Trauma & Stressor-Related Disorders PPT

when do we see PTSD?

it follows an identifiable stressor or event

when did our knowledge of PTSD begin?

with veteran’s experience after Vietnam (relatively new concept)

what does trauma-informed care help in?

the care of all patients and families

what’s the goal in the care for trauma and stressor disorders?

restore the person’s functioning

what are the characteristics of meds for  trauma and stressor disorders?

generally the same as those used to treat anxiety

what’s the goal/what do we want to do for our pts with regards to their disease?

increase the person’s insight into the causes, reactions, and coping with the stressors

define trauma

extremely distressing experience that causes emotional shock and lasting effects

what’s PTSD historically 

Formerly known as shell shock, battle fatigue, accident neurosis, or posttraumatic neurosis.

what are the characteristics of PTSD?

•High incidence in Vietnam veterans (1970s).

•First use of PTSD diagnosis was in the DSM-3 in 1980.

•About 10% exposed to trauma will develop PTSD

•More common in women than men (higher percentage)

define PTSD

A reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone

your pt presents w the following:

•Re-experiencing the traumatic event (flashbacks, nightmares)

•A sustained high level of anxiety or arousal

•Hypervigilance, exaggerated startle response

•Intrusive recollections or nightmares

•Trouble concentrating

•Amnesia to certain aspects of the trauma

•Insomnia

•Depression; survivor’s guilt

•Substance abuse

•Irritability, anger and aggression

•Relationship problems (feeling of detachment from others)

what’s going on?

PTSD

what are some examples of trauma that can cause PTSD ?

•natural or man-made disasters,

•combat, witnessing the violent death of others

•serious accidents,

•being the victim of torture, terrorism, rape, or other crimes

•NOT related to normal life events

•May be the person or witnesses to the event

•More than 1 month with significant impairment

•Symptoms may begin within the first 3 months after the trauma, or there may be a delay of several months or even years

what would you see in your assessment for PTSD?

•Re-experiencing the traumatic event (flashbacks, nightmares)

•A sustained high level of anxiety or arousal

•Hypervigilance, exaggerated startle response

•Intrusive recollections or nightmares

•Trouble concentrating

•Amnesia to certain aspects of the trauma

•Insomnia

•Depression; survivor’s guilt

•Substance abuse

•Irritability, anger and aggression

•Relationship problems (feeling of detachment from others)

what are some psychosocial factors that determine the severity of PTSD?

•Severity or duration of the stressor

•Extent of preparation for the event

•Exposure to death

•Number of people affected

•Amount of control over repeated events

•Location

•Coping abilities

•Previous history of mental illness

•Outcomes of previous traumatic events

•Availability of support

•Attitudes of society

•Cultural influences

what is acute stress disorder (ASD)?

•Like PTSD – event as trigger

•Symptoms are time limited: 3 days up to 1 month

•If the symptoms last longer than 1 month, the diagnosis would be PTSD

•Characterized by a maladaptive reaction

•Symptoms occur within 3 months of the stressor and last no longer than 6 months

when would an ASD pt be dx w PTSD

if the symptoms last longer than 1 month,

define adjustment disorders?

Maladaptive reaction (more excessive than expected) to identified stressors with impairment in functioning (shorter than PTSD); impairment in social or occupational areas is present

what are the different types of adjustment disorders?

•With Depressed Mood

•With Anxiety

•With Mixed Anxiety and Depressed Mood

•With Disturbance of Conduct

•With Mixed Disturbance of Emotions and Conduct

•Related to Bereavement

Unspecified

what are some factors of adjustment disorders?

•Primary feature is emotional disturbance (anxiety/depression) with conduct disturbance – or acting out (fighting, skipping school, etc.)

•May withdraw from others

•May have physical complaints

•May have impaired work or school performance

•Fail to cope with continuous or shock stressors

•Occurs within 3 months and resolves within 6 months after the stressor/event

what are some problems associated with adjustment disorders?

•Complicated grieving – real or perceived loss

•Risk-prone health behavior

•Anxiety

what does trauma informed care do?

•Improves all care – physical and mental health

what are the aspects of trauma informed care?

•Approach that values awareness of trauma when assessing, planning and implementing care

•Realizes the impact of trauma and paths for recovery

•Recognizes the s/s of trauma in patient, family, and peers

•Responds with policies, procedures, and practices that integrate trauma perspective

•Avoid retraumatizing the survivor

•Must see trauma in themselves and how it impacts their ability to provide care

what is important in trauma informed care?

Must see trauma in themselves and how it impacts their ability to provide care

slide 16 for 6 guiding principles to trauma-informed approach

slide 16 for 6 guiding principles to trauma-informed approach

slide 17 for PTSD assessment tool

slide 17 for PTSD assessment tool

what does PCL-5 do for a PTSD assessment?

determine a provisional diagnosis in two ways

break does the scoring for the PCL-5 for PTSD?

• 3 = Quite a bit

• 4 = Extremely •

• Summing all 20 items (range 0-80) and using a cut-point score of 31-33 appears to be reasonable based upon current psychometric work.

• when choosing a cutoff score: it is essential to consider the goals of the assessment and the population being assessed.

• The lower the cutoff score, the more lenient the criteria for inclusion, increasing the possible number of false-positives. The higher the cutoff score, the more stringent the inclusion criteria and the more potential for false-negatives.

what’s the baseline goal of PTSD care?

restore the client to prior functioning

what do we want to see in the outcomes of PTSD patient care?

The client:

•Can acknowledge the trauma and the impact on his or her life

•Can demonstrate adaptive coping strategies

•Has made realistic goals for the future

•Has worked through feelings of survivor’s guilt

•Attends support group of individuals recovering from similar traumatic experiences

•Verbalizes desire to put trauma in the past and progress with his or her life

what is PTSD evaluation of care for the pt based on?

(with a trauma-related disorder) is based on successful achievement of the previously established outcome criteria

what’s the previously established outcome criteria when evaluating someone in recovery for PTSD?

•Can the client discuss the traumatic event without experiencing panic anxiety?

•Has the client learned new, adaptive coping strategies for assistance with recovery?

what are the nursing care actions when treating someone for PTSD?

•Provide consistent staffing

•Non-threatening and non-judgmental approach

•*Reassurance of safety for client(both)

•*Nurse presence during flashbacks/panic

•Encourage emotional expression (both)

•*Discuss and evaluate coping methods (replace maladaptive coping, teach and demonstrate better coping like relaxation and deep breathing) (both)

•Allow expression of guilt

what are the nursing care actions when treating someone for Adjustment Disorders?

•Assess stage of grief

•Assist with ADLs if needed

•*SAFETY: Assess for suicidal ideation and risk (both)

•Develop trusting relationship, show empathy, be accepting of all emotions

•Normalize grief process but allow individual differences

•Explore spirituality

•Discuss life changes

Identify resources (both)

what is our adjustment disorders and goals for the pt?

The client:

•Verbalizes acceptable grieving behaviors

•Demonstrates a reinvestment in the environment

•Accomplishes ADLs independently

•Demonstrates ability to function adequately

•Accepts change in health status

•Sets realistic goals for the future

•Demonstrates ability to cope effectively with change in lifestyle

what are the Nursing interventions for the client with an adjustment disorder is aimed at (what’s your planning/implementation)?

•Adaptive progression through the grief process

•Helping the client achieve acceptance of a change in health status

•Assisting with strategies to maintain anxiety at a manageable level

see the nursing care card

the Evaluation for adjustment disorders is based on accomplishment of previously established outcome criteria. what is this criteria?

•Does client demonstrate progression in the grief process?

•Does client discuss the change in health status and modification of lifestyle it will affect?

•Does client set realistic goals for the future?

what are the different treatment modalities for trauma-related disorders (PTSD & ASD)?

•Cognitive therapy  - change thinking and perception, reframe

•Prolonged exposure therapy

•Group/family therapy

•Eye movement desensitization and reprocessing (EMDR)

•Psychopharmacology 

what are the treatment modalities specific to adjustment disorders?

•Individual psychotherapy

•Family therapy

•Behavior therapy

•Self-help groups

•Crisis intervention

•Psychopharmacology

•EMDR- Eye movement Desensitization and Reprocessing – uses brain’s information procession and memories

what are the first line meds for trauma-related disorders?

SSRIs

what SSRIs are used as the first line meds for trauma-related disorders?

• Fluoxetine/Prozac**

• Fluvoxamine/Luvox

• Paroxetine/Paxil

• Sertraline/Zoloft

what are some things you want to be aware of bc they might interact with Prozac?

•St. John’s Wort- avoid

•Ibuprofen- monitor

•Magnesium citrate- monitor

•Mannitol- monitor

Hypoglycemic patient - monitor blood glucose

what can happen if a pt takes St. John’s Wort w Prozac?

•avoid combo: combo may incr. risk of serotonin syndrome (additive effects)

what can happen if a pt takes ibuprofen w Prozac?

•monitor

•caution advised, monitor sodium: combo may increase risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

what can happen if a pt takes magnesium citrate w Prozac?

•monitor

•monitor sodium: combo may increase risk of hyponatremia, SIADH, seizures (additive effects, electrolyte abnormalities)

what can happen if a pt takes mannitol w Prozac?

•monitor

monitor sodium: combo may increase risk of SIADH, hyponatremia, other adverse effects (additive effects)

what are some other meds taken for trauma-related disorders?

•Anxiolytics – Alprazolam (Xanax), buspirone (Buspar)

•Antihypertensives – beta blockers – propranolol (Inderal), alpha receptor – clonidine (Catapres) has calming effect too

•Anesthetic – ketamine (off label use under investigation)

•Trazadone (Desyrel) used for sleep disturbances (antidepressant and sedation, may reduce nightmares) Do not give within 14 days of MAOI, with lithium, buspirone, St. John’s wort, or migraine medications.  Can cause dizziness, fainting, and irregular heartbeat.

what’s the timeline for PTSD?

more than 1 month with significant impairment

what’re the characteristics of PTSD?

intrusive thoughts, marked reactions to stimuli, avoidance of distressing memories, negative beliefs or emotional state (reaction may be delayed)

what’s the timeline for ASD?

time limited response=1 month following the trauma

what’re the characteristics of ASD?

recurrent distressing dreams, memories, negative mood, avoidance, hypervigilance

what’s the timeline for AD?

reaction occurs within 3 months of the stressor and lasts no longer than 6 months after the stressor

what’re the characteristics of AD?

symptoms depend on type of adjustment disorder

what does McKee like about the DSL-5 for PTSD?

very good list of symptoms