Ch 29: PTSD and Stress Related Disorders

Conceptualizing Trauma and Resilience

Physical Trauma: Includes accidents (falls, automobile crashes), self-inflicted damage often linked to mental disorders, and violence (intimate partner abuse, elder abuse, and sexual assault).

Psychological Trauma: Results from events such as harassment, childhood abuse, bullying, domestic violence, employment discrimination, police brutality, and exposure to war or natural disasters

Posttraumatic Stress Disorder (PTSD)

PTSD is diagnosed following exposure to death, serious injury, or sexual violence. Symptoms must persist for at least 30 days.

Timeline: Symptoms usually develop within days of the event, but "delayed-onset PTSD" may manifest up to six months later.

Progression: Approximately one-third of patients develop chronic symptoms that fluctuate in intensity, often worsening during periods of high stress

Core Symptom Clusters of PTSD: Intrusion

Involuntary memories, flashbacks, or terrifying nightmares

Core Symptom Clusters of PTSD: Avoidance

Evading people, places, or activities that serve as reminders of trauma

Core Symptom Clusters of PTSD: Negative Mood and Cognition

Irritability distorted beliefs (no one can be trusted), and difficulty experiencing joy

Core Symptom Clusters of PTSD: Hyperarousal

Permanent high alert status, hypervigilance and being easily startled

Complex PTSD

CPTSD is a subgroup of PTSD resulting from severe, chronic, and repetitive trauma (e.g., human trafficking, long-term domestic abuse, or extreme childhood neglect)

Key Differences: While PTSD focuses on threat and avoidance, CPTSD is understood as a betrayal of trust.

Additional Symptoms: Affective dysregulation, negative self-concept, and significant interpersonal issues

Lifespan Considerations: children (6 and under)

Trauma may be expressed through play. Children may experience intrusive memories and irritability without being able to explain the content of their distressing dreams

Lifespan Considerations: Adolescents

Automobile accidents represent a major trauma threat for this age group

Lifespan Considerations: Older Adults

 Longevity increases the chance of traumatic exposure. PTSD in this demographic may be triggered by new trauma or past events (e.g., Vietnam veterans experiencing symptoms later in life) and is often complicated by physical health issues like cardiovascular disease and chronic pain

Epidemiology and Risk Factors: Gender

Females have higher prevalence rates (9.7% vs. 3.6% in males) and higher psychological stress responses post-trauma. Heritability for PTSD is estimated at 35% for females

Epidemiology and Risk Factors: Veterans

High rates are observed in those deployed to Iraq and Afghanistan (15.7%). Risks are higher in female veterans (nearly 20%) and are linked to TBI and relationship difficulties

Epidemiology and Risk Factors: LGBTQ +

Face "minority stress" including discrimination, family rejection, and internalized self-stigma

Epidemiology and Risk Factors: Ethnicity and Culture

Underrepresented groups face higher PTSD rates due to discrimination, hate crimes, and racial violence. Latinx immigrants and African Americans are noted as having increased vulnerability

Biological Theories of PTSD: Complex Interaction

Genetics, environment (Childhood experiences, severity of traumatic exposure), neurobiology

Biological Theories of PTSD: Key Brain Structures

Amygdala, hippocampus, thalamus, sensory cortex: Stimuli elicit traumatic memories through interaction between cortex and amygdala

Neurochemical systems: Norepinephrine, dopamine, glutamate, corticotropin-releasing; Regulate fear conditioning

Biological Theories of PTSD: Mechanisms of Hyperarousal

Increased noradrenergic function → anxiety and alertness

Increased dopamine activity → sense of being threatened

Psychosocial Theories of PTSD: Behavioral Sensitization

Minor stressor → prior severe trauma → magnified stress response 

Psychosocial Theories of PTSD: Altered Connectivity

Traumatic exposure physically alters neurotransmitter connectivity in frontal areas

Results in intense fear, anxiety, panic, to minor stimuli

Psychosocial Theories of PTSD: Impact of Prior Trauma

Experience increased PTSD risk from future events

Ex: Veterans who experienced childhood abuse are more likely to develop PTSD after combat exposure compared to those w/o prior trauma

Common Co-morbidities

PTSD rarely exists in isolation. Nearly 60% of individuals with PTSD also have a substance use disorder. Other common comorbid conditions include:

Depression and anxiety

Suicidality

Medical illnesses like cardiovascular disease and autoimmune conditions

Therapeutic Interventions: Exposure Therapy

Helps patients face and control fear through mental imagery, writing, or visiting the trauma site

Therapeutic Interventions: Cognitive Restructuring

Reframes bad memories realistically and addresses feelings of guilt or shame

Therapeutic Interventions: Cognitive Processing Therapy

Focuses on how the trauma changed thoughts and beliefs, aiding those struggling with recovery.

Therapeutic Interventions: Stress Inoculation training

Teaches anxiety reduction techniques to help view memories in a healthy way

Therapeutic Interventions: Eye Movement Desensitization and Reprocessing (EDMR)

Involves reviewing disturbing memories under deep relaxation while focusing on lateral movement (e.g., the clinician's finger) for desensitization

Therapeutic Interventions: Virtual Reality Exposure

Uses virtual environments for the emotional processing of traumatic memories

SSRIs

Sertraline and Paroxetine are approved for treating PTSD

Meds for Sleep/Nightmares

Prazosin may be used off-label for nightmares, while Zolpidem helps with insomnia

Note for Meds

Benzodiazepines (like Lorazepam) may be used for acute anxiety but are generally not recommended for long-term PTSD treatment

Nursing Care and Management: Nursing Assessment

Trust Building: Patients may be reluctant to disclose trauma, especially if it involved a violation of trust (e.g., rape). Nurses must use a warm, empathic, nonjudgmental approach.

Symptom Identification: Recognize intrusive thoughts, insomnia, and hypervigilance.

Comorbidity Assessment: Nearly 60% of people with PTSD have a co-occurring substance use disorder. Assessing for suicide risk and aggression is crucial

Nursing Interventions and Goals

Safety: Implement suicide precautions and substance misuse measures if necessary.

Sleep Hygiene: Teach improved sleep hygiene and monitor patterns to reduce PTSD symptoms.

Resilience Support: Examine physical and psychosocial strengths; encourage positive social interactions, nutrition, and exercise.

Marital/Family Support: Develop plans for marital counseling post-discharge and address parenting stresses

Reactive Attachment Disorder (RAD)

Inhibited, emotionally withdrawn behavior in children who rarely seek comfort.

Disinhibited Social Engagement Disorder (DSED)

A child's pattern of being overly familiar with unfamiliar adults.

Acute Stress Disorder

Similar to PTSD but symptoms resolve within one month.

Adjustment Disorder

Distress out of proportion to a stressor, occurring within 3 months of the event

Dissociative Disorders: Dissociative Amnesia

Inability to recall stressful information.

Dissociative Disorders: Depersonalization/Derealization

Feeling detached from one's body or feeling the world is unreal

Dissociative Disorders: Dissociative Identity Disorder (DID)

Presence of two or more distinct personality states; it is a complex developmental disorder

Recovery and Continuum of Care

Recovery takes time- gradual process, healing is individual, patience is key

Trauma Informed Care- safety is priority, empathy and understanding

Primary Community Treatment- community/individual therapy or short term hospitalization for safety and meds

Integrated Care Approach- Addressing physical and psychological needs, multiple specialties collab