A less frequent problem but a management nightmare for the clinician occurs when the claimant was the victim of a severe trauma in the distant past, but adjusted well without any evidence of impairment or disability. He then raises the issue of the past trauma as the focus of a claim that is really being filed as a grievance over a more recent personnel action or an extraoccupational stress. The principal symptom in PTSD that leads to disability is phobic avoidance, which means being afraid of returning to the site of the trauma. Another common problem in genuine PTSD is that the victim may be loathe to return to a work site in a high crime area, a reaction that is understandable. Most recent studies on Post-Traumatic Stress Disorder treatment focus upon early diagnosis and immediate and aggressive therapy.
Critical incident debriefing for all victims is an important early intervention.
Antidepressants may help in some individual cases, but in most instances, behavioral desensitization therapy on a short term basis while the applicant continues to work, at least on a restricted basis, seems most effective. A new treatment using behavioral technique and rapid eye-movement exercises called EMDR is widely researched and is showing promise. Therapy provided six months after the event, especially in a medical- legal setting, is most often useless and counterproductive. It is important for the therapist to define specific goals and time limits for treatment to prevent secondary gain issues as well as assumption of a victim role that would derail any constructive attempts at rehabilitation. If a patient is not significantly improved within six months, it is usually appropriate to issue a permanent and stationary report with an outline of the resultant permanent disability and apportionment.