Ch 16: Trauma, Stressor-Related, and Dissociative Disorders

what are attachment disorders?

Psychiatric conditions in children caused by inadequate emotional bonding experiences with caregivers before 8 months of age.

what behavior characterizes reactive attachment disorder (RAD)?

Inhibited, emotionally withdrawn behavior; child rarely seeks or responds to comfort when distressed.

What behavior characterizes disinhibited social engagement disorder (DSED)?

No normal fear of strangers; overly friendly, willing to go with unfamiliar people, and unfazed by separation from caregivers.

How common are reactive attachment disorder and disinhibited social engagement disorder in the general population under age 5?

About 1% of all children.

What happens when nurturing caregivers are absent during early development?

Disruption of neural development and attachment, increasing risk for attachment disorders.

Name 5 major risk factors for developing attachment disorders.

• Institutional living

• Frequent foster home changes

• Impaired parenting (e.g., mental illness, substance abuse)

• Prolonged caregiver separation (e.g., hospitalization)

• Inconsistent caregiving

What are possible long-term effects of untreated attachment disorders?

lifelong problems with trust, security and relationships

Can children with attachment disorders develop healthy relationships later in life?

yes, especially with support, due to their natural resilience

What assessments are important when diagnosing attachment disorders?

comprehensive psychiatric and physical evaluations (to rule out medical causes).

What are the primary goals of treatment for attachment disorders?

Strengthen the child-caregiver relationship and ensure a safe, stable environment.

What is the standard treatment approach for attachment disorders?

Involves both the child and caregivers in individual and family therapy.

How might PTSD manifest in preschool-aged children through play?

As reduced play and play that reenacts aspects of the traumatic event

what emotional symptoms are common in children with PTSD?

Fear, guilt, anger, horror, sadness, shame, and confusion.

What behavioral symptoms may be seen in children with PTSD?

Social withdrawal, self-blame, detachment from others, loss of interest in activities, irritability, aggression, self-destructive behavior, sleep disturbances, difficulty concentrating, and hypervigilance.

Can children suffer from trauma-related symptoms without meeting full PTSD criteria?

yes, they may still have nightmares, trust issues, trust issues, phobias, somatic symptoms, impulse control, and identity issues

What are common comorbid conditions associated with PTSD in children and adolescents?

learning/attention problems, behavioral issues, sleep disorders, sleep disorders, depression, suicide attempts, dissociations and substance abuse

Why is recognizing comorbidities in traumatized children important for care?

without proper care, children may face cycles of medications, punishments, and revictimization, leading to stigmatization and inadequate treatment

What may happen to a traumatized child or adolescent if care is not provided?

they may experience delayed development

Where should nurses assess for PTSD and safety in traumatized youth?

In schools, community settings, and juvenile detention centers

what determines the type of assessment data collected?

The setting, severity of the problem, and availability of resources.

What methods are used to collect assessment data?

Interviewing, screening, testing (neurological, psychological, intelligence), observing, and interacting.

what sources are used to collect history in assessment?

parents, caregivers, the child/adolescent, teachers, and other adults

What broad categories are assessed in a mental status exam for children?

• Safety

• General appearance

• Socialization

• Activity level

• Speech

• Coordination and motor function

• Affect

• Manner of relating

• Intellectual function

• Thought processes/content

• Characteristics of play

What does a semistructured interview focus on in a child’s assessment?

The child’s home and school environments, family relationships, and developmental history

what techniques are used for assessing younger children who can’t express themselves?

Play activities like games, drawings, and puppets.

Why is the initial interview with child and caregiver so important?

It helps observe interactions and build trust and rapport.

What are common posttraumatic symptoms in children?

• Nightmares/night terrors

• Intrusive thoughts

• Flashbacks

• Numbing

• Avoidance of trauma-related stimuli

What are examples of self-injurious behaviors and somatic symptoms in traumatized children?

• Self-harm due to anxiety

• Headaches, stomachaches, or pain

• Memory issues like amnesia or trance states

How might trauma be expressed through play?

the child may re-enact the trauma during play activities

What are three assessment tools used for trauma-related symptoms in children?

• Child Dissociative Checklist

• Trauma Symptoms Checklist for Children

• Child Sexual Behavior Inventory

Who typically administers specialized trauma assessment tools?

Advanced practice professionals (e.g., NPs or psychologists).

Why is developmental assessment important for traumatized children?

trauma can cause significant developmental delays

what does a developmental assessment determine?

Whether the child’s behavior and function match chronological age or lag behind.

What is the priority nursing diagnosis for children and adults with PTSD?

Post trauma response- it directly addresses the core medical problem of PTSD

What are 7 additional nursing diagnoses relevant to PTSD?

• Anxiety (moderate, severe, panic)

• Impaired coping

• Social isolation

• Insomnia

• Sleep deprivation

• Hopelessness

• Chronic low self-esteem

• Self-care deficit

What is the general outcome goal for the nursing diagnosis of post trauma response?

improved responses to trauma

What is one outcome goal related to managing anxiety in trauma-affected patients?

the patient manages anxiety using relaxation techniques, achieves adequate sleep, and maintains role or work responsibilities

What is one outcome goal related to enhanced self-esteem?

the patient maintains grooming/hygiene, makes eye contact, expresses positive self-statements, and accepts self-limitations

What is one outcome goal related to improved coping ability?

the patient shows a decrease in physical symptoms, is able to ask for help, and seeks information about treatment

What is the first stage of trauma treatment for adults?

providing safety and stabilization through a safe, predictable environment

What techniques can be used to reduce arousal and regulate emotion in trauma patients?

Deep breathing, imagery, and mindfulness exercises

How can nurses help improve socialization in patients with PTSD?

by encouraging connection with support groups, family, and friends to reduce isolation and improve self-esteem

How can nurses help patients begin to heal from trauma through storytelling?

By encouraging them to develop a narrative of the trauma and reflect on its meaning, while gently challenging feelings of guilt or responsibility.

why is educating the patient and family about PTSD important?

it helps normalize their reactions, and reassure them they are not “crazy” and reduce feelings of personal failure or weakness

What are common trauma-related symptoms that patients and families should be educated about?

Problems with interpersonal relationships, occupational functioning, and substance use

What strategies should be taught to enhance coping and self-care in trauma patients?

coping skills, symptom recognition, and simple relaxation techniques like slow, deep breathing

What should nurses ensure before a trauma patient is discharged?

The patient is aware of community supports and receives a referral for follow-up care.

what is a key indicator that a trauma patient understands their condition?

The patient recognizes symptoms as related to the trauma

what shows that a trauma patient is using effective coping skills?

The patient uses newly learned strategies to manage anxiety.

what signifies that a patient is no longer experiencing intrusive trauma symptoms?

the patient has not flashbacks or intrusive thoughts

What outcome indicates improved sleep in a trauma patient?

the patient can sleep adequately without nightmares

What shows restored functioning and relationships in a recovering trauma patient?

The patient assumes usual roles and maintains satisfying interpersonal relationships.

what is the primary treatment for PTSD?

trauma-focused psychotherapy

What class of medications is often used to treat depression, anxiety, sleep, and concentration issues in PTSD?

Antidepressants, especially SSRIs

Which two SSRIs are FDA-approved for PTSD?

• Sertraline (Zoloft)

• Paroxetine (Paxil)

What other antidepressants are prescribed off-label for PTSD?

• Fluoxetine (Prozac)

• Venlafaxine (Effexor)

• Nefazodone (Serzone)

• Imipramine (Tofranil)

• Phenelzine (Nardil)

which medications are not recommended for PTSD due to lack of efficacy and risk of adverse effects?

• Atypical antipsychotics

• Citalopram (Celexa)

• Amitriptyline (Elavil)

• Topiramate (Topamax)

• Lamotrigine (Lamictal)

What are the two major components often included in trauma-focused psychotherapy?

• exposure therapy

• cognitive restructuring

What does EMDR stand for, and what is its role in PTSD treatment?

Eye Movement Desensitization and Reprocessing; it is used as a trauma-focused therapy for PTSD

What therapy techniques are often combined with trauma-focused therapy to reduce symptoms?

• Anxiety management

• Stress reduction

What are some additional therapy modalities that can help with PTSD?

• Brief psychodynamic psychotherapy

• Imagery

• Relaxation techniques

• Hypnosis

• Group therapy

What is Acute Stress Disorder (ASD)?

a stress reaction that may develop after exposure to a highly traumatic event

When can ASD be diagnosed after a traumatic event?

between 3 days and 1 month after the trauma

How many symptoms must be present to diagnose ASD?

at least 8 out of the 14 symptoms

What are the dissociative symptoms of ASD?

• Subjective sense of numbing

• Derealization (feeling the environment is unreal)

• Inability to remember an important aspect of the event

What are the intrusion symptoms of ASD?

• Intrusive distressing memories

• Recurrent distressing dreams

• Flashbacks or feeling the event is recurring

What are the avoidance and arousal symptoms of ASD?

• Avoidance of thoughts/feelings about the trauma

• Sleep disturbances

• Hypervigilance

• Exaggerated startle response

What are the emotional and behavioral symptoms of ASD?

• Intense prolonged distress or physiological reactivity

• Irritable, angry, or aggressive behavior

• Agitation or restlessness

How does nursing assessment for Acute Stress Disorder (ASD) differ from PTSD?

Individuals with ASD may have more difficulty sharing symptoms and are more likely to experience derealization, requiring a non-rushed, reassuring approach.

What screening tool is used for both PTSD and ASD?

PC-PTSD-5 (Primary Care PTSD Screen for DSM-5).

What tool is specific to ASD and predictive of later PTSD?

Acute Stress Disorder Scale

What is the priority nursing diagnosis for ASD?

post trauma response

What are two other appropriate nursing diagnoses for ASD?

• Impaired adaptation

• Anxiety (specify severity)

What are three key outcomes for a patient with ASD?

• Reduced response to trauma

• Improved adaptation

• Decreased anxiety

What are the nurse’s primary roles in treating a patient with ASD?

• Establish a therapeutic relationship

• Help with problem-solving

• Connect to supports (family/friends)

• Educate about ASD

• Coordinate care

• Ensure safety

• Monitor treatment response/adherence

How is the evaluation of care for ASD similar to PTSD?

The same evaluation criteria for PTSD are used—e.g., recognition of symptoms, effective coping, reduced flashbacks, improved sleep, and functional role performance.

What psychological therapy has been shown to reduce the development of PTSD in individuals with ASD?

Cognitive Behavioral Therapy (CBT)

What trauma-focused therapy has specialized protocols for recent trauma in ASD treatment?

EMDR (Eye Movement Desensitization and Reprocessing).

Name three EMDR-based protocols used for Acute Stress Disorder.

• EMDR Protocol for Recent Critical Incidents (EMDR-PRECI)

• Recent Event Protocol (Luber, 2009)

• Recent Traumatic Episode Protocol (R-TEP)

What is adjustment disorder?

A milder and less specific form of ASD or PTSD, triggered by a stressful (but not necessarily traumatic) event

How soon can adjustment disorder be diagnosed after a stressor?

immediately or within 3 months of exposure

What types of events may trigger adjustment disorder?

events like retirement, chronic illness, or a breakup- less severe than traumatic

What emotional symptoms are common in adjustment disorder?

guilt, depression, anxiety, and anger

What are physical and functional symptoms seen in adjustment disorder?

• Physical complaints

• Social withdrawal

• Impaired occupational functioning

• Academic decline

What is complicated grieving?

a type of adjustment disorder that occurs within 12 months of the death of a loved one, marked by intense yearning and sorrow

What are symptoms of complicated grief?

• Deep sorrow/emotional pain

• Preoccupation with the deceased

• Anger

• Emptiness

• Diminished sense of self

• Difficulty in relationships and future planning

What is the standard intervention for adjustment disorder?

Psychotherapy, including:

• Reality orientation

• Crisis intervention

• Family therapy

• Group treatment

What is the goal of psychotherapy in adjustment disorder?

to encourage verbalization of emotions related to stressors

what medications are used to treat symptoms in adjustment disorder?

• Antidepressants for depressive symptoms

• Benzodiazepines for anxiety symptoms

What are dissociative disorders?

Disorders that occur after trauma, marked by a severe interruption of consciousness and disturbances in memory, self-identity, perception, and awareness.

what is dissociation as a defense mechanism?

An unconscious emotional separation that protects against overwhelming anxiety

How do common dissociative experiences differ from pathological dissociation?

Common experiences are brief and voluntary (e.g., “autopilot” driving), while pathological dissociation is involuntaryand results in fragmentation of awareness and memory.

What are positive symptoms of dissociation?

unwanted additions to mental activity, like flashbacks

What are negative symptoms of dissociation?

deficits in functioning, such as memory loss or loss of control over body parts

How does dissociation function as a protective mechanism in children?

It allows children to fragment abusive experiences, enabling continued attachment to abusive caregivers.

what are common presenting problems for people with dissociative disorders?

patients often seek treatment for anxiety or depression, not for dissociation itself

What are major risk factors for dissociative disorders?

Childhood physical, sexual, or emotional abuse, and other traumatic life events.

What role does genetics play in dissociative disorders?

Minimal; dissociation is primarily related to extreme environmental stress, though genetics may influence stress reactivity.

What is the structural dissociation theory of the personality?

A theory proposing that trauma creates a split between the apparently normal part and the emotional part of the personality, each with its own responses and memories.

What types of environmental events may lead to dissociative disorders?

• Combat

• Motor vehicle accidents

• Verbal/emotional abuse

• Neglect/incest

• Imprisonment

• Any overwhelming trauma