Trauma and Stressor Related Disorders

Trauma

an individual’s unique response to an event, series of events, or set of circumstances experienced by the individual as physically or emotionally harmful or life threatening.

• An individual’s experience of the event determines whether it is traumatic​

• Can include adverse physical, social, emotional, or spiritual consequences.​

• Risk for developing a disorder increases with history of ACEs (adverse childhood experiences

Acute Trauma

A single traumatic event that is limited in time (such as car accident, natural disaster).

Chronic Trauma

Exposure to multiple and/or persistent traumatic events (such as abuse, social-emotional neglect, isolation, poverty, or hunger).

Complex Trauma

Exposure to chronic trauma that also distorts the individual’s fundamental sense of self (persistent social inequity, racism, discrimination due to sexual orientation or gender identity).

System-induced Trauma

Trauma that is experienced during movement through organizational systems (such as foster care or juvenile detention).

Vicarious Trauma

Also called secondary trauma, it is an indirect trauma that results from engaging with victims of trauma. (Health care personnel during COVID-19, first responders after 9/11 or Hurricane Katrina).

Historical Trauma

Psychosocial distress resulting from trauma or adversity passed down through generations of groups of people who share an identity, affiliation, or circumstance.

Trauma Includes

• Sexual, physical, emotional abuse/assault

• Neglect

• Accidents, illnesses, medical procedures

• Being a victim or witness to domestic/interpersonal or community violence

• Historical trauma

• School violence/bullying

• Disasters

• War, terrorism, political violence

Violence

• Intentional injury or threat of injury

• Ranges from simple assault to homicide

• Includes child abuse, interpersonal violence, rape, elder abuse

• Suicide is a form of self-directed violence.

• Intimate partner violence (IPV)—any type of physical, sexual, or psychological harm by an intimate or ex-partner

• Rape—forced sexual intercourse

Injury

• The experience of physical or emotional harm or damage

• May result from intention (violence) or accident

• Unintentional injury a wide-ranging category

Intimate Partner Violence

• Aggressive behavior between individuals in an intimate or dating relationship

• Encompasses many types of abuse and violence

• More frequently committed by men against women

• Usually related to dynamics of power and control over a partner or significant others

• Includes financial abuse—controlling access to money or resources in an attempt to reduce autonomy and further exert control

Abusive Relationship Warning Signs

• Isolation

• Jealousy

• Threats to harm partner, their children, relatives, themselves

• Aggressive behavior

• Control of access to finances, transportation, children

• Criticism or humiliation of a partner

• Control or restriction of movement, activities

• Physical harm

• Overprotectiveness

• Sudden anger, volatility, hostility

• Rigid sex roles, use of force during sex

Sexual Violence Nursing Interventions

• SANE—Sexual Assault Nurse Examiner

  • Treatment includes access to testing and prophylaxis for STIs, HIV, and pregnancy if appropriate.

• Follow reporting requirements for child or adolescent

• Focus on safety, confidentiality, empowerment

▪ Encourage patients to make own decisions

▪ Engage in safety planning

▪ Ensure safe transportation to a safe location on discharge

Reactive Attachment Disorder

Children typically do not seek comfort when distressed and barely respond to efforts to comfort them.

• They often display limited positive affect and experience periods of irritability and sadness, even during normal interactions with caregivers.

• Fearfulness may also be seen.

• A history of persistent neglect and repeated changes in caregivers are common among children with RAD.

Disinhibited Social Engagement Disorder

Children readily engage with adult strangers, typically using language and behaviors that are outside the cultural norms of familiarity.

• These children tend to wander from caregivers without seeking permission, even in unfamiliar settings.

• They often willingly go off with strangers.

  • Nurses caring for children with histories of neglect or foster care should be aware that behaviors associated with disinhibited social engagement disorder may persist once the child is placed in appropriate care.

• Results from absence of caregiving

Adjustment Disorder

Symptoms within 3 months of onset of stressor(s) but for no longer than 6 months

• Stressor not as severe as those indentified under PTSD

• Clinicians should specify sub-type.

  • Depressed mood, anxiety, disturbance of conduct, mixed, unspecified

PTSD

Group of symptoms following exposure to traumatic events

• Death

• Threat of death

• Serious injury

• Sexual violence

highest rates of PTSD are seen in individuals who witness someone being badly injured or killed; are involved in a fire, flood, or natural disaster; experience a life-threatening accidence; experience rape, captivity, or genocide; or experience combat exposure.

PTSD Sx

• Symptoms of intrusion, distressing memories, labile mood states, cognitive disturbances, hypervigilance

• Sleep disturbances

• Self-destructive behavior, irritability, aggression

• Flashbacks—memories of a traumatizing event that feel like the event is recurring in the present

PTSD Intrusion Sx

• Unwanted upsetting memories

• Nightmares

• Flashbacks

• Emotional distress after exposure to traumatic reminders

• Physical reactivity after exposure to traumatic reminders

1 required for Dx

PTSD Avoidance Sx

• Trauma-related thoughts or feelings

• Trauma-related external reminders

one required for Dx

PTSD Negative Alterations in Cognition (or mood) Sx

• Inability to recall key features of the trauma

• Overly negative thoughts and assumptions about oneself or the world

• Exaggerated blame of self or others for causing the trauma

• Negative affect

• Decreased interest in activities

• Feeling isolated

• Difficulty experiencing positive affect

2 required for dx

PTSD Alterations in Arousal Sx

• Irritability or aggression

• Risky or destructive behavior

• Hypervigilance

• Heightened startle reaction

• Difficulty concentrating

• Difficulty sleeping

2 required for Dx

PTSD Dx criteria

all of the following for 1 month or more:

• One or more reexperiencing symptoms, such as flashbacks, bad dreams, or frightening thoughts

• One or more avoidance symptoms

• Two or more arousal and reactivity symptoms

• Two or more cognition or mood symptoms

PTSD Risk Factors

• Traumatic events; natural disaster, war, rape, assault, etc

• Diagnosis of life threatening disease or undergoing invasive medical procedures

• Sudden unexpected death of family or close friend

• Working in a profession that involves repeated exposure to trauma (e.g., fire fighters, EMS professionals, law enforcement officers, emergency department nurses and staff)

PTSD Resilience Factors

• Seeking support from others

• Learning to feel good about one’s own actions during the event

• Having a positive coping strategy

• Being able to act and respond effectively despite feeling fear

• Being aware of risk factors for PTSD

PTSD Dx Children

Criteria slightly different for children age 6 or younger

• Physical symptoms—stomachache, headache

• Temper tantrums

• Repetitive play expressing aspects of the event or reenacting the event (Post-traumatic play and reenactment)

• Nightmares

• Remember events in wrong order

• Omen formation

Complex PTSD

Prolonged exposure to life-threatening or horrific events with no possibility of escape

• Repeated child abuse

• Torture, slavery, genocide

• Prolonged IPV

• Diagnosis of PTSD must be met with additional symptoms of

  • pervasive negative self-concept

  • pervasive emotional dysregulation

  • persistent disturbances in relationships.

Acute Stress Disorder

Acute stress response in which symptoms are exhibited for at least three days and up to one month after exposure to the traumatic event.

• Significant distress or impairment in one or more areas of functioning occurs.

• Many of the symptoms of acute stress disorder are similar to those associated with PTSD

• Time-limited condition.

• If symptoms persist past 4 weeks after the event, a diagnosis of PTSD may be made.

< 1 month

Depersonalization

Experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).

Derealization

Experience of unreality, distance, or distortion (e.g., "things are not real").

PTSD Assessment

• Safety Assessment

• Suicide risk assessment

• Injury assessment

• Observe nonverbal behaviors and cues

• Assess for guarding, hypervigilance

• Determine chief/complaints, concerns

PTSD Education

• Treatment adherence.

• Nurses help patients identify triggers, set goals for social interactions, and identify ways to improve sleep

PTSD Meds

• SSRIs, SNRIs

• Prazosin for nightmares

PTSD Therapy

Trauma Focused

• Prolonged exposure therapy

• Cognitive processing therapy

• Eye movement desensitization and reprocessing (EMDR)

Others

• Acceptance and commitment therapy

• Dialectical behavior therapy

• Mindfulness-based cognitive therapy