NOT DONE Week 5: Trauma and Stressor Related Disorders

Crisis

a sudden, overwhelming and unexpected event that significantly disrupts a person’s life

A crisis is “time limited” and lasts less than…

4-6 weeks

Positive outcomes of crisis

• Development

• Maturation

• Opportunity for growth and change

• New ways of coping

• Abnormal development (e.g., being unable to leave the house)

• Anxiety

• Depression

• Suicide

• PTSD

Steps of crisis development

1. A problem arises that contributes to increase in anxiety levels, which initiates the usual problem-solving techniques of the person

2. The usual problem-solving techniques are ineffective, leading to an increase in anxiety — trial and error methods are made to restore balance 

3. The trial and error attempts fail, leading to anxiety accelerating to severe or panic levels — person adopts automatic relief behaviors (e.g., alcohol)

4. When these measures do not reduce anxiety, it can overwhelm the person and lead to serious personality disorganization, which signals the person is in crisis

The first priority and roles of nurses in working towards recovery

• First priority is safety

• Nurse’s roles are to: 

  • assessment 

  • provide a framework of support systems 

Parts of nursing assessment during a patient crisis

• Safety

• Physical health 

• Emotional health 

• Coping strength 

• Social functioning

• Social support

Trauma

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being

Trauma has adverse effects on the individual’s health (3) and well-being (2):

• mental health 

• physical health 

• emotional health

• spiritual well-being

• social well-being

Examples of physical trauma

• serious accident 

• self-inflicted injury 

• severe medical illness that threatens death

• violence by others

Psychological trauma

a deeply distressing and disturbing experience that can have a profound impact on a person's mental, emotional, and physical well-being

Homeostasis

body’s tendency to resist physiologic change and hold bodily functions relatively consistent, well-coordinated, and usually stable

Allostasis

how the body adapts to maintain physiologic stability

• A dynamic regulatory process involving functions of the autonomic nervous system; the hypothalamic–pituitary–adrenal (HPA) axis; and the cardiovascular, metabolic, and immune systems respond to internal and external stimuli

Coping

a deliberate, planned, and psychological activity to manage stressful demands 

• problem focused (changes the person–environment relationship)

• emotion focused (changes the meaning of the situation)

• successful coping leads to adaptation

• unsuccessful coping leads to maladaptation

Adaption

a person’s capacity to survive, flourish, and adapt (learn and grow)

• enhanced health

• psychological sense of well-being

• maximum social functioning

Goals in the nursing management of stress

• resolve the stressful person-environment situation

• reduce the stress response

• help patient develop positive coping skills

What 4 factors impact response to trauma?

• characteristics of the traumatic event 

• biological factors

• individual characteristics 

• psycho-social factors

Biological factors of trauma responses

• genetics 

• alterations in brain chemistry

• neurochemical and endocrine factors 

Adverse childhood experiences (ACES) alters the ____ response to stress, resulting in…

• HPA axis 

• disrupts organ development 

• damages stress response system 

• leads to dysregulation of response to stress

• increases the risk for psychopathology (impaired stress response is centra to many psychiatric illnesses

Childhood trauma/stress increases risk of conditions such as (6)…

• anxiety disorders

• mood disorders

• eating disorders

• alcohol and drug use/dependence

• PTSD

• suicidal behavior

ACES may develop these maladaptive emotional and behavioral responses to stress

• emotional liability

• avoidance

• withdrawl

• impulsivity 

• irritability

• anger

• aggression/violence

• self harm and suicidality  

What adverse effects may occur d/t childhood trauma?

• Mental health 

• Physical health 

• Emotional/behavioral/spiritual health 

• Social health 

Individual characteristics that impact trauma responses

• Age 

• Personal history/past experiences

• Resilience 

• Coping skills 

• Beliefs

• Meaning of the trauma

Resilience

• Resilience reduces the impact of stress and promotes recovery from stressful experiences

• Develops in association with positive self-concept, self-worth, and sense of control/power

• Begins to form during childhood

Appraisal

the perception that an event or situation is a threat

Psycho-Social factors that impact trauma responses

• Social support 

• Culture

• Famuly

• Religion

• Value/goals

• Financial resources 

• Social supports 

• Gender

• Employment factors

• Environment during recovery 

Treatment of the Acute Reaction Stage of trauma

• Assess safety

• Obtain history and physical examination

• Education 

• Brief psychotherapy sessions (not intense)

• Acute symptom management (e.g., sleep disturbances)

• Pharmacotherapy (meds)

What is HIGHLY discouraged during the acute stage? Why?

debriefing is NOT recommended

• because they are not ready yet to address the trauma and need to stabilize before debriefing 

• debriefing too early has the potential to harm and interfere with their recovery bc it will remind them of their trauma

Pharmacotherapy medications used for the acute stage of trauma

• SSRIs

• Benzodiazapines (only for ST treatment)

• Beta-blockers

• Alpha-blockers

Trauma-focused therapies used during the the chronic reaction stage (6)

• Cognitive Processing Therapy (CPT)

• Eye movement, desensitization, and reprocessing (EMDR)

• Prolonged Exposure Therapy 

• Trauma-focused CBT

• Stress management

• Group therapy

Cognitive Processing Therapy (CPT)

• helps challenge and change unhelpful beliefs related to the trauma 

• focuses on a new understanding of the event that lessens its negative impact

Eye movement, desensitization, and reprocessing (EMDR)

• Process of reviewing and visualizing trauma (in a safe setting) to reduce long-term impact

  • not re-exposed to trauma, thinking about so many things that the person is accessing the trauma without  bringing about the feelings of panic that normally comes with it

• Sets up a learning state that allows these experiences to be stored appropriately in the brain

• Progressive desensitization

Prolonged Exposure Therapy

• gradually exposure to trauma-related stimuli, both in imagination and real life

• helps habituate to anxiety and reduce its power

Prolonged exposure therapy types (3)

• In vivo

• Imaginal

• Virtual reality

Trauma-Focused CBT (TF-CBT)

specialized version of CBT (focus on changing negative evaluation of situations, thoughts, feelings (cognitive restructuring)) combines cognitive restructuring, exposure techniques, and play therapy to help process traumatic experience

• often used for children and adolescents

Pharmacotherapy for the Chronic Reaction Stage 

• SSRIs

• SNRIs

• Beta-blockers

• Alpha-blockers

• 2nd Generation Antipsychotic

PTSD

Development of intrusive, dissociative, avoidant, mood, cognitive, or hyperarousal symptoms following exposure to a traumatic event.

PTSD diagnosis duration requirement

more than 1 month

To be diagnosed with PTSD, you must have exposure to…(3) in one of the following ways (4):

Exposure to:

• Actual or threatened death

• Serious injury 

• Sexual violence

Type of exposure:

• Directly experienced

• Witnessed

• learned that the traumatic event(s) occurred to a close family member/friend

• d/t repeated or extreme exposure to aversive events

Intrusion symptoms of PTSD (3)

• Recurrent, involuntary, intrusive thoughts, memories, or dreams (nightmares) of traumatic events

• Dissociative reactions

• Intense/prolonged psychological distress or marked physiological reactions to internal or external cues of trauma

Dissociative reaction as an intrusive symptoms

feels or acts as like the traumatic event(s) are recurring (flashbacks)

Derealization

experiences of unreality of surroundings

Depersonalization 

feeling detached from, and as if one were an outside observer of, one’s mental processes or body