PTSD

Mild Anxiety

Restless, increased motivation, irritability

Moderate Anxiety

Agitation and muscle tightness

Severe Anxiety

Inability to function, ritualistic behavior, unresponsive

Panic Anxiety

Distorted perception, loss of rational thought, immobility

Interventions for Mild to Moderate Anxiety

• Use active listening to demonstrate willingness to help, specific communication techniques

• Evaluate past coping mechanisms

• Explore alternatives to problem situations

• Encourage participation in activities to relieve feelings

Interventions for Severe to Panic anxiety

• Provide environment that meets physical and safety of patient. Remain with patient and remain calm

• Provide quiet environment

• Use medications and restraint ONLY AFTER less restrictive measures have been taken and failed

• Encourage walking

• Set limits using firm, short, and simple statements

• Direct client to acknowledge reality or what is present in the environment

PTSD

Can occur in any individual who has had exposure to a trauma severe enough to be outside the range of normal human experience

Onset comes months (about 3) after the exposure to an event and symptoms last longer than a month

Acute Stress Disorder

a mental health condition that can develop after a traumatic event, lasting from a few days to a month. Shorter term than PTSD

The onset is immediate after exposure to the event. The symptoms last for 3 days to a month

Events that can cause PTSD

Being a survivor of a critical illness

Combat or military experiences

Learning about violent or accidental death or injury of loved one

Child sexual or physical abuse

Serious accidents

Natural disasters

Pandemic

Pregnancy complications (hemorrhage, stillbirth, nicu baby)

Risk Factors for PTSD

Pretraumatic:

Age at Traumatic event

Female gender

Personal or family hx of psych illness

Other: Lower education level, presence of disease, bipolar disorder or MDD

Veterans: Younger age, female, lower education. Racial minority, lack of social support

Criteria to meet to be diagnosed with PTSD

Have to have 1 symptom from each category and last longer than a month

Intrusive: memories, flashbacks or nightmares

Avoidance: Avoiding stimuli associated with or reminiscent of traumatic event

Cognition/Mood: Negative changes. Fear, anger, guilt/shame, flat affect

Reactivity or Arousal: hypervigilant, reckless behavior, sleep disturbances

Intrusive

Flashbacks happening at inappropriate times. Person may feel or act as event is happening again

Distressing recollections of event. Distressing dreams or nightmares.

Intense or prolonged psychological distress at exposure to cues about the event. Reactions can be internal or external

Avoidance

Avoiding thoughts, feelings or talking about event

Avoiding external reminders of event like people, places, or activities that activate memories

Can go at great lengths to avoid being reminded

Cognition/Mood

Has persistent and exaggerated negative beliefs

Negative emotional state like guilt, fear, anger or shame

Decreased interest in current activities

Distorted cognitions about the cause or consequences of the event

Detachment or estrangement from others

Reactivity and Arousal

Near-constant state of “high alert”

Irritable behavior and angry outbursts

Hypervigilance and startle responses

Sleep disturbances

Distress or impairment in social, occupational, or other important areas of functioning

Reckless or destructive behavior

Can have drastic mood swings can go with hyperreactivity

People with PTSD have what levels?

They have lower levels of serotonin. That is why they are given SSRI’s

PTSD in children

There has to be a traumatic event

Manifestations vary based on age and developmental level. They can demonstrate trauma through their play or drawings. Flashbacks are common

There is persistent avoidance of stimuli associated with the trauma. Increased arousal symptoms (aggressive, reckless) and numbing of general responsiveness

Other traumatic events can include bullying, recreational accidents, and school accidents

EX: if child was in car accident, they may refuse to get into car/carseat, crying, “stiffboarding”

Diagnosing PTSD in children

Difficult to assess in very young

Young Child PTSD Checklist: addresses trauma exposure, PTSD symptoms, and presence of an impairment

For children 6 and under:

They need 3 symptoms from the cluster

Reexperiencing, avoidance and negative alternations in cognition and mood, and hyperarousal

For School aged and Teens

Need at least 1 symptom from each of the 4 clusters

PTSD for ICU Patients: Intrusive

Factual, delusional or hallucinated memories

Potential triggers from everyday life: Beeping noises, smell of disinfectants, sound of labored breathing, color of PPE gowns, clear plastic used in PPE face shields, pain, difficulty breathing when laying down

PTSD for ICU Patients: Avoidance

Skipping medical appointments

Avoiding: looking or touching parts of one’s body, TV/movies with medical themes, activities that bring on sensations such as getting out of breath

PTSD for ICU Patients: Negative Cognition/ Mood

Perceived negative & permanent changes to oneself, beliefs of vulnerability, distrust of others, feelings of hopelessness, sadness, shame, and anger

PTSD for ICU Patients: Arousal

Hypervigilance to internal states- s/s which may indicate illness, poor sleep

Hypervigilance: Obsessing over vital signs or how things are happening in their body

Care for ICU survivors

uAwareness that this can occur

uPost-ICU care should include a psychological component

uMonths after ICU are filled with various PT/OT/ST

uBodies are recovering and healing

uAt risk individuals should be offered individual, trauma focused, cognitive behavioral therapy within 1 month of traumatic event

Best way to prevent PTSD is early intervention and support

Recommend therapy or other resources within that month of the event or ICU stay

Risk Factors for PTSD for Healthcare Workers

Female

Younger

Diagnosed with psychiatric illness (depression, anxiety)

Experiencing burnout

Poor social support

Direct contact with COVID 19 patients

The first 4 meds that are tried for PTSD are

Sertraline (zoloft)

Fluoxetine (prozac)

Paroxetine (paxil)

Venlafaxine (effexor)

Serotonin syndrome

Sertraline and Paroxetine

SSRI and Antidepressants

 Inhibits reuptake of the neurotransmitter serotonin

Treats MDD and panic disorder

Mood elevation and decreasing depression

Monitor BP, serotonin syndrome, emotional status

Don’t take w/I 14 days of MAOI

Use sugarless gum/hard candy to decrease dry mouth

Venlafaxine

SNRI, Antidepressant

 Inhibits reuptake of serotonin, norepi-nephrine, and dopamine (to a lesser degree)

Mood Elevation, Decreases depression

Treats MDD, anxiety disorder, PTSD

Avoid with MAOI’s.

Don’t use w/pts with hx of seizures, or glaucoma, neuro impairment

Emotional status

May be drowsiness/dizziness.

Serotonin syndrome

Don’t take within 14 days of MAOI

Amitriptyline

Tricyclic Antidepressant

Increases effect of norepinephrine in CNS

Decreases depression

Mood elevation

Monitor BP

Monitor Hepatic and renal status

Avoid sudden position changes

May take several weeks to work

Avoid pregnant, and breast-feeding

Prazosin

Antihypertensive, A1 blocker

Blocks noradrenergic stimulation of alpha-1 receptors

 Lessens symptoms associated with PTSD and decreases Nightmares

Monitor for hypotension and arrhythmias

Dizziness can occur, Don’t change positions too fast

Buspirone

Antianxiety med

Binds to serotonin and dopamine D2 receptors in brain. ↑ norepinephrine biotransformation in brain.

Relief of anxiety

No grapefruit juice

No MAOI 14 days before

Monitor hepatic and renal status

Take regularly for 3-4 weeks for full effect

Alprazolam

Benzodiazepine, Antianxiety

Muscle relaxant properties.

Anxiolytic bc of CNS depression

Treats Severe/panic anxiety

Sedation & decreased anxiety

Monitor for Resp depression, hyperglycemia

Not sent home with it.

Do not keep at bedside, may become dependent

Prolonged Exposure

Teaches patient to gradually approach trauma-related memories, feelings, and situations that have been avoided. Confronting them can decrease PTSD symptoms

Provider will give an overview of treatment. Patient will learn a breathing technique to manage anxiety

Cognitive Processing Therapy

Helps change your thoughts and the way you feel about the trauma

Teaches how to evaluate and change the upsetting thoughts had about the trauma

Eye Movement Desensitization and Reprocessing

Helps process upsetting memories, thoughts and feelings related to the trauma

Patient pays attention to a back and forth movement or sound while calling to mind the upsetting memory until you shift the way you experience that memory and information

Learns new coping skills

Acupuncture

Can be effective with mental and physical symptoms

Used as complementary and not alternative therapy

Client Centered care for PTSD

Stay with the client when they are having symptoms like flashbacks and nightmares

Help the patient recognize when they are using avoidance

Provide therapeutic relationship, ensure safety and promote adaptive coping for negative cognition/mood

Ensure safety of client and others if arousable behavior

Develop coping behaviors for anger or frustration

Low stimuli environment and low steady voice