving paraprofessionals in identifying and addressing risks in the lives of young children.

Law enforcement officers are often reported to frequently abuse alcohol due to occupational stress. However, few studies have examined alcohol use among U.S. police officers. This study investigated the prevalence of alcohol use and the relation between alcohol use and amount of subjective work-related traumatic distress, work-related but nontraumatic stress, personal relationship stress, posttraumatic stress disorder (PTSD) symptoms, depression, and age among law enforcement officers (N = 193) working in a midwestern state. Multiple regression analyses showed that greater subjective posttraumatic distress and PTSD avoidance symptoms were the most significant predictors of greater alcohol use among officers. Implications for practice are discussed.

Writing about traumatic events can produce physical and psychological health benefits, especially when individuals use language to transform emotionally laden events into meaningful narratives. Because religion often facilitates the search for meaning, we predicted that the use of religious themes in writing would moderate mood-related outcomes. Fifteen individuals with posttraumatic stress disorder (PTSD) wrote in each of 3 sessions about their PTSD-triggering events. Religious themes were evident in essays written by 80 percent of participants. Relative to participants who did not frame their traumas in religious terms, those who used religious framing reported a greater shift toward negative mood after the first writing session than those without such framing. By the third session, however, religious framing was associated with more positive mood after writing, whereas nonreligious framing was still associated with more negative mood. The nature of religious references was important. Positive references and specific religious behaviors (e.g., prayer) were associated with more positive mood states, whereas negative religious references were not associated with mood. Implications for research and practice are discussed.

Research with survivors of torture has generated considerable variability in prevalence rates of posttraumatic stress disorder (PTSD). Multiple risk and resilience factors may affect this variability, increasing or decreasing the likelihood of experiencing psychological distress. This study sought to investigate the effect of several such resilience factors, coping style, social support, cognitive appraisals, and social comparisons on PTSD symptom severity. Furthermore, this study examined whether coping style moderated the relationship between resilience variables and PTSD symptoms. Seventy-five torture survivors completed an intake interview and several self-report measures upon entry into a treatment program for survivors of torture. Results indicated that emotion-focused coping styles significantly moderated the relationship between cognitive appraisal and social comparison variables and PTSD, and usually increased the likelihood of developing severe symptoms. These results indicate that the salience of resilience variables may differ depending on the individual's coping style, which present implications for clinical practice with torture survivors.