Chapter 12: Trauma- and Stressor-Related Disorders

Chapter 12: Trauma- and Stressor-Related Disorders

Disorders develop after exposure to extreme stressors (e.g., perceived life-threatening events, interpersonal violence).

Contributing Factors:

• Adverse Childhood Experiences (ACEs):

  • Repeated toxic stress alters brain development and structures

  • Impacts health and behavior long-term

Clinical Relevance for Nurses:

• Must recognize how trauma/stress affects the brain and health

• Essential to assess and provide care for clients experiencing these disorders

Specific Trauma- and Stressor-Related Disorders

Acute Stress Disorder (ASD)

• Exposure to traumatic events → anxiety, detachment, other symptoms

• Duration: ≥3 days but <1 month after event

Posttraumatic Stress Disorder (PTSD)

• Exposure to traumatic events → anxiety, detachment, other symptoms

• Duration: >1 month after event

• Can persist for years

Adjustment Disorder

• Stressor → mood changes and/or dysfunction in daily activities

• Less severe than ASD or PTSD

Dissociative Disorders

Depersonalization/Derealization Disorder

• Temporary altered awareness in response to stress

• Depersonalization: feeling detached from own personality/body (observing from distance)

• Derealization: feeling external events are unreal, dreamlike, or distorted

Dissociative Amnesia

• Inability to recall personal information related to trauma/stress

• Memory loss may cover specific time periods or certain details

Dissociative Fugue

• Subtype of dissociative amnesia

• Client travels to new area, unable to recall identity or past

• Duration: weeks to months

• Usually follows traumatic event

Dissociative Identity Disorder (DID)

• Client exhibits more than one personality

• Stressful events precipitate switch from one personality to another

Pediatric Disorders

Reactive Attachment Disorder (RAD)

• Child does not seek comfort from caregivers

• Poor social interaction, minimal bonding

• Usually from unmet needs/neglect in early childhood

• Diagnosed before age 5 (often infancy >9 months)

Disinhibited Social Engagement Disorder (DSED)

• Overly friendly/indiscriminate behavior with strangers

• Failure to observe appropriate social boundaries

• Often linked to neglect or inconsistent caregiving

• Diagnosed before age 5 (infancy >9 months)

Health Promotion and Disease Prevention

Nursing Role:

• Monitor for child physical and sexual abuse → may lead to ASD or PTSD

• Report suspected abuse promptly to proper authorities (prevents severe trauma responses)

• Recognize high-risk occupations (e.g., military, first responders) → provide early support/treatment to prevent PTSD

PTSD Prevention

Health promotion during/after traumatic incidents (e.g., mass casualty):

• Ensure rest, hydration, nutrition, breaks during incident

• Provide emotional support to those affected

• Encourage peer support among staff

• Debrief after the incident

• Encourage expression of feelings by all involved

• Promote use of counseling resources

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder?

Select all that apply.

a

Avoid thinking about the incident when it is over.

b

Take breaks during the incident for food and water.

c

Debrief with others following the incident.

d

Avoid displays of emotion in the days following the incident.

e

Take advantage of offered counseling.

b Take breaks during the incident for food and water.

c Debrief with others following the incident.

e Take advantage of offered counseling.

Trauma- and Stressor-Related Disorders Risk Factors

Adverse Childhood Experiences (ACEs):

• Cause psychological/behavioral issues in children → stigma, barriers to safe/supportive relationships

• High risk: women with ≥4 ACEs or history of interpersonal violence

• ACEs = major risk factor for trauma-related disorders

ASD, PTSD, and Adjustment Disorder

• Exposure to traumatic event/experience: motor vehicle crash, sexual assault, physical abuse

• Adjustment disorder: can follow less severe stressors (e.g., breakup, job loss)

• Exposure to trauma: natural disaster (fire, storm) or man-made (terrorism)

• Occupational trauma: medical personnel, law enforcement

• Traumatic event involving family/close friend (e.g., plane crash, homicide)

• PTSD increases risk for: dissociative disorders, anxiety, depression, substance use disorders

ASD and PTSD

• Severity of trauma: duration, personal threat, location (home vs unfamiliar)

• Individual vulnerabilities: coping mechanisms, personality, preexisting mental disorders

• Insufficient treatment/support: weak social supports, negative societal attitudes, cultural barriers

Adjustment Disorder

• Lifelong difficulty accepting change

• Difficulty with social skills/coping strategies → stress response out of proportion to stressor

Dissociative Disorders

• Linked to traumatic life events

• Linked to childhood abuse/trauma

Trauma- and Stressor-Related Disorders Expected Findings

ASD and PTSD

• Intrusive findings: recurrent memories, flashbacks, trauma-related dreams

• Memories recur involuntarily and distress client

• Flashbacks: reliving trauma (e.g., veteran relives combat after hearing loud noise)

• Nightmares about trauma

• Avoidance of reminders (people, places, events, situations)

• Avoidance of thinking/talking about trauma

Mood and Cognitive Alterations

• Anxiety or depressive disorders

• Anger, irritability

• Decreased interest in activities

• Guilt, negative self-beliefs (“I am responsible for everything bad that happens”)

• Detachment from others (friends, family)

• Inability to feel positive emotions (love, tenderness)

• Dissociative symptoms: amnesia, derealization, depersonalization

Behavioral Manifestations

• Aggression, irritability, angry outbursts

• Hypervigilance, exaggerated startle reflex

• Inability to focus/concentrate

• Sleep disturbances (insomnia)

• Destructive behaviors: suicidal thoughts, harming others

Adjustment Disorder

• Depression

• Anxiety

• Behavior changes (arguing, reckless driving)

Dissociative Disorders

• Depersonalization/Derealization Disorder: feeling detached from body or environment, sense of unreality

• Dissociative Amnesia: memory loss (can span entire lifetime or specific timeframes)

• Dissociative Identity Disorder (DID): ≥2 separate personalities, distinct from each other

Trauma- and Stressor-Related Disorders Diagnostic Procedures

ASD, PTSD, and Adjustment Disorder

• Screening tools: Primary Care PTSD Screen, PTSD Checklist

• Screening for anxiety and depression

• Ask about suicidal ideation

• Conduct mental status examination

Dissociative Disorders

• Physical assessment, EEG, x-ray → rule out brain injury/epilepsy

• Screen for substance use

• Mental status exam and nursing history

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Nursing Actions

• Assess recent/remote memory for gaps or contradictions

• Identify family and occupational difficulties

• Ask about stressful events

• Assess for depression, mood changes, anxiety

• Use screening tools:

  • Dissociative Disorders Interview Schedule

  • Cambridge Depersonalization Scale

  • Somatoform Dissociation Questionnaire

  • Dissociative Experience Scale

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Select all that apply.

a

Difficulty concentrating on tasks

b

Obsessive need to talk about the traumatic event

c

Negative self-image

d

Recurring nightmares

e

Diminished reflexes

a Difficulty concentrating on tasks

c Negative self-image

d Recurring nightmares

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect?

a

The client remembers many details about the traumatic incident.

b

The client expresses heightened elation about what is happening.

c

The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred.

d

The client expresses a sense of unreality about the traumatic incident.

d The client expresses a sense of unreality about the traumatic incident.

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The client who has ASD tends to be unable to remember details about the incident and can block the entire incident from memory.

The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, and anxiety). Elation is an emotion that can occur in clients who have mania.

Manifestations of ASD occur immediately to a few days following the event.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

a

The client describes a feeling of floating above the ground.

b

The client has suspicions of being targeted in order to be killed and robbed.

c

The client states that the furniture in the room seems to be small and far away.

d

The client cannot recall anything that happened during the past 2 weeks.

c The client states that the furniture in the room seems to be small and far away.

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Feeling that one’s body is floating above the ground is an example of depersonalization, in which the person seems to observe their own body from a distance.

Having the idea of being targeted in order to be killed and robbed is an example of a paranoid delusion

Being unable to recall any events from the past 2 weeks is an example of amnesia.

Trauma- and Stressor-Related Disorders Nursing Care

Trauma-Informed Care:

• Care management that acknowledges trauma’s impact

• Addresses emotional, psychological, physiological needs

Universal Trauma Precautions

• Assume everyone may have experienced trauma

• Use careful tone, eye contact, body language

• Respect culture, gender, race, ethnicity, sexual orientation

• Support client choices when possible

• Keep noise levels low

• Encourage self-care and support networks

ASD, PTSD, and Adjustment Disorder

• Build a therapeutic relationship; encourage sharing

• Provide safe, nonthreatening, routine environment

• Assess for suicidal ideation; take precautions

• Use strategies to reduce anxiety:

  • Music therapy

  • Guided imagery

  • Massage

  • Relaxation therapy

  • Breathing techniques

• If child: involve caregivers, use play, art, age-appropriate stress-reduction

Dissociative Disorders

• During dissociative episodes → help client make decisions to reduce stress

• Encourage independence/decision-making when client shows readiness

• Use grounding techniques (clap hands, touch object)

• Avoid overwhelming client with too much past-trauma information (can increase stress)

Client Education

• Practice anxiety-reducing strategies

• Verbalize negative feelings and progress at client’s own pace

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

a

Teach the client to recognize how stress brings on a personality change in the client.

b

Repeatedly present the client with information about past events.

c

Make decisions for the client regarding routine daily activities.

d

Work with the client on grounding techniques.

d Work with the client on grounding techniques.

Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.

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The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding their identity and past.

Avoid flooding the client with information about past events, which can increase the client’s level of anxiety.

Encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decrease the client’s feelings of powerlessness.

Trauma- and Stressor-Related Disorders Therapeutic Procedures

Cognitive-Behavioral Therapy (CBT / Cognitive Restructuring):

• Helps client change distorted appraisal of events and negative thoughts

Prolonged Exposure Therapy:

• Combines relaxation + exposure to traumatic situation

• Exposure: imagined (discussion) or real-life (in vivo)

• Repeated safe exposure → decreased anxiety

Psychodynamic Psychotherapy:

• Focus on conscious and unconscious thought processes

Eye Movement Desensitization and Reprocessing (EMDR):

• Uses rapid eye movements during desensitization, multi-phase therapy

• Contraindicated in: suicidal ideation, psychosis, severe dissociative disorders, retinal disease, unstable substance use

• Includes relaxation training to enhance coping during treatment

Other Therapies:

• Group/Family therapy: support groups or formal therapy

• Crisis intervention: immediately after traumatic incident

• Somatic therapy (dissociative disorders): increases present awareness, reduces dissociation

• Hypnotherapy: for dissociative disorders

• Biofeedback/Neurofeedback: builds awareness and control of reactions to triggers

Trauma- and Stressor-Related Disorders Interprofessional Care

Refer to social workers/case managers for community coordination

Collaborate with psychotherapists for integrated care

Client Education

• Practice relaxation/anxiety-reducing strategies

• Monitor causes and symptoms of disorder

• Avoid caffeine and alcohol

• Use grounding techniques (touch object, shower, journaling) to manage dissociation and emotions

Major Medications for Trauma- and Stressor-Related Disorders (STaMiNa)

Antidepressants

• SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

• SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

• Tricyclic antidepressants: Amitriptyline, Imipramine

• MAOI (Monoamine oxidase inhibitor): Phenelzine

• NaSSA (Noradrenergic & specific serotonergic antidepressant): Mirtazapine

Other Medications

• Beta blockers: Propranolol → decreases vital signs, anxiety, panic, hypervigilance, insomnia

• Peripherally acting antiadrenergics: Prazosin → reduces hypervigilance, insomnia

• Centrally acting adrenergics: Clonidine

Adjustment Disorder & Dissociative Disorders

• Medications not usually prescribed

• May be used if specific findings of depression or anxiety require treatment

Antidepressants (STaMiNA)

Antidepressants enhance my STAMINA

• S

  • SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

  • SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

• T

  • Tricyclic antidepressants: Amitriptyline, Imipramine

• M

  • MAOI (Monoamine oxidase inhibitor): Phenelzine

• N

  • NaSSA (Noradrenergic & specific serotonergic antidepressant): Mirtazapine

• A

  • Atypical Antidepressants (Bupropion)

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Taper

Takes weeks for full effects

No ETOH or hazards (sedation risk)

Report suicidal thoughts

NaSSA (Noradrenergic & specific serotonergic antidepressant) vs SSRI vs SNRI

Antagonizes (blocks) specific norepinephrine and serotonin receptors

• Increase the overall availability of norepinephrine and serotonin.

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Inhibits the reuptake of serotonin

• Raises serotonin levels in the synapse

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Inhibits the reuptake of both serotonin and norepinephrine

• Increases the levels of both neurotransmitters.