Trauma and Stressor Related Disorders PDF

**Chapter 19: Trauma and Stressor Related Disorders** **History** - Historical names: Shell Shock, Battle Fatigue, Accident Neurosis, Post-traumatic Neurosis - DSM-3 (1980): Post-traumatic stress disorder (PTSD) 1st appearance - Dx criteria outline based on new research into psychi...

**Chapter 19: Trauma and Stressor Related Disorders** **History** - Historical names: Shell Shock, Battle Fatigue, Accident Neurosis, Post-traumatic Neurosis - DSM-3 (1980): Post-traumatic stress disorder (PTSD) 1st appearance - Dx criteria outline based on new research into psychiatric problems experience by vietnam veterans & increasing natural disasters - Research and literature: renewed interest in 1970's in response to problems encountered by Vietnam veterans **Epidemiology** - More than 50% of women & 60% men will experience a traumatic event in their lifetime - Less than 10% will develop PTSD - Traumatic event: one that is "outside the range of usual human experience" - PTSD is more common in women - Women: SA & childhood sexual abuse - Men: accidents, physical assaults, combat, witness death or injury - Adjustment Disorders - Difficulties with stress reactions to more "normal" events - Adjustment disorders can occur at any age - Up to 50% of people with specific medical problems or stressors have an adjustment disorder - More common in women, unmarried people, younger people **Theories for Predisposing Factors** - Psychosocial theory: Why do some develop PTSD and others don't? - Variables include elements of the traumatic experience; The recovery environment; Individual psychological characteristics of the person experiencing it - Learning theory - Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. - Avoidance behaviors \[ex. Using substances\] and psychic numbing - Cognitive theory - Cognitive appraisal of an event and assumptions the individual makes about the world - Benevolent & a source of joy; Meaningful & controllable; self is worth - A person is vulnerable to PTSD when A sense of helplessness and hopelessness prevail and - Fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended - Biological aspects: - Opioids peptide response: - Increased production during arousal that result in increased feelings of comfort and control - Stressor termination results in opioid withdrawal. These s/s bear a strong resemblance to PTSD - Dysregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways **KNOW Trauma-informed care \[TIC\]** - A philosophical approach that values awareness and understanding of trauma when assessing, planning, and implementing care. - A strength-based framework: - Grounded in understanding of, and responsiveness to, the impact of trauma - Emphasizes physical, psychological, and emotional safety for both providers and survivors - Goal to rebuild a sense of control and empowerment. - **4 principles of TIC, pg. 510**: - **Realizes** widespread impact of trauma & various paths for recovery - **Recognizes** the s/s of trauma in clients, families, staff, and all those involved with the system - **Responds** by fully integrating knowledge about trauma in policies, procedures, & practices - Seeks to actively **resist** retraumatization - Intervention highlight importance of **respect for client, collaboration & connection, provides info about links b/t trauma & other health concerns, instills hope, & empowers the trauma survivor** to guide & direct the recovery plan **All DSM-5 trauma and stress related disorders:** - **Attachment**: reactive attachment and disinhibited social engagement disorder - These are identified as childhood disorders associated with absence of adequate caregiving during childhood - **Trauma**: PTSD and acute stress disorder - Difference b/t the 2 is the timing - **Adjustment**: adjustment disorder (more common in women than men) - Examples of situations that result in adjustment disorder: giving birth to a stillborn child, being a victim of bullying or harassment, or being incarcerated (book) - Other: other specified trauma and stressor-related disorders and unspecified trauma and stress-related disorder **KNOW Post-traumatic stress disorder (PTSD)** - **KNOW** Defined as a reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone - Triggered by natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes. - **KNOW PTSD Symptoms** - Must be present for **at least 1 month & cause significant impairment** in social, occupational, and other areas of functioning. - **Symptoms clusters, box 19-1:** - Characteristic symptoms include reexperiencing the traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness - Exposure to actual or threatened death, serious injury, or sexual violence - **Intrusive Symptoms:** recurrent distressing dreams, flashbacks, distressing memories of the traumatic events - **Avoidance Symptoms:** avoidance of or efforts to avoid distressing memories - **Negative Cognitions:** inability to remember a specific aspect of the traumatic event due to dissociative amnesia and NOT other factors like ETOH, drugs; persistent negative beliefs oneself, others, and the world - **Arousal & Reactivity:** irritable behaviors, angry outburst, hypervigilance, problems with concentration, and sleep disturbances - **Specify with or without dissociative symptoms** - **Some symptoms manifest differently in children below 6 years old** - **Associated Features**: Depression, Survivor's guilt, Substance abuse, Anger and aggression, Difficulty maintaining stable relationships, Auditory pseudohallucinations \[illusions\], Paranoia, Difficulties regulating emotions, Dissociative symptoms - **KNOW** **Interventions: PTSD** - Short-term - **Priority to assess for self-destructive bx** - Assign the same staff when possible. Use non-threatening approach - Respecting a patient's wishes is interacting with specific genders. Be consistent - Long-term - Stay with patient during incidents of flashbacks, nightmares, and significant triggering events - Obtain accurate history from significant others about the trauma and the patient's response - Encourage talking about trauma. Coping skills development. Assist in comprehension of trauma **KNOW Acute Stress Disorder, box 19-2** - Etiology similar to PTSD regarding exposure to traumatic event - Symptoms similar to PTSD but are time limited - **Lasts 3 days to 1 month after the event** - **Criteria 1**: exposed to actual or threatened death, serious injury, or sexual violation - Exposure is direct, witnessing, learning the event that occurred to a close family member to friend, or repeated exposure to traumatic events - **Criteria 2:** presence of 9 or more of the following symptoms: intrusion symptoms, negative mood, dissociative s/s, avoidant s/s, arousal s/s **KNOW Adjustment disorder \[AD\]** - **KNOW** Characterized by maladaptive rxn to an identifiable stressor/s that result in the development of clinically significant emotional or behavioral symptoms - Symptoms occur **w/in 3 months of the stressor & lasts no longer than 6 months after the stressor has ended** - **Clinical symptoms associated with adjustment disorders include inability to function socially or occupationally in response to an identifiable stressor.** - **Prolonged grief disorder:** is diagnosed when the stressor is specifically the death of a person who was close to the bereaved individual and clinically significant distress endures beyond a year of associated death - **KNOW Types of adjustment disorders**: - **Adjustment disorder with Depressed Mood:** most common; depressed mood, tearfulness, and feelings of hopelessness, the depressed mood exceeds what is an expected or normative response - **Adjustment disorder with Anxiety:** This category denotes a maladaptive response to a stressor in which the predominant manifestation is anxiety. - For example, the symptoms may reveal nervousness, worry, and jitteriness. The clinician must differentiate this diagnosis from those of anxiety disorders. - **Adjustment disorder with Mixed anxiety and Depressed mood:** The predominant features of this category include disturbances in mood (depression, feelings of hopelessness and sadness) and manifestations of anxiety (nervousness, worry, jitteriness) that are more intense than what would be expected or considered to be a normative response to an identified stressor. - **Adjustment disorder with Disturbance of Conduct:** This category is characterized by conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. - Examples include truancy \[staying away from school\], vandalism, reckless driving, fighting, and defaulting on legal responsibilities. Differential diagnosis must be made from conduct disorder or antisocial personality disorder. - **Adjustment disorder with Mixed disturbance of Emotions and Conduct:** The predominant features of this category include emotional disturbances (e.g., anxiety or depression) as well as disturbances of conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules (e.g., truancy, vandalism, fighting). - **Adjustment disorder Unspecified:** This subtype is used when the maladaptive reaction is not consistent with any of the other categories. The individual may have physical complaints, withdraw from relationships, or exhibit impaired work or academic performance but without significant disturbance in emotions or conduct. - Predisposing factors - Biological aspects - Genetics factors influence risk for maladaptive stress response - Vulnerability related to chronic disorders such as neurocognitive or intellectual developmental disorders can impair ability to adapt to stressful event - Psychosocial theories - Adjustment disorders are precipitated by specific meaningful stressor and a point of vulnerability - Childhood trauma, increased dependency, arrested ego development - Constitutional factor (birth characteristics);Developmental stage and timing of the stressor - Available support systems; Dysfunctional grieving process - **Theory: Transactional model of stress/adaptation** - Takes into consideration the interaction between individual and environment - Type of stressor: sudden shock vs continuous - Situational factors: personal/general economics; occupational and recreational opportunities; and the availability of social supports - Intrapersonal factors: social skills, coping strategies, presence of psychiatric illness, degree of flexibility, and level of intelligence Nursing diagnosis for trauma-related disorders may include - **Risk-prone health behavior** related to change in health status requiring modification in lifestyle (e.g., chronic illness, physical disability), as evidenced by inability to problem solve or set realistic goals for the future (appropriate diagnosis for the person with an adjustment disorder if the precipitating stressor was a change in health status) - **Anxiety** (moderate to severe) related to situational and/or maturational crisis as evidenced by restlessness, increased helplessness, and diminished productivity - Post-trauma syndrome related to distressing event considered to be outside the range of usual human experience - Complicated grieving related to loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event **Trauma-related disorders: Goals**, pg. 515, table 19-1 **Nursing dx: Post-trauma syndrome:** - **Short-Term Goals:** Patients will begin a healthy grief resolution, initiating the process of psychological healing (within a time frame specific to individual). Patients will demonstrate the ability to deal with emotional reactions in an individually appropriate manner. - **Long-Term Goal:** Patients will integrate the traumatic experience into their persona, renew significant relationships, and establish meaningful goals for the future. **Nursing dx: Maladaptive grief:** - **Short-Term Goal:** Patient will verbalize feelings (guilt, anger, self-blame, hopelessness) associated with the trauma - **Long-Term Goal**: Patient will demonstrate progress in dealing with stages of grief and will verbalize a sense of optimism and hope for the future Outcome criteria - The patient will: - Acknowledge trauma\'s impact on life. Fewer flashbacks, recollections, nightmares. - Show adaptive coping (e.g., relaxation, imagery, art). Set realistic future goals. - Involve and accept support from loved ones.No self-harm ideas or intent. - Address survivor\'s guilt.Ensure sufficient sleep for safety. - Know community resources for stress help. Attend support groups for similar trauma recovery. - Express desire to move past trauma and move forward. Planning and Implementation - Nursing care of the client with a trauma-related disorder is aimed at: - Reassurance of safety; Decrease in maladaptive symptoms - Demonstration of more adaptive coping strategies; Adaptive progression through the grieving process - Post-trauma syndrome VS Complicated grieving **KNOW** **Interventions: Complicated/Maladaptive Grieving for trauma-related disorders** - **Short-term:** - Acknowledge feelings of guilt or shame. Assess stages of grief & discuss normalcy - **Long-term** - Assess impact of trauma on ADLs, for self-destructive ideas & behavior and maladaptive coping - Identify community resources available - **Table 27-3: Nursing interventions** - Assess pt's current grief process; develop trust \[show empathy, concern & unconditional positive regard\] - Help pt actualize loss \["ask when did it happen?" "How did it happen?"\] - Help pt ID & express feelings \[anger, guilt, anxiety & helplessness\] - Provide adequate time to grieve; ID pathological defenses for coping \[drugs, alcohol, isolation\] **Evaluation** - Discuss traumatic events without panic anxiety? Voluntarily discuss traumatic events? - Address life changes due to the event? Experience flashbacks or nightmares? - Sleep without medication? Learn new coping strategies for recovery? - Demonstrate use of coping strategies during stress? Verbalize grief stages and associated behaviors? - Recognize your own position in the grieving process? Alleviate guilt? - Maintain/regain satisfactory relationships? Have a plan for symptom recurrence? - Look to the future with optimism? Attend a support group for similar trauma victims? **KNOW Trauma-related disorders: Treatment Modalities \[KNOW when to use each of them\]** - **KNOW Cognitive therapy** - Recognize & modify trauma-related thoughts & beliefs. The individual learns to modify the relationships b/t thoughts & feelings, and to ID & challenge inaccurate or extreme automatic negative thoughts - **Goal**: replace negative thoughts w/ more accurate & less distressing thoughts and to cope more effectively w/ feelings such as anger, guilt, & fear - **Stress inoculation therapy (SIT)** is a type of cognitive behavior therapy (CBT) that focuses on learning new ways of coping with stressful events through education and practicing alternative responses like meditation, deep breathing, and other relaxation exercises - **KNOW Prolonged exposure therapy** - Behavioral therapy somewhat similar to implosion therapy or flooding. Can be conducted in imagined or real \[in vivo\] situation - Involves systematic confrontation outside of therapy & w/in safe limits to trauma-related stimuli that are feared & avoided - 4 main parts: Education about tx, breath retraining for relaxation, imagine exposure through repeated discussion about trauma w/ therapist, & exposure to real-world situations related to trauma - **KNOW Group/family therapy** - Strongly advocated for clients with PTSD. it has proved especially effective with military veterans - Somes PTSD groups are informal & leaderless \[self-help groups or support groups\] & some are led by group therapists - **KNOW Eye movement desensitization and reprocessing (EMDR)** - Some studies have indicated that eye movements cause a decrease in imagery vividness and distress as well as an increase in memory access.The process involves rapid eye movements while processing painful emotions. - **The process allows the brain to resolve unprocessed traumatic memories and "resume its natural healing process".** - Efficacy not fully understood & requires an assessment for neurological impairments - Proven effectiveness for clients w/ PTSD & other trauma-related disorders \[depression, adjustment disorder, phobias, addictions, GAD, & panic disorder\] - **Contraindications**: seizure disorder, severe dissociative disorder, or unstable substance abuse/psychosis - Psychopharmacology - SSRI are first line (paroxetine and sertraline); SNRI (fluoxetine and venlafaxine), TCA, MAOI, anxiolytics, ketamine - Trazodone \[serotonin receptor antagonist and reuptake inhibitor, SARI\], benzodiazepine (alprazolam), buspirone, beta-blockers (propranolol), alpha 2 agonists (clonidine), alpha 1 antagonists (prazosin) Outcomes Criteria - Verbalizes acceptable grieving behaviors. Demonstrates a reinvestment in the environment - Accomplishes activities of daily living independently. Demonstrates ability to function adequately - Accepts change in health status. Sets realistic goals for the future - Demonstrates ability to cope effectively with change in lifestyle Planning and implementation - Nursing intervention for the client with an adjustment disorder is aimed at: - Adaptive progression through the grief process. Helping the client achieve acceptance of a change in health status. Assisting with strategies to maintain anxiety at a manageable level Adjustment Disorders: Goals - Complicated grieving: "a disorder that occurs after the death of a significant other (or any other loss of significance to the individual), in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment." - Risk-prone health behavior: "impaired ability to modify lifestyle/behaviors in a manner that improves health status." Evaluation - Client\'s understanding of the grief process and their position. Recognition of adaptive/maladaptive grief behaviors - Progression in grief response. Independent accomplishment of daily activities - Adequate performance in occupational and social activities. Discussion of health status and lifestyle modification - Acceptance of lifestyle modification. Participation in decision making and problem solving - Setting realistic future goals. Adoption of new coping strategies. Awareness of available support resources **Adjustment Disorders: Treatment Modalities** - Individual psychotherapy, Family therapy, Behavior therapy, Self-help groups, Crisis intervention, Psychopharmacology