trauma and stressor related disorders

SSRIs

• sertraline

• paroxetine

• fluoxetine

SNRIs

• venlafaxine

MAOIs

• phenelzine

trauma related disorders

• acute stress disorder

• post traumatic stress disorder (PTSD)

• attachment disorders 

  • reactive attachment disorder

  • disinhibited social engagement disorder

• adjustment disorder

trauma related disorders

depersonalization/derealization disorder

what are traumatic events

• military combat, prisoner of war exposure

• crime related

• natural disasters

• human disasters

• interpersonal trauma

  • physical, sexual, and/or emotional abuse

  • emotional and/or physical neglect

• sudden and traumatic loss in any stage of life

acute stress disorder (ASD)

• diagnosed 3 days to one month following traumatic event

  • does not last more than a month

• continually re-experiences event

• avoids situations that remind them of event

• has increased anxiety and excitation that negatively affects lifestyle

• if symptoms persist beyond one month, diagnosis is changed to PTSD

ASD intrusion symptoms

• recurrent, involuntary, intrusive and distressing memories, dreams or flashbacks related to event

• intense psychological or physiological distress when reminded of event

ASD avoidance symptoms

• avoiding distressing memories, thoughts, feelings, or external reminders associated with event

ASD symptoms

• sleep disturbance

• irritability or angry outbursts

• hypervigilance (hyperaware)

• exaggerated startle response

• persistent inability to experience positive emotions

• subjective sense of numbing or detachment, reduced awareness of surroundings, derealization, depersonalization, or dissociative amnesia

  • dissociative symptoms

post traumatic stress disorder (PTSD)

• can begin 1 month after exposure, but symptom delay of months or years is not uncommon

• persistent reexperiencing of traumatic event

• responses of intense fear, helplessness, or horror are felt

• diagnosis for PTSD requires specific types of trauma exposure

  • directly experiencing traumatic event

  • witnessing a traumatic event that happened to someone else

  • learning about traumatic event happening to close friend or family member

  • does not include exposure to electronic media

PTSD intrusive and avoidant symptoms

• recurrent, involuntary, intrusive and distressing memories, dreams, or flashbacks related to event

• intense psychological or physiological distress when reminded of event

• avoiding memories, thoughts, feelings, or external reminders associated with event

PTSD symptoms

• irritability or angry outbursts

• reckless or self-destructive behaviors

• hypervigilance

• exaggerated startle response

• difficulty concentrating

• sleep disturbance

• derealization

• depersonalization

• persistent inability to experience positive emotions

• negative thoughts and feelings leading to distorted beliefs about cause or consequence of events

• decreased interest or participation in activities

• feelings of detachment or estrangement from others

• memory; inability to remember important aspect of event

PTSD in preschool children

may manifest as reduction in play

• play that includes aspects of traumatic event, social withdrawal, and negative emotions (fear, guilt, anger, horror, sadness, shame, or confusion)

• may blame themselves for traumatic event

other symptoms of PTSD in children and adolescents

• reliving event repeatedly in thought or play

• becoming very upset when something causes memories of event

• becoming very upset when something causes memories of event

• hypervigilance or constantly looking for possible threats, being easily startled

• denying event happened or feeling numb

• lack of positive emotions

• acting helpless, hopeless, or withdrawn

• nightmares and sleep problems

• irritability, aggressive or self destructive behaviors

• problems concentrating

• feelings of detachment or estrangement from others including avoiding places or people associated with event

• diminished interest or participation in significant activities

• somatic symptoms (headaches, stomach aches, or pain; memory problems)

PTSD risk factors

• being exposed to previous traumatic events, particularly during childhood

• getting hurt or seeing people hurt or killed

• feeling horror, helplessness, or extreme fear

• having little or no social support after event

• dealing with extra stress after event (loss of loved one, pain and injury, loss of job, etc)

• having personal or family history of substance use or mental illness

PTSD comorbidity

most common

• MDD

• anxiety disorder

• sleep disorders

• dissociative disorders

• substance use disorders

recognize and analyze cues

• no test to diagnose ASD or PTSD

• assessments to gauge severity

• onset, frequency, severity, level of distress and degree of function impairment

• suicidal or violent ideations

• mental status exam

• social withdrawal

• family and social supports

• current life stressors

• past medical and psychiatric history and current meds

prioritize hypotheses

• risk for suicide or self harm

• anxiety

• fear

• ineffective or impaired coping

• disturbed sleep pattern

• social isolation

• self care deficits

potential outcomes

• not harm self

• verbalize SIs

• implement two strategies to reduce anxiety

• demonstrated reduced anxiety as evidenced by HR and BP within normal limits

• identify maladaptive coping behaviors

• acknowledge traumatic events and demonstrate interventions to cope effectively

• participate in self care activities 

interventions

• establish a therapeutic relationship

• assess for SI

• assess environment for safety and provide calm and safe environment

• assess current coping strategies and effectiveness

• encourage participation in plan of care

• health and teaching

  • ASD/PTSD and trauma symptoms

  • coping strategies

  • relaxation techniques

  • sleep hygiene

• encourage connections to family, friends, and participation in peer support groups or programs

treatment for ASD

• psychotherapy

  • CBT (trauma focused)

• EMDR

• minimal evidence for pharmacotherapy

pharmacotherapy for ASD

• SSRI (sertraline, paroxetine, fluoxetine)

• SNRI (venlafaxine)

• MAOI (phenelzine)

PTSD treatments for children and adolescents

• traumatized child may experience delayed development if care is not available

• treatment will depend on childs age, symptoms, and general health and how severe condition is 

• CBT (first line)

• EMDR (first line)

• play therapy

• no FDA approved pharmacotherapy

eye movement desensitization and reprocessing therapy (EMDR)

• evidence based treatment for children and adults

• recommend as first line treatment for children

• helps people process traumatic memories

  • think about traumatic event while focusing on other stimulation

• EMDR may work through neurological and physiological changes that help process and integrate traumatic memories

evaluate outcomes

• can recognize symptoms as related to trauma

• is able to use newly learned strategies to manage anxiety

• experiences no flashbacks or intrusive thoughts about traumatic event

• is able to sleep adequately without nightmares

• can assume usual roles and maintains satisfying interpersonal relationships

trauma informed care

• treatment framework that involves recognizing and responding to effects of all types of trauma, recognizing signs and symptoms of trauma and actively avoiding retraumatization

• healthcare organizations and care teams need to have complete picture of patients life situation (past and present) to provide effective health care services with healing orientation

inpatient management of PTSD

• use of trauma informed care conceptual model

• provider recognition of patients who may have PTSD

• collaboration

• individualizing care

inpatient issues that may affect PTSD

• sleep hygiene

• pain

• anxiety and anger

depersonalization/derealization disorder

• results in persistent or recurrent episodes of depersonalization, derealization, or both

• episodes of depersonalization-derealization disorder may last hours, days, weeks, or months

• impacts relationships, work and daily activities

depersonalization

extremely uncomfortable feleing of being an observer of ones own body or mental processes

• feelings of unreality, detachment, or unfamiliarity with parts of self or whole self are features of disorder

• patient may feel detached from entire self, aspects of herself/himself

derealization

focus is on outside world; recurring feeling that ones surroundings are unreal or distant

• may feel like walking in fog, bubble, or dream; may feel like invisible veil between them and rest of world

• visual distortions are manifested in blurriness, changes in visual field and altered size of objects

• auditory distortions (muting or heightening of sound)

why depersonalization/derealization disorder

• cause is not well understood

• some more likely than others to experience sue to genetic and environmental factors; levels of stress and fear may lead to episodes

• occurs with MDD, anxiety disorders, and personality disorders

risk factors for developing depersonalization/derealization disorder

• certain personality traits

• serious trauma in children or adult such as experiencing or witnessing a traumatic event such as violence or abuse

• severe stress

• depression and anxiety

• substance misuse

treatment of D/D disorder

• often short lived and go away on their own

• self hypnosis, CBT, and repetitive transcranial magnetic stimulation

• no medications proven to effectively treat disorder but may be used to treat comorbid disorders and symptoms

adjustment disorder

• emotional or behavioral reaction within 3 months of exposure to stressor

• distress affects ability to function

• reaction is out of proportion to stressor severity

• symptoms end by 6 months

• requires support, understanding and encouragement

  • active listening, therapeutic communication skills

  • assist in increasing coping skills

symptoms of adjustment disorder

• anxiety

• depression

• mixed

• regressive behaviors in children

• fearful or acting out behavior

attachment disorders for children

• reactive attachment disorder

• disinhibited social engagement disorder

reactive attachment disorder

child has difficulty forming healthy emotional attachments with caregivers sue to early childhood trauma or neglect

• other causes may be abuse, inconsistent caregiving, frequent changes in primary caregivers, or institutional care with limited emotional responsiveness

• typically develops in infancy or early childhood and is characterized by disturbed and developmentally inappropriate social relatedness

• can affect childs social, emotional, and cognitive development

behaviors associated with reactive attachment disorder

• unexplained withdrawal, fear, sadness, or irritability that is not readily explained

• sad and listless appearance

• not seeking comfort or showing no response when comfort given

• failure to smile

• watching others closely but not engaging in social interaction

• failing to ask for support or assistance

• failure to reach out when picked up

• no interest in playing peekaboo or other interactive games

disinhibited social engagement disorder

• demonstrate no normal fear of adult strangers or shyness when meeting people for first time

• seem unfazed in response to separation from primary caregiver

• tend to be overly friendly and are willing to go with someone they dont know

• younger children may allow unfamiliar people to pick them up, feed them, or play with them

• strongly linked to early childhood experiences of neglect or inconsistent caregiving such as growing up in foster care or institutional settings

RAD and DSED treatments

• child may have lifelong consequences without treatment

• physical assessment is essential to rule out physical causes of withdrawn or outgoing behavior

• treatment always involves both child and caregivers in individual and family therapy

• primary goal is to strengthen relationship between child and caregiver

• educate caregivers about condition

• create nurturing environment by ensuring child

  • experiences positive interactions with caregivers and staff

  • experiences attachment through five senses

  • has safe and stable living situation after discharge

    • be nurturing, responsive and caring

    • provide consistent caregivers

    • provide positive, stimulating interactive environment

    • addressing childs medical, safety, and housing needs

    • increase touch, talk and socialization