1. Copyright © 2014. F.A. Davis Company Trauma- and Stressor-Related Disorders Chapter 28 Chapter 28

2. Copyright © 2014. F.A. Davis Company Historical and Epidemiological Data Posttrauma response was historically known as shell shock, battle fatigue, accident neurosis, or posttraumatic neurosis. Renewed interest in the disorder began in the 1970s in response to problems encountered by Vietnam veterans. Diagnosis of Posttraumatic Stress Disorder (PTSD) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders: DSM-III, 1980).

3. Copyright © 2014. F.A. Davis Company More than half of all individuals will experience a traumatic event in their lifetimes, but less than 10 percent will develop PTSD. The traumatic event is described as one that is outside the range of usual human experience. PTSD is more common in women than in men. Historical and Epidemiological Data (cont.)

4. Copyright © 2014. F.A. Davis Company Individuals who have difficulties with stress reactions to more normal events may be diagnosed with Adjustment Disorder. Adjustment disorders are quite common, and can occur at any age. Historical and Epidemiological Data (cont.)

5. Copyright © 2014. F.A. Davis Company Posttraumatic Stress Disorder – 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. Application of the Nursing Process: Trauma-Related Disorders

6. Copyright © 2014. F.A. Davis Company Posttraumatic Stress Disorder (cont.) Characteristic symptoms include: – Reexperiencing the traumatic event – A sustained high level of anxiety or arousal – A general numbing of responsiveness – Intrusive recollections or nightmares – Amnesia to certain aspects of the trauma – Depression, survivors guilt – Substance abuse – Anger and aggression – Relationship problems

7. Copyright © 2014. F.A. Davis Company Symptoms may begin within the first 3 months after the trauma, or there may be a delay of several months or even years. Posttraumatic Stress Disorder (cont.)

8. Copyright © 2014. F.A. Davis Company Acute Stress Disorder (ASD) Similar to PTSD in terms of precipitating traumatic events and symptomatology Symptoms are time limited—up to 1 month following the trauma If the symptoms last longer than 1 month, the diagnosis would be PTSD.

9. Copyright © 2014. F.A. Davis Company Predisposing Factors – Psychosocial theory Seeks to explain why some individuals exposed to massive trauma develop PTSD while others do not Variables include characteristics that relate to: – The traumatic experience – The individual – The recovery environment Trauma-Related Disorders (cont.)

10. Copyright © 2014. F.A. Davis Company Predisposing Factors (cont.) 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

11. Copyright © 2014. F.A. Davis Company Cognitive Theory – A person is vulnerable to PTSD when fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail. Predisposing Factors (cont.)

12. Copyright © 2014. F.A. Davis Company Biological Aspects – It is suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal and which result in increased feelings of comfort and control. – When the stressor terminates, the individual may experience opioid withdrawal, the symptoms of which bear strong resemblance to those of PTSD. Predisposing Factors (cont.)

13. Copyright © 2014. F.A. Davis Company Biological Aspects (cont.) – Dysregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may also be involved in the pathophysiology of PTSD. Predisposing Factors (cont.)

14. Copyright © 2014. F.A. Davis Company Nursing diagnoses for Trauma-Related Disorders may include: – Posttrauma syndrome – Complicated grieving Nursing Diagnosis/Outcome Identification

15. Copyright © 2014. F.A. Davis Company Outcome Criteria The Client: – Can acknowledge the trauma and the impact on his or her life – Can demonstrate adaptive coping strategies – Has made realistic goals for the future – Has worked through feelings of survivor’s guilt – Attends support group of individuals recovering from similar traumatic experiences – Verbalizes desire to put trauma in the past and progress with his or her life

16. Copyright © 2014. F.A. Davis Company 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 Planning/Implementation

17. Copyright © 2014. F.A. Davis CompanyEvaluation Evaluation of care for the client with a trauma- related disorder is based on successful achievement of the previously established outcome criteria. – Can the client discuss the traumatic event without experiencing panic anxiety? – Has the client learned new, adaptive coping strategies for assistance with recovery?

18. Copyright © 2014. 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. Exception: The “Related to Bereavement” subtype

19. Copyright © 2014. F.A. Davis Company Types of Adjustment Disorders – With Depressed Mood – With Anxiety – With Mixed Anxiety and Depressed Mood – With Disturbance of Conduct – With Mixed Disturbance of Emotions and Conduct – Related to Bereavement – Unspecified Adjustment Disorders (cont.)

20. Copyright © 2014. F.A. Davis Company Predisposing Factors – Biological theories Genetics Vulnerability related to neurocognitive or intellectual developmental disorders Adjustment Disorders (cont.)

21. Copyright © 2014. F.A. Davis Company Predisposing Factors (cont.) – Psychosocial theories Childhood trauma, dependency, arrested development Constitutional factor (birth characteristics) Developmental stage and timing of the stressor Available support systems Dysfunctional grieving process Adjustment Disorders (cont.)

22. Copyright © 2014. F.A. Davis Company Predisposing Factors (cont.) – Transactional model of stress/adaptation Interaction between individual and environment Type of stressor Situational factors Intrapersonal factors Adjustment Disorders (cont.)

23. Copyright © 2014. F.A. Davis Company Nursing Diagnosis – Complicated grieving – Risk-prone health behavior – Anxiety Adjustment Disorders (cont.)

24. Copyright © 2014. F.A. Davis Company Outcome Criteria – The Client: Verbalizes acceptable grieving behaviors Demonstrates a reinvestment in the environment Accomplishes ADLs 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 Adjustment Disorders (cont.)

25. Copyright © 2014. F.A. Davis Company Planning/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 (cont.)

26. Copyright © 2014. F.A. Davis Company Evaluation – Evaluation is based on accomplishment of previously established outcome criteria. Does client demonstrate progression in the grief process? Does client discuss the change in health status and modification of lifestyle it will affect? Does client set realistic goals for the future? Adjustment Disorders (cont.)

27. Copyright © 2014. F.A. Davis Company Treatment Modalities Trauma-Related Disorders – Cognitive therapy – Prolonged exposure therapy – Group/family therapy – Eye movement desensitization and reprocessing – Psychopharmacology

28. Copyright © 2014. F.A. Davis Company Adjustment Disorders – Individual psychotherapy – Family therapy – Behavior therapy – Self-help groups – Crisis intervention – Psychopharmacology Treatment Modalities (cont.)

29. Copyright © 2014. 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.

30. Copyright © 2014. F.A. Davis Company 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. Nursing Process (cont.)

31. Copyright © 2014. F.A. Davis Company Treatment Modalities 1.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

32. Copyright © 2014. F.A. Davis Company 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. Treatment Modalities (cont.)