Trauma- and Stressor-Related Disorders PDF

Chapter 28 Trauma- and Stressor-Related Disorders Copyright ©2021 F.A. Davis Company  Historical and Epidemiological Data  Post-trauma response was known as shell s...

Chapter 28 Trauma- and Stressor-Related Disorders Copyright ©2021 F.A. Davis Company  Historical and Epidemiological Data  Post-trauma response was known as shell shock, battle fatigue, accident neurosis, or posttraumatic neurosis.  Very little was written about posttraumatic neurosis between 1950 and 1970.  From the 1970s to 1980s expansive research and writing was done primarily about Vietnam veterans.  Diagnosis of posttraumatic stress disorder (PTSD) first appeared in the DSM-III. Copyright ©2021 F.A. Davis Company  Historical and Epidemiological Data (continued_1)  DSM-IV-TR described trauma that precedes PTSD Event outside the range of usual human experience Rape, war, physical attack, torture, or natural/manmade disaster  More than half of all individuals will experience a traumatic event. Less than 10 percent will develop PTSD.  PTSD is more common in women than in men. Copyright ©2021 F.A. Davis Company  Historical and Epidemiological Data (continued_2)  Individuals who have difficulties with stress reactions to more “normal” events may be diagnosed with adjustment disorder.  Adjustment disorders are more common in women, unmarried persons, and adolescents. Can occur at any age, from childhood to senescence. Copyright ©2021 F.A. Davis Company  PTSD and ACD  Trauma Extremely distressing experience that causes severe emotional shock and may have long-lasting psychological effects  Posttraumatic stress disorder (PTSD) A reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or manmade disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes Copyright ©2021 F.A. Davis Company  PTSD and ACD (continued_1)  Characteristic symptoms Re-experiencing the traumatic event Sustained high level of anxiety or arousal General numbing of responsiveness Intrusive recollections or nightmares Amnesia to certain aspects of the trauma Depression Survivor’s guilt Substance abuse Anger and aggression Relationship problems Copyright ©2021 F.A. Davis Company  PTSD and ACD (continued_2)  PTSD symptoms May begin within the first 3 months after the trauma May be a delay of several months or even years Copyright ©2021 F.A. Davis Company  PTSD and ACD (continued_3)  Acute stress disorder (ASD) is similar to PTSD in terms of precipitating traumatic events and symptomatology.  Symptoms are time limited. Up to 1 month following the trauma If symptoms last longer than 1 month, the diagnosis is PTSD. Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders  Predisposing factors Psychosocial theory ‒ Seeks to explain why some individuals exposed to massive trauma develop PTSD while others do not ‒ Variables include characteristics. 1. The traumatic experience 2. The individual 3. The recovery environment Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders (continued_1)  Predisposing factors (continued) Learning theory ‒ Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. ‒ Avoidance behaviors ‒ Psychic numbing Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders (continued_2)  Predisposing factors (continued) Cognitive theory ‒ Models consider the cognitive appraisal of an event and focus on world assumptions an individual makes. ‒ Three fundamental beliefs people construct within a personal theory of reality. 1. The world is benevolent and a source of joy. 2. The world is meaningful and controllable. 3. The self is worthy. Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders (continued_3)  Predisposing factors (continued) Biological aspects ‒ Exposure to trauma associated with the hyperarousal of the sympathetic nervous system, excessive amygdala activity, and decreased hippocampus volume, all of which are neurobiological reactions to heightened stress ‒ Dysfunctions in the hypothalamic-pituitary-adrenal axis have been linked to psychiatric illnesses including PTSD, depression, Alzheimer’s disease, and substance. ‒ Studies have shown opioids administered shortly after exposure to a trauma reduced the incidence of PTSD. Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders (continued_4)  Predisposing factors (continued) Biological aspects (continued) ‒ Norepinephrine, dopamine, and benzodiazepine receptors are other neurotransmitters believed to be dysregulated in individuals with PTSD. ‒ It is likely a complex dynamic of biological, social, and psychological factors is involved. Copyright ©2021 F.A. Davis Company  Trauma-Related Disorders (continued_5)  Trauma-informed care Realizes the widespread impact of trauma and various paths for recovery Recognizes the signs and symptoms of trauma in clients, families, staff, and all those involved with the system Responds by fully integrating knowledge about trauma in policies, procedures, and practices Seeks to actively resist retraumatization Copyright ©2021 F.A. Davis Company  Nursing Diagnoses  Nursing diagnoses for trauma-related disorders Posttrauma syndrome Complicated grieving Copyright ©2021 F.A. Davis Company  Outcome Criteria  The patient Can acknowledge the traumatic event and the impact it has had on his or her life Is experiencing fewer flashbacks, intrusive recollections, and nightmares than he or she was on admission Can demonstrate adaptive coping strategies Can concentrate and has made realistic goals for the future Copyright ©2021 F.A. Davis Company  Outcome Criteria (continued_1)  The patient (continued) Includes significant others in the recovery process and willingly accepts their support Verbalizes no ideas or intent of self-harm Has worked through feelings of survivor’s guilt Gets enough sleep to avoid risk of injury Verbalizes community resources from which he or she may seek assistance in times of stress Copyright ©2021 F.A. Davis Company  Outcome Criteria (continued_2)  The patient (continued) Attends support group of individuals who have recovered or are recovering from similar traumatic experiences Verbalizes desire to put the trauma in the past and progress with his or her life Copyright ©2021 F.A. Davis Company  Planning/Implementation  Nursing care of the client with a trauma- related disorder Reassurance of safety Decrease in maladaptive symptoms Demonstration of more adaptive coping strategies Adaptive progression through the grieving process Copyright ©2021 F.A. Davis Company  Planning/Implementation (continued_1)  Post trauma Syndrome Defined as “a sustained maladaptive response to a traumatic, overwhelming event” Goals and interventions  Complicated Grieving Defined as “a disorder that occurs after death of a significant other in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment” Goals and interventions Copyright ©2021 F.A. Davis Company  Evaluation  Care for patient with a trauma-related disorder  Can the patient: Discuss the traumatic event without experiencing panic anxiety? Voluntarily discuss the traumatic event? Discuss changes that have occurred in his or her life because of the traumatic event? Verbalize that “flashbacks have decreased in intensity or frequency”? Copyright ©2021 F.A. Davis Company  Evaluation (continued_1)  Care for patient with trauma-related disorder (continued) Sleep without medication? Verbalize that nightmares have subsided? Identify new, adaptive coping strategies for assistance with recovery? Demonstrate successful use of new coping strategies in times of stress? Verbalize stages of grief and the normal behaviors associated with each? Copyright ©2021 F.A. Davis Company  Evaluation (continued_2)  Care for patient with trauma-related disorder (continued) Recognize own position in grieving process? Verbalize that feelings of guilt have decreased in intensity or subsided? Maintain satisfactory relationships with significant others? Look to the future with optimism? Verbalize intent to attend a regular support group? Identify a plan for dealing with symptoms? Copyright ©2021 F.A. Davis Company  Application of the Nursing Process: Stressor-Related Disorders  Adjustment disorders Characterized by a maladaptive reaction to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms Symptoms occur within 3 months of the stressor and last no longer than 6 months. Copyright ©2021 F.A. Davis Company  Adjustment Disorders  Types of adjustment disorders A number of clinical presentations are associated with adjustment disorders. A number of categories identified by the DSM-5 are distinguished by the predominant features of the maladaptive response. Copyright ©2021 F.A. Davis Company  Adjustment Disorders (continued_1)  Adjustment disorder with depressed mood This category is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depressive disorder (MDD). The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what is an expected or normative response to an identified stressor. Copyright ©2021 F.A. Davis Company  Adjustment Disorders (continued_2)  Adjustment disorder with mixed anxiety and depressed mood  Predominant features of this category include Disturbances in mood (depression, feelings of hopelessness and sadness) Manifestations of anxiety (nervousness, worry, jitteriness) more intense than would be expected to be a normative response to an identified stressor Copyright ©2021 F.A. Davis Company  Adjustment Disorders (continued_3)  Adjustment disorder with disturbance of conduct 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, vandalism, reckless driving, fighting, and defaulting on legal responsibilities. Differential diagnosis must be made from conduct disorder or antisocial personality disorder. Copyright ©2021 F.A. Davis Company  Adjustment Disorders (continued_4)  Adjustment disorder with mixed disturbance of emotions and conduct  Predominant features of this category include Emotional disturbances (e.g., anxiety or depression) 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) Copyright ©2021 F.A. Davis Company  Adjustment Disorders (continued_5)  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. Copyright ©2021 F.A. Davis Company  Predisposing Factors to Adjustment Disorders  Biological theories Genetics Vulnerability related to neurocognitive or intellectual developmental disorders Copyright ©2021 F.A. Davis Company  Predisposing Factors to Adjustment Disorders (continued_1)  Psychosocial theories Childhood trauma, dependency, arrested development Constitutional factor (birth characteristics) Developmental stage and timing of the stressor Available support systems Dysfunctional grieving process Copyright ©2021 F.A. Davis Company  Predisposing Factors to Adjustment Disorders (continued_2)  Transactional model of stress/adaptation Interaction between individual and environment Type of stressor Situational factors Intrapersonal factors Copyright ©2021 F.A. Davis Company  Nursing Diagnoses (continued)  Nursing diagnosis Complicated grieving Risk-prone health behavior Anxiety Copyright ©2021 F.A. Davis Company  Outcome Criteria (continued_3)  The patient Verbalizes acceptable grieving behaviors Demonstrates a reinvestment in the environment Accomplishes activities of daily living independently Demonstrates ability to function adequately Verbalizes awareness of change in health status and the effect it will have on lifestyle Copyright ©2021 F.A. Davis Company  Outcome Criteria (continued_4)  The patient (continued) Solves problems and sets realistic goals for the future Demonstrates ability to cope effectively with change in lifestyle Copyright ©2021 F.A. Davis Company  Planning/Implementation (continued_2)  Nursing intervention for the client with an adjustment disorder 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 Copyright ©2021 F.A. Davis Company  Planning/Implementation (continued_3)  Complicated grieving Defined as “a disorder that occurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment” Goals and interventions Copyright ©2021 F.A. Davis Company  Planning/Implementation (continued_4)  Risk-prone health behavior Defined as “impaired ability to modify lifestyle/behaviors in a manner that improves health status” Goals and interventions  Concept Care Mapping Copyright ©2021 F.A. Davis Company  Evaluation (continued_3)  Evaluation is based on accomplishment of previously established outcome criteria Verbalize understanding of the grief process and his or her position in the process Recognize adaptive and maladaptive behaviors associated with the grief response Demonstrate evidence of progression along the grief response Accomplish activities of daily living independently Copyright ©2021 F.A. Davis Company  Evaluation (continued_4)  Evaluation (continued) Demonstrate the ability to perform occupational and social activities adequately Discuss the change in health status and modification of lifestyle it will affect Demonstrate acceptance of the modification Participate in decision making and problem solving for their future Copyright ©2021 F.A. Davis Company  Evaluation (continued_5)  Evaluation (continued) Set realistic goals for the future? Demonstrate new adaptive coping strategies for dealing with the change in lifestyle? Identify available resources for support or assistance should it be necessary? Copyright ©2021 F.A. Davis Company  Treatment Modalities  Trauma-related disorders Cognitive therapy Prolonged exposure therapy Group/family therapy Eye movement desensitization and reprocessing Psychopharmacology Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_1)  Cognitive therapy For PTSD and ASD, cognitive therapy strives to help the individual recognize and modify trauma- related thoughts and beliefs. The individual learns to modify the relationships between thoughts and feelings, and to identify and challenge inaccurate or extreme automatic negative thoughts. Goal is to replace these negative thoughts with more accurate and less distressing thoughts, and cope more effectively with feelings such as anger, guilt, and fear. Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_2)  Prolonged exposure therapy (PE) PE is a behavioral therapy similar to implosion therapy or flooding. Conducted in an imagined or real (in vivo) situation PE has four main parts. 1. Education about the treatment 2. Breathing retraining for relaxation 3. Imagined exposure through repeated discussion about the trauma with a therapist 4. Exposure to real-world situations related to the trauma Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_3)  Group/family therapy Strongly advocated for clients with PTSD and has proved especially effective with military veterans Share their experiences with empathetic fellow veterans Talk about problems in social adaptation Discuss options for managing aggression toward others has been emphasized Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_4)  Eye movement desensitization and reprocessing (EMDR) Integrative psychotherapy approach with a theoretical model that emphasizes brain’s information processing system and memories of disturbing experiences as the basis of pathology Although some individuals report rapid results with this therapy, research has indicated that between 5 and 12 sessions are required to achieve lasting treatment effects. Treatment encompasses an eight-phase process. Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_5)  EMDR eight-phase process Phase 1: History and treatment planning Phase 2: Preparation Phase 3: Assessment Phase 4: Desensitization Phase 5: Installation Phase 6: Body scan Phase 7: Closure Phase 8: Reevaluation Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_6)  Psychopharmacology Antidepressants Anxiolytics Antihypertensives Other medications Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_7)  Adjustment disorders Individual psychotherapy Family therapy Behavior therapy Self-help groups Crisis intervention Psychopharmacology Copyright ©2021 F.A. Davis Company  Nursing Process 1. Two months ago, Ms. T was sexually assaulted while jogging in an isolated park. She is hospitalized for suicidal ideation at this time. She awakens in the middle of the night screaming about having nightmares of the incident. Which of the following is the most appropriate initial nursing intervention? A. Call the doctor to report the incident. B. Stay with Ms. T until the anxiety has subsided. C. Administer prn alprazolam. D. Allow her some privacy to work through the emotions. Copyright ©2021 F.A. Davis Company  Nursing Process (continued) Correct Answer: B  It is important to not leave a client who is experiencing flashbacks or nightmares alone.  Clients often feel they are “going crazy” when this happens, and the presence of a trusted individual calms fears and reassures the client of her safety. Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_8) 2. Which of the following medications is considered to be a first-line medication of choice in the treatment of PTSD? A. Alprazolam B. Propranolol C. Carbamazepine D. Paroxetine Copyright ©2021 F.A. Davis Company  Treatment Modalities (continued_9) Correct Answer: D  The SSRIs are now considered first-line treatment of choice for PTSD because of their efficacy, tolerability, and safety ratings.  Paroxetine and sertraline have been approved by the FDA for this purpose. Copyright ©2021 F.A. Davis Company