Understanding Grief and Trauma

Stages of Grief

• Denial: Difficulty accepting the loss.
• Anger: Characterized by sadness, guilt, shame, helplessness, hopelessness and self-blame.
• Bargaining: Involves praying or pleading for the person to come back.
• Depression: Feelings of sadness.
• Acceptance: Acknowledging the loss.
• Finding Meaning: Transforming grief into peace and hopefulness.

Grief Interventions

• Ascertain which stage of grief the patient is experiencing.
• Clarify the stages of grief and their behaviors.
• Enable the patient to express anger.
• Help the patient release pent-up emotions through activities like walking, jogging, or exercise.
• Have patients re-evaluate how they perceive the loss or change.
• Acknowledge that crying is okay.
• Aid the patient in devising adaptive coping mechanisms.

Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD)

• Stem from exposure to actual or threatened death, serious injury, or sexual abuse.
• Exposure types: Directly experiencing trauma, witnessing it, learning it happened to a close person, or repeated exposure to traumatic details.

Similarities Between ASD and PTSD

• Both involve reliving the event through dreams or flashbacks.

Differences Between ASD and PTSD

• PTSD entails flashbacks, delusions or hallucinations.

Manifestations of ASD and PTSD

• Sleep disturbances.
• Irritability.
• Dissociativeness is linked to acute stress disorder.
• Depersonalization/decreased awareness of surroundings is linked to acute stress disorder.
• Difficulty concentrating is linked to PTSD.
• Avoiding trauma related stimuli is linked to PTSD.
• Inability to show feelings is linked to PTSD.

DREAMS (Detachment, Reexperiencing event, Emotional effects, Avoidance, Medication, Sympathetic Hyperactivity)

• Detachment: Feeling emotionally unresponsive or detached from others.
• Reexperiencing: Intrusive recollections, flashbacks, nightmares.
• Emotional effects.
• Avoidance: Avoiding situations or people that trigger memories.
• Medication: Self-medicating with drugs or alcohol to cope with trauma.
• Sympathetic Hyperactivity: Displaying irritability and trouble sleeping.

Interventions for ASD and PTSD

• Assign the same staff.
• Use a nonthreatening and friendly approach.
• Respect the patient's wishes when interacting with individuals of opposite gender.
• Be consistent and spend time with the patient.
• Stay with the patient during flashbacks and nightmares.
• Encourage open communication about the trauma.
• Explore coping strategies.
• Help the individual understand the trauma.
• Acknowledge feelings such as guilt.

ASD and PTSD Treatment Modalities

• Cognitive behavior therapy.
• Prolonged exposure therapy.
• Group and family therapy.
• Eye movement desensitization and reprocessing (EMDR).
• Digital therapeutics that use an app to detect heart rates during nightmares.
• Psychopharmacology: Antidepressants (SSRIs) for PTSD and benzos for acute stress.
• Anxiolytics.
• Antihypertensives.
• Other medications, like ketamine for short-term PTSD management.

Dissociative Identity Disorder (DID)

• Formerly known as multiple personality disorder.
• Individuals experience a splitting of identity.
• A mental process occurs where thoughts, feelings, memories, and sense of identity are disconnected.
• Alters are distinct identities or personality traits.
• Usually, one alter is more dominant.
• Alters can vary in age, gender, and characteristics.
• Switching- triggered by reminders of a traumatic event, and can be rapid, noticeable, or gradual.
• Individuals experience gaps in memory, conversations, or skills.
• Treatment focuses on achieving integration.
• Achievement of integration- blending personality states into one, and it take a very long time.
• Treatment includes intensive long-term psychotherapy.

Signs of PTSD in Children and Teens

• Nightmares
• Insomnia
• Increased irritability
• Withdrawal
• Difficulty concentrating
• Depression and numbness

Clinical Picture of Somatic Disorders

• Somatization- psychological and emotional distress shown through physical symptoms.
• Instead of depression/anxiety, individuals have headaches, chest pain, paralysis, skin rashes.
• These patients are more likely to be seen in primary care.

Somatic Symptom Disorder

• High stress due to several physical symptoms that have no medical explanation.
• Insistence that symptoms are due to physical illness, but all procedures are negative.
• Excessive response or concern over health.
• Patient symptoms are authentic.
• Psychological, biological, and social factors account for symptoms.Somatic symptom disorder is difficult to distinguish from conditions that have organic causes.

Illness Anxiety Disorder (Hypochondriasis)

• Extreme worry about having a disease with few to no symptoms.
• Normal sensations misinterpreted as serious illness.
• Excessive worry/fear.
• Thoughts of illness are hard to dismiss.
• Frequent medical appointments to seek reassurance.
• Avoidance of healthcare providers for fear of confirmation.

Conversion Disorder (Functional Neurological Symptom Disorder)

• Physical symptoms with no medical explanation.
• Psychological component that resolves an internal conflict.
• Neurological symptoms occur without neurological diagnosis.
• Deficits in voluntary motor or sensory functions.
• Symptoms channel emotional conflicts/stressors.
• Patients believe in the symptoms.
• La belle indifference, indifference to serious symptoms.

Factitious Disorder

• Consciously pretending to get emotional.
• Hard to control with very skillful fabrication.
• Self-harm to show symptoms and assume a sick role.

Factitious Disorder Imposed on Another

• Caregivers will falsify their loved one's illness.
• Diagnosis is given to perpetrator not victim.
• Desire to be noticed.
• Example of this is Dee Dee Blanchard, who fabricated her daughters illnesses.

Malingering

• Fabrication or exaggeration of symptoms for material gain.
• Done to become eligible for disability compensation, commit fraud, obtain medication, evade military service.

Biological Factors of Somatic Disorders

• Somatic disorders tend to run in families.
• Monozygotic twins display higher risk of conversion disorder.
• First-degree relatives are more likely to have depressive disorder or alcohol dependence.

Psychological Factors of Somatic Disorders

• Psychodynamic theories state that repression of conflict can lead to pain and loss of function.
• Seen in conversion disorder.
• Behavioral theories state that those with somatic symptoms use their condition to manipulate others.
• Seen in malingering and factitious.
• Cognitive theories state that the patient focuses on body sensations and become alarmed.
• Seen in illness anxiety disorder.

Environmental Factors of Somatic Disorders

• Childhood events can lead to lifelong issues.
• Exposure to childhood trauma can lead to later diagnoses.

Implementation of Somatic Disorders

• Patients often are not admitted to psychiatric setting, so treatment will have to be outpatient.
• Help the patient form a relationship.
• Teach the patient effective coping skills.
• If a patient is asking for medication, give it to them, the patient will see it as subjective.
• Consider safety in cases of factitious disorder.

Treatment Modalities for Somatic Disorders

• Individual psychotherapy.
• Cognitive behavioral therapy.
• Dialectical behavior therapy.
• Group psychotherapy.
• Psychoeducation.
• Psychopharmacology, SSRIs, mainly for illness anxiety.

Facts About Abuse

• 10% sexual abuse
• 16% physical abuse
• 76% neglect
• SAVE act states women who are married have to have two forms of identification to be able to vote.

Types of Abuse

• Physical- Uses physical pain or threat of force.
• Sexual- Uses any type of unwanted sexual contact.
• Neglect- To fail to provide for the basic needs.
• Economic- Controls access to economic resources.

Abuse

• Child abuse; Intimate partner violence or Older adult abuse.

Cycle of Battering: Occurrence of abuse

• Profile of the victim is largely women, of all races, ages, and cultures.
• They often have low self esteem.
• The abuser is largely men.
• Possessive.

Cycle of Violence

• Tension Building: Victim tries to use rationalization.
• Acute Battery - Largely violent.
• Honeymoon: Abuser promises this won't happen again.

Why Does the Victim Stay?

• The victim stays so they don't get harmed.
• Hoping the partner will change.
• The victim has a 75% greater risk of being killed once they leave the relationship.

The Assesment

• Perform a physical assessment.
• Use non-threatening language and be supportive.
• Give the patient the time to be able to tell their story without interruption.
• Use language that the patient will understand.
• Let the patient know if you have to report abuse to children or adults.

Abuse: Infants

• Any bruising before 6 months is suspected abuse.
• Use language that the patient will understand.
• Let the patient know if you have to report abuse to children or adults.

Abuse: Older adults

• Consider abuse if the explanation of injury doesn't match.
• Sexual abuse- observe when a child reenacts adult interactions.

Trauma-Informed Care: THE FOUR R's

• Realize that trauma is wide-spread.
• Recognize trauma while recognizing behaviors and emotion.
• Respond in a way that creates a safe environment.
• Resist re-traumatization.

Patient Centered Care:

• Be sure to show mandatory reporting and proper documentation.
• Provide basic care to treat injuries.
• Make referrals.
• Help the client develop a safety plan.

Prevention

• Primary, secondary, tertiary.

Sexual Violence

• Includes sexual coercion, penetration, and unwanted sexual experiences.

Sexual Assult

• When someone is forced against their will.

Rape

• Is the expression of power and dominance.

Acquaintance Rape

• In which the rapist is known to the victim

Martial Rape

• Held liable by the marriage partner's will.

Statutory Rape

• Person over the age of consent with a person under the age of consent.

Age of Consent

• Is the age of which an individual can consent.

Profile of the Victimizer

• Someone who seeks out vulnerable people and violates human rights.
• Use of drugs.

Facts

• Every 68 seconds, an American is being sexually assaulted.
• Younger people have a higher risk of sexual violence.
• One out of every 4 women.
• one out of every 26 men.

Rape Trauma Syndrome

• Form of PTSD.
• Identify in terms of: Expressed or Controlled.

Identify In Terms of; Days and Weeks after Attack:

• Expressed and Controlled.
• Compound rape reaction: Depression, suicide, and substance abuse issues.
• Silent rape reaction: Telling NO ONE.
• Evident in Days and Weeks after Attack: Confusion, headache, stomach aches, vaginal discharge, fear, and self-blame.
• Suppressed and repressed feelings.

Drugs Associated for Date Rape

• Euphoric in nature with confusion and sedation.
• The dye turns drinks blue if something bad has been added.
• Could be GHB, Rohypnol, or Ketamine.

Patient Centered Reaction

• The person has to be sexually assaulted.
• Has to have a safe place.
• The victim has no fault and do everything you can to maintain their privacy.
• Make sure they give account of the assault.

SANE ( The Sexual Assult Nurse Examiner)

• Preform a self-assessment.
• Every time they take a swab they need to be consented.
• Every Patient has the right to decline.
• Obtain informed consent to use any data as evidence.
• Evaluate for pregnancy risks.