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

Negative outcomes d/t a crisis

• 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 or acute stress disorder, 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 reactions as an intrusive symptoms

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

• Derealization

• Depersonalization

• Spacing out/numbing/amnesia

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

Avoidant symptoms

Persistent avoidance of stimuli associated with the traumatic events in order to avoid distressing memories, thoughts, or feelings about the traumatic event

• Stimuli may include people, places, convos, activities, objects, or situations

Negative changes in mood and cognition as a criteria for PTSD (9)

• Fear

• Guilt/shame for surviving

• Blame self/others

• Difficulty experiencing positive emotions (happiness, love, satisfaction)

• Exaggerated negative beliefs about self/others/world

• Inability to remember important aspects of trauma

• Diminished interest or participation in significant activities

• Feelings of detachment or estrangement from others

• Mistrust

Changes in arousal and reactivity as a criteria for PTSD

Hyperarousal / hypervigilance for signs of danger

• Easily startled

• Overreactions to stimuli, including non-threatening ones 

• Problems with concentration 

• Difficulties sleeping

What differences in PTSD reactions are expressed in children compared to adults?

intrusive thoughts/memories may not appear distressing and may be expressed through play (acting out an event)

Acute Stress Disorder

development of symptoms related to PTSD after exposure to trauma from 3 days to 1 month after the traumatic event

• may progress to PTSD

Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred (5):

• Intrusion Symptoms

• Negative Mood

• Dissociative Symptoms

• Avoidance Symptoms

• Arousal Symptoms

Adjustment disorder

a mental health condition characterized by emotional and behavioral symptoms that develop in response to a significant life stressor w/in 3 months of the onset of the stressor

• that does NOT meet criteria for PTSD

Criteria to diagnose adjustment disorder

• emotional or behavioral symptoms occur within 3 months of the onset of the stressor(s).

• These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

• The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

• The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder.

• Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

To diagnose adjustment disorder, the clinically relevant symptoms or behaviors must be evidenced by one or both of these:

1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.

2. Significant impairment in social, occupational, or other important areas of functioning.

Disinhibited Social Engagement Disorder (specific to children)

childhood attachment disorder characterized by excessive and indiscriminate friendliness towards unfamiliar adults, including hugging or going with strangers without hesitation

What diagnostic criteria is required to diagnose Disinhibited Social Engagement Disorder and Reactive Attachment Disorder?

the absence of adequate caregiving during childhood

What causes the development of Disinhibited Social Engagement Disorder? What 3 aspects can be evidenced by this?

The absence of adequate caregiving during childhood, as evidenced by at least one of the following: 

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.

2. Repeated changes of primary caregivers that limit opportunities to form stable at­tachments (e.g., frequent changes in foster care).

3. Rearing in unusual settings that severely limit opportunities to form selective at­tachments (e.g., institutions with high child-to-caregiver ratios).

Disinhibited Social Engagement Disorder manifestations (3)

• Child is culturally inappropriate and overly familiar with adult strangers.

• Diminished/absent checking back with adult caregiver after venturing away (even in unfamiliar settings)

• Willing to go off with an unfamiliar adult with minimal or no hesitation

Reactive Attachment Disorder (specific to children)

• mental health condition that affects children who have experienced severe neglect or abuse in their early years

• It is characterized by an inability to form healthy emotional attachments with caregivers, leading to difficulties in social interactions, trust, and emotional regulation

PTSD risk factors (7)

• Exposure to traumatic events

• Extent, duration, and intensity of trauma 

• History of trauma

• Prior diagnoses if acute stress disorder or anxiety at baseline

• Environmental factions 

• Socioeconomic factors 

• Low self esteem

PTSD Neurological Theory (roles of amygdala, hippocampus, cortex, and NTs/systems)

• The amygdala and hippocampus are involved in fear conditioning and memory — excess glucocorticoids may cause atrophy

• Interactions between hippocampus and cortex may elicit traumatic memories 

• Norepinephrine, dopamine, corticotropin system, and NMDA involved in learning/processing related to trauma and hyperarousal

PTSD Behavioral Sensitization Theory

The idea that repeated, intermittent exposure to certain stimuli causes a progressive and long-lasting increase in the behavioral response to that stimulus

• opposite of tolerance

Key components of Behavioral Sensitization Theory (5)

• Sensitized fear and anxiety

• Altered HPA axis 

• Lowered activation threshold

• Hyper-reactivity to cues 

• Comorbidity with other disorders

What is the 1st priority with a trauma patient? Why?

SAFETY!

• Increased risk of suicide or suicide attempt in victims of trauma

• Increased risk of self-directed violence (e.g. self harm)

• Increased risk of other-directed violence/aggression

• Increased risk of substance use as coping

Physical Health Assessment for trauma patients

• Monitor physical functioning 

• Sleep

• Pain

• Somatic responses

• Nutrition 

• Exercise 

• Self-care

• Meds 

• Substance use 

Psychological Assessment for trauma patients

• Symptoms + severity

• Level of daily functioning/decline in functioning 

• Emotional response (e.g., guilt, shame, remorse)

• Mood/affect/cognition 

• Stress + coping patterns

• Coping skills

• Strength-based assessment

Nursing interventions for trauma patients (6)

• Establish goals and wellness plans 

• Sleep hygiene (e.g., avoid naps and alc)

• Interventions for families 

• Exercise and yoga

• Nutrition 

• Substance use education 

Psychological first aid

evidence-based approach to providing immediate support and assistance to individuals experiencing a traumatic or stressful event

• advises against forcing people to "process" what happened

What is the aim of psychological first aid?

aims to reduce initial distress, promote coping mechanisms, and connect survivors with resources to facilitate their recovery

Key principles of psychological first aid

• Protect and connect 

• Calming and Comforting 

• Assessing Needs 

• Connecting with Support

• Empowering Individuals

ABCs of psychological first aid

A — Arousal

B — Behavior is abnormal or irrational

C — Cognition and disorientation