Topic 13: Trauma, Stresor-Related, and Dissociative Disorders

trauma informed care

involves recognizing and responding to the effects of all types of trauma, which focuses on the client’s past experiences of violence and on the role these experiences currently play in their lives

attachment disorders

psychiatric conditions in children who have problems with emotional attachments to others, which are caused by grossly inadequate nurturing environments and very poor bonding experiences with parents or caregivers by 8 months old; types: reactive and disinhibited social engagement

reactive attachment disorder

attachment disorder that is characterized by a consistent pattern of inhibited and emotionally withdrawn behavior from a child in which the child rarely seeks comfort or rarely responds to comfort from parents/caregivers when in distress;

ie. a child scrapes his knees, the parents run to the child, and the child shows little/no emotion to the comforting response form the parents

disinhibited social engagement disorder

attachment disorder that is characterized by an unfazed response to the separation of the parents/caregiver in which the child demonstrates no normal fears of strangers and are instead overly friends with them

ie. a child allows a stranger to pick them up, feed them, or play with them

• foster care with frequent changes in homes and caregivers

• orphanages

• prolonged separation from caregivers due to extended hospitalization

• impaired parenting due to severe psychiatric problems, criminal behavior, or substance use disorder

what are the RF for attachment disorders in kids

• reduction in play, which includes the aspects of the traumatic event

• social withdrawal and negative emotions like fear, guilt, anger, horror, sadness, shame, or confusion

• blame themselves, have a feeling of detachment/estrangement, and diminished interest in activities

• irritable and aggressive with self-destructive behavior

• sleep disturbances, nightmares, night terrors

• intrusive thoughts and memories

• flashbacks

• numbing

• trust issues

• phobias

• poor impulse control

• depression, SI, substance abuse

• avoidance of the stimuli associated with the event

• hypervigilance

what are s/s of PTSD in children

• report abuse (confirmed or suspected) of ALL minors

• provide a safe, stable, and predictable environment

• stop self-destructive behaviors

• use an interactive process to resolve a trauma

• establish trust and safety

• use developmentally appropriate language

• teach relaxation techniques before trauma exploration

• help identify and cope with feelings through art and play

• include caretaker unless they are the source of the trauma

• educate children and parents on the grief process and response to trauma

• assist the parent in resolving their own emotional distress over the trauma

• coordinate with social workers for protection as needed

what are the nursing interventions when caring for a child with PTSD

• medication combined with EMDR therapy

• trauma-focused psychotherapy with elements of exposure/cognitive restructuring

• Meds that target s/s and comorbidities like ADHD or MDD

what does treatment for PTSD in children include

eye movement desensitization and reprocessing (EMDR)

therapy that helps people process traumatic memories, in which they are encouraged to think about the trauma while also focusing on other stimulation such as eye movements, audio tones, or tapping; may work through neurologic and psychosocial changes that help to process and integrate traumatic memories

• military combat

• being a prisoner of war or held hostage

• crime: bombing, assault, mugging, rape

• natural disasters: flood, tornado, earthquake

• human disasters: car, plane, train accident

• being diagnosed with a serious or life threatening illness

what can cause PTSD in adults

longer than one month

how does do s/s of PTSD have to occur for an official diagnosis to be made

• antidepressants

  • SSRIS: sertraline, paroxetine

  • off-label: fluoxetine, venlafaxine

  • nefazodone, imipramine, phenelzine if others are ineffective

  • avoid atypical antidepressants

• trauma focused psychotherapy with exposure/cognitive restructuring

• EMDR

what is used to treat PTSD in adults

acute stress disorder

may develop after expsure to a highly traumatic event that has the same s/s of PTSD, except the s/s develop within 3 days of the event and resolve within a month

• 8 of the following 14:

  • numbing

  • derealization

  • inability to remember at least one important aspect of the event

  • intrusive, distressing memories of the event

  • recurrent distressing dreams

  • feeling as if the event is recurring

  • intense, prolonged distress or physiological reactivity

  • avoidance of thoughts or feelings about the event

  • sleep disturbances

  • hypervigilience

  • agitation or restlessness

• may have more difficulty sharing s/s due to recent nature of event

what are the S/S of acute stress disorder

• CBT to reduce the development of PTSD

• Specialized EMDR

  • EMDR protocol for recent critical incident

  • Recent traumatic episode protocol

what are the treatments for acute stress disorder

adjustment disorder

a milder version of ASD and PTSD that is precipitated by a stressful event; however, the event may not be as severe and may not be considered a traumatic event like retirement, chronic illness, or a breakup; may be diagnosed immediately or within 3 months of exposure

• guilt

• depression

• anxiety

• anger

• physical complaints

• social withdrawal

• impaired occupational activities

• academic decline

what are the s/s of adjustment disorder

• reality orientation

• crisis intervention

• family or group therapy

• antidepressants for depressive s/s

• benzos for anxiety s/s

what are the treatments for adjustment disorder

dissociative disorder

occurs after significant adverse experiences/traumas, individuals respond to stress with a severe interruption of consciousness, which is an unconscious defense mechanism to protect the individual against overwhelming anxiety through emotional separation, resulting in disturbances in memory, consciousness, self-identity, and perception

• positive: unwanted additions to mental activity, like flashbacks

• negative: deficits such as memory problems, the ability to sense or control different parts of the body

• may decrease the immediate distress of the trauma and continue to protect the individual from full awareness of the disturbing event

what are the s/s of dissociative disorder

dissociative amnesia

The inability to recall important personal information, often of a traumatic or stressful nature, and the lack of memory is too pervasive to be explained by ordinary forgetfulness; autobiographical memory is available but not accessible

dissociative fugue

a subtype of dissociative amnesia, which is characterized by sudden, unexpected travel from a familiar location to a new location where the person has a new identity and is unable to recall their past identity and information about the past; tend to lead rather simple lives, rarely calling attention to themselves; after a few weeks, they may remember their former identity and develop amnesia for the time spent in the fugue state; usually is precipitated by a stressful event, but will function adequately in their new identities

• benzos short term

• will usually revert once the stressful situation has resolved/person is exposed to cues from the past

• hypnosis to regress the patient back to the time before amnesia commenced

What are the treatments for dissociative amnesia

depersonalization

persistent or recurrent episodes of focus on self, extremely uncomfortable feeling of being an observer of one’s own body or mental processes; feelings of unreality, detachment, or unfamiliarity with parts of the self/whole self, including feelings, thoughts, body parts, or sensations

derealization

persistent or recurrent episodes of focus on the outside would, recurring feeling that one’s surroundings are unreal or distant, and like they are walking around in a fog, bubble, or dream

• usually short-lived and go away without treatment

• self-hypnosis

• rTMS

• CBT

• meds for comorbid conditions

what are the treatments for depersonalization/derealization disorders

dissociative identify disorder (DID)

presence of two or more distinct personality states that recurrently take control of behavior, and each alternate personality (alter) has its own pattern of perceiving, relating to, and thinking about self and the environment; aka multiple personality disorder

severe sexual, physical, or psychological trauma in childhood

what are the RF for dissociative identify disorder (DID)

• have at least 2 identified states

  • primary one functions on a daily basis and blocks access and responses to traumatic memories

  • alter state is fixated on the traumatic memories

• each alter has its own memories, behavioral patterns, and social relationships

• often the primary is moralistic and the alter is pleasure seeking and nonconforming

• primary is usually not aware of the alter and is perplexed by lost time, unexplained events like finding unfamiliar clothes in the closet, being called a different name by a stranger, or not having any childhood memories

what are the s/s of dissociative identify disorder (DID)

• offer emotional presence

• provide a safe, stable, and predictable environment with frequent observation

• encourage an optimal level of functioning and independence

  • can assist with major decision-making until memory returns

• provide an undemanding, simple routine

• confirm the identity of the patient and orientation to time and place

• support the patient’s feelings

• do not flood the patient with data regarding past events

• allow the patient to progress at their own pace as memory is recovered

• listen empathetically

• teach stress reduction techniques

• accept the patient’s expression of negative feelings

• teach grounding techniques to keep the patient in the present; holding an ice cube, taking a shower, deep breathing, touching fabric on. a chiar, counting beads, stomping feet

what are the nursing interventions for dissociative identify disorder (DID)

• no specific meds, may use some for hyperarousal and intrusive s/s of PTSD and dissociation

  • antidepressants, anxiolytics, antipsychotics

• CBT

• psychodynamic psychotherapy

• exposure therapy

• modified EMDR therapy

• hypnotherapy

• neruofeedback

• ego state therapies

• somatic therapies

what are the treatments for dissociative identify disorder (DID)