1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Trauma and Stressor-Related Disorders

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Traumatic Events or Stressors Occur to Many People Characteristics include: –Experiences that are extraordinary in intensity or severity –These stressors are well beyond the stress of daily life.

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Examples of Trauma or Stress Individual trauma/stressors: –Abuse –Illness –Victim of crime (robbery, etc.) Group trauma/stress: –War –Natural disaster –Community loss (death of prominent citizen)

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of Stress/Trauma Poor coping Difficulty managing stress Emotional difficulties Difficulty resuming activities of daily life Other symptoms: –Anxiety –Insomnia –Grief

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychiatric Problems Related to Trauma/Stress Adjustment disorder Depression Complicated grieving Acute stress disorder Posttraumatic stress disorder (PTSD) Dissociative disorder

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma/Stress-Induced Disturbed Patterns of Behavior Intense memories of the trauma Dreams/nightmares Flashbacks Intense, recurrent, intrusive thoughts Emotional numbing Increased irritability Hyperarousal

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Three Major Elements of PTSD Experiencing the trauma leads to: –1. Dreams or intrusive, recurrent thoughts of the trauma –2. Emotional numbing (feeling detached from others) –3. Hyperarousal (being on guard, irritable) (Review Box 13.2: PTSD Checklist)

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Stress Disorder Versus PTSD Acute stress disorder = event occurred <3 months PTSD = event occurred >3 months PTSD is chronic in nature with periods of exacerbation during increased stress. PTSD can lead to other psychiatric disorders such as depression/anxiety/substance abuse.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins PTSD Occurrence 25% of survivors of physical assault → PTSD 70% of survivors of rape → PTSD PTSD can occur in children and in adults and older adults.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Predictors of PTSD (Risk Factors) Directly involved in the traumatic event Experiences of physical injury Loss of loved one(s) Lack of social supports Pervious psychiatric history or personality factors

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins PTSD Considerations for the Adolescent Adolescents are more likely to develop PTSD than children or adults. There is an increased incidence related to: –Age –Gender –Type of trauma –Repeated trauma

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Adolescents Suffering from PTSD Have Increased Risk for: Suicide Substance abuse Poor social supports Academic problems Health concerns

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Persons who witness a traumatic event are likely to develop posttraumatic stress disorder (PTSD).

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Not all people, nor even most people, who witness a traumatic event will develop posttraumatic stress disorder (PTSD). Those most likely to develop PTSD are those who were directly involved in the event, not just merely witness to the event; those who experienced physical injury or loss of a loved one; those with a lack of social supports; or previous psychiatric history/repeated trauma.

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins PTSD Treatment Options Psychotherapy (individual or group) Medications (antidepressants, anxiolytics, sleep aids) Self-help groups Exposure therapy Relaxation techniques Adaptive disclosure Cognitive processing therapy

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dissociation A subconscious defense mechanism used to prevent recognition of a horrific or traumatic event. The major characteristic of all dissociative phenomena involves a detachment from reality—rather than a loss of reality as in psychosis. This allows the person to forget or remove himself or herself from the painful situation or memory of the situation.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dissociative Disorder Characterized by: –Disruption in integration of consciousness, memory, identity, and environmental perception. –People with dissociative disorders use dissociation, a defense mechanism, pathologically and involuntarily.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dissociative Disorder (cont.) Dissociative disorder leads to disturbance in: –Relationships –Ability to function (activities of daily living) –Ability to cope  People with PTSD often experience dissociative symptoms.

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Dissociative Disorders Three main types of dissociative disorders: –1. Dissociative amnesia –2. Dissociative identity disorder (formerly multiple personality disorder) –3. Depersonalization/derealization disorder

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dissociative Disorder Treatment Options Individual therapy Group therapy –Focus in therapy is on reassociation Medications (antidepressants, anxiolytics)

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dissociative Disorder Treatment Options (cont.) Goals of treatment: –1. Improve quality of life –2. Improve functional abilities –3. Decrease symptoms

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which person is most likely to experience a dissociative disorder? –A. A survivor of a car accident –B. A survivor of childhood sexual abuse –C. A survivor of a natural disaster –D. A patient with a sudden, severe illness

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. A survivor of childhood sexual abuse Rationale: Dissociative disorders are most prevalent among those persons with a history of childhood physical and/or sexual abuse. Dissociative disorders are relatively rare in the general population.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Assessment Focused assessment of: –History of trauma/stress or abuse –When trauma/stress/abuse occurred –Observation of the patient’s appearance and motor behavior, specifically: hyperalertness, anxiety, restlessness, increased personal space, or fetal positioning

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Assessment (cont.) Mood and affect –Can range from passive to angry, frightened, agitated, hostile Thought process/content –Experience nightmares, flashbacks, intrusive thoughts, hallucinations, self-destructive thoughts, fantasies

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Assessment (cont.) Sensorium and intellectual processes –Memory gaps –Poor decision making Roles and relationships –Problems with: relationships, work, social, or authority

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Assessment (cont.) Physiologic concerns –Disturbed sleep –Change in appetite –Alcohol and drug use

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Nursing Diagnoses Risk for suicide/self-mutilation Ineffective coping Posttrauma syndrome Powerlessness Chronic low self-esteem Risk for self– or other-directed violence

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Nursing Diagnoses (cont.) Other related diagnoses: –Anxiety –Fear –Disturbed sensory perception –Sleep deprivation/disturbed sleep pattern –Sexual dysfunction –Spiritual distress –Social isolation

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Trauma and Stressor-Related Outcomes and Interventions Focus is to improve self-esteem and promote empowerment: –Refer to patient as “survivor” rather than “victim” –Identification of flashback triggers –Encourage journaling of feelings –Utilize distractions and relaxation techniques

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? It may require years for patients of trauma to achieve their outcomes.

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Patients with trauma or stress-related disorders make gradual progress in their treatment. The effects of trauma and abuse can be far reaching and can last a lifetime.

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Grounding Techniques Helpful with dissociation or flashback Remind the person that he/she is present, an adult, and safe. Increases contact with reality Diminishes the dissociative experience by focusing on current senses: –Can you see me and the room we are in? –Can you feel the watch on your wrist?

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Becoming comfortable asking patients about abuse, trauma, stress-related issues Listening to accounts of trauma from patients and families Recognizing patient’s strengths, not just problems Dealing with own feelings about traumatic events, abuse, natural disasters Maintaining confidentiality at all times