NRSE345 EXAM#2 trauma and stress related disorders

Criteria/ signs and symptoms: Acute stress disorder

• Exposure to a traumatic event (firsthand, witnessing, learning of close friend/family trauma, or repeated exposure)

• Intrusion manifestations, Negative alteration in cognition/mood, Dissociative manifestations, Avoidance manifestations, Arousal manifestations

• Clinically significant distress negatively impacts personal functioning

Start/ duration: acute stress disorder

3 days to 1 month post-trauma

Trauma

Any disturbing experience that results in significant feelings of fear, confusion, and dissociation that negatively impact an individual’s behaviors, attitudes, or functioning. Leaves invisible wounds altering neurobiological development

crisis

A situation or event which causes emotional or cognitive stress to those involved.

disaster

An incident or event that could end human life or cause health-related harm, requiring immediate response in resources and workforce (Natural or Human-caused)

resilience

The capacity to withstand stress and catastrophe, develops over time. The stronger the resilience, the less likely the individual will experience reactions that lead to maladaptive outcomes.

Medications used to treat acute stress disorder

Prescribed to treat symptoms (no 'memory repairing' medications exist):

• SSRIs: sertraline, paroxetine, fluoxetine

• SNRIs: venlafaxine

• Benzodiazepines: alprazolam, chlordiazepoxide, diazepam, lorazepam (used to treat anxiety-related manifestations)

Treatments & Therapies: acute stress disorder

• Cognitive behavior therapy (CBT)

• Prolonged exposure therapy

• Eye movement desensitization and reprocessing (EMDR)

• Group / family therapy

• Crisis Intervention: Therapeutic response, De-escalation (Verbal, Nonverbal, Support of team members

stress

• Natural part of life 

• Positive experience: helps develop successful coping skills

• Negative experience: can result in negative mental and physical health consequences

• Associated with development or exacerbation of symptoms of mental illness 

• Approached from several overlapping theoretical perspectives: physiologic, psychological, social

stressor

• An event, situation, or condition that results in psychological or physical stress. These can be internal (in the individual) or external (outside the individual)

acute stress

Intense biopsychosocial reaction to a threatening event. Usually time is limited. Can lead to physiologic overload. “Fight-or-Flight” response

Biologic Perspective of Stress: Chronic Stress

• Oncoming physiologic reaction to events resulting in “wear and tear” on body

• Negatively impacts health and well-being

• Maladaptive when prolonged 

• Contribute to risk for illness

• General adaptation syndrome (GAS)

allostasis

• dynamic regulatory process that maintains homeostasis through a process of adaptation

Levels of Anxiety: Hildegard Peplau

• Mild, moderate, severe, panic

• Identify what level patient is at

• More severe requires shorter words, more directed communication due to brain shutting down

defense mechanisms

• Conscious and unconscious process: self protection and survival. Reduce pain, stress, or anxiety

•  Development: neurophysiological and psychological growth. Based on ability to emotional handle stress- emotional homeostasis 

Adaptive (mature) defense mechanisms:

does not distort reality, find a way out to cope and learn 

Maladaptive (immature) defense mechanism:

escape mechanism, ignore a situation

common defense mechanism

compensation, denial, dissociation, regression, repression, splitting 

Mental Health Nursing: Assessment #1

Physical Assessment: need to medical clear them

• Review systems, physical functioning

• Pharmacologic assessment: Addictive substances, prescriptions, over the counter, herbs 

Mental Health Nursing: Assessment #2

Psychosocial Assessment 

• Focus on emotions and severity, coping strategies, therapeutic communication techniques, negative versus positive emotions, problem focused or emotion focused coping strategies, recent life changes questionnaire

Mental Health Nursing: Assessment #3:

Psychosocial Assessment (cont.)

• Social network, Size and extent of social network, Functions that network serves, Degree of reciprocity between patient and network members, Degree of interconnectivity

coping style

• Problem focused

• Emotion focused

• Avoidant: cause problems, avoiding stress (most common is alcohol)

stress manifestations

• anxiety,irritability, depression, panic attacks, increased sadness, excessive worry, eating disorders

• Substance use disorders or addictive behaviors such as gambling

• Alterations in executive functioning, including language and problem-solving

• Delayed development or regression

• Compulsive behaviors such as shopping and sex

• Physical manifestations: body aches, exhaustion, high BP, muscle tension 

Techniques for Stress Alleviation and Health Promotion:

• Fosters mind-to-body and body-to-mind approach: Manage and reduce stress, Improve health, Improve quality of life

• Relaxation response: Opposite of stress response, Place body at rest: Lowers blood pressure and heart rate, Slows respiratory rate

Mediators of Stress response:

• risk factors: genetics, low serotonin

• protective factors: self awareness 

• Stress defenses: exercise, music, snacks 

• Health promoting behaviors: positive affirmations, deep breathing

Etiology and risk factors for acute stress disorder

• The single causative factor for developing a trauma-related disorder is experiencing or witnessing a traumatic event 

• Traumatic events: Childhood maltreatment, Interpersonal violence, Chronic exposure to adverse childhood events, Witnessing the loss of life or limb

Trauma In adults:

• Military violence is responsible for life-long effects for deployed service members

• When an older adult experiences trauma, memories of a lifetime of previous traumas and abuse influence the current experience

• Loss of partners, friends, and family members through death, marriage, or relocation can add to the trauma

Trauma in Childhood:

• CDC-Kaiser ACE study categorizes adverse childhood experiences into three groups:

• Abuse (emotional, physical, sexual)

• Household challenges (mother treated violently, household substance abuse, mental illness in household, parental separation or divorce, criminal household member)

• Neglect (emotional, physical)

Bowlby’s Attachment Theory

• John Bowlby (1969) Framework

• Attachment Relationships

• Caregivers – parents

• Occur during Infancy into early childhood

• Necessary for survival and brain development

early childhood and attachment relationships

Resilience during life relies upon early childhood and the ability and willingness of an adult caregiver to respond to infant cues for unmet needs. Safe, stable, supportive relationships in early life are required to buffer adversity and build resilience

resilience

 the capacity to withstand stress and catastrophe, develops over time

screen tool: acute stress disorder

Primary Care PTSD Screen (simple PTSD checklist), Dissociative Disorder Interview Schedule tool, GAD-7, PHQ-9, Risk Assessment (asking about suicidal thoughts), Mental Status Exam.

acute stress disorder: 4C’s

• Calm: pay attention to how one feels when one cares for clients

• Contain: limit impact of trauma and maintain emotions; and physical safety 

• Care: practice self care and self compassion

• Cope: emphasize positive coping skills and relationships and build resilience

PTSD: criteria

• Exposed to, witnessed, or learned about a traumatic event

• Intrusive manifestations: unwanted memories, nightmares, flashbacks

• Avoidance of trauma-related stimuli

• Negative Alteration in cognition or mood: Anger, Fear, Distorted thought process, can’t trust

• Arousal or reactive manifestations: Irritability or aggression, Risky or destructive behavior

PTSD timeline

•  longer than 1 month after exposure to trauma (can be delayed)

Dissociative symptoms: PTSD

Disruption in the normally occurring linkages among subjective awareness, feelings, thoughts, behavior, and memories

Dissociative symptoms explained: PTSD

1. Derealization (feelings of unreality) and depersonalization (the experience of self or the environment as strange or unreal) 

2. Periods of disengagement from the immediate environment during stress, such as “spacing out”

3. Alterations in bodily perceptions

4. Emotional numbing

5. Out-of-body experiences 

6. Amnesia about abuse-related memories

PTSD: recovery

• Recovery takes time, Involves support and patience from family and friends

• Trauma-informed care important

• Early recognition of symptoms and treatment lead to more successful outcomes with less likelihood of major complications

Distinguishing feature of PTSD and acute stress disorder

Timeline

• Acute stress: 3 days to 1 month post-trauma 

• Post-traumatic stress disorder: longer than 1 month 

Criteria/ signs and symptoms: Adjustment disorder

less severe than PTSD and acute stress disorder

• Response to stress could be with depressed mood, anxiety, mixed, or conduct disturbance.

• Experience distress that seems out of proportion to the severity of the stressor/ may be unable to function socially

• After the situation is resolved, the symptoms subside

Adjustment disorder: timeline

• Occurs 0-3 months after exposure to stressful events

Adjustment disorder: crisis intervention

• Therapeutic response

• De-escalation: Verbal, Nonverbal, Support of team members

Adjustment disorder: protective factors

• Social/developmental: Ex: Secure attachment as a child

• Physiological/physical health: Ex: Healthy diet, exercise, and sleep

• Mental health: Ex: Learned positive coping skills, positive self-regard

• Behaviors/practices: Ex:  Ability for emotional self-regulation

Adjustment disorder: therapies

cognitive behavior therapy, prolonged exposure therapy, eye movement desensitization and reprocessing, group/ family therapy 

• Allostasis: maintaining homeostasis during stressful situations (cope, adjust, to refine homeostasis)  

Pharmacotherapy for Trauma and stress related disorders:

• There are no “memory repairing" medications Medications are prescribed to treat symptoms.

Medications prescribed for clients experiencing traumatic events include:

• Selective serotonin reuptake inhibitors (SSRIs) sertraline, paroxetine, and fluoxetine

• selective serotonin and norepinephrine reuptake inhibitor (SNRI): venlafaxine

• Benzodiazepines such as alprazolam, chlordiazepoxide, diazepam, and lorazepam are used to treat anxiety-related manifestations