chapter 16Comprehensive Nursing Notes on Acute Stress, Adjustment, and Dissociative Disorders

Acute Stress Disorder (ASD)

• Timeline and Diagnosis: Acute Stress Disorder is typically diagnosed within a specific timeframe: from $3$ days up to $1$ month after a traumatic event has occurred.
• Patient Interaction Challenges: Patients with ASD may find it significantly more difficult to share information regarding the trauma compared to those with other disorders.
• Core Symptom: Derealization: Patients often experience a sense of derealization regarding their general environment.
• Diagnostic Criteria: To be diagnosed with ASD, a patient must exhibit $8$ or more of the following symptoms during or after the event:     * Recurrent distressing dreams where the event feels as if it is occurring again.     * Prolonged psychological distress.     * Sleep disturbances.     * Hypervigilance.     * Agitation or restlessness.
• Nursing Approach:     * Establish a nice, safe space for the patient.     * Maintain a good, trusting rapport.     * Utilize a non-rushed approach. Comprehensive assessment may not be possible in a single session and may require several sessions for the patient to fully open up.

Application of the Nursing Process for Trauma

• Nursing Diagnosis:     * Common diagnoses include Anxiety.     * Example of a full diagnosis: "Anxiety related to a traumatic event at a store as evidenced by checking uncontrollable bottles."     * Other diagnoses are available in standard handbooks and should be used for clinical paperwork.
• Outcomes Identification:     * Primary goal: Decrease anxiety.     * Short-term Goals: These should be realistic and can be set for intervals of $2$, $5$, $10$, or $60$ minutes.     * Long-term Goals: These cover periods of a week or a month.     * Evaluation Note: Nurses should not feel they have failed if a goal is not reached; goals are set to be reevaluated based on clinical progression.
• Implementation & Evaluation for ASD:     * Requires a therapeutic relationship and a heavy focus on the safety piece.     * Evaluation is similar to the process for PTSD (Post-Traumatic Stress Disorder). It is essential to go back and evaluate interventions to determine if they were effective in "fixing" or improving the situation.

Treatment Modalities: CBT and EMDR

• Cognitive Behavioral Therapy (CBT): Effective for both PTSD and Acute Stress Disorder.
• Eye Movement Desensitization and Reprocessing (EMDR):     * Function: Works by facilitating communication between the right and left brain.     * Tools: Often involves the use of "tapping paddles."     * Process: It helps "unlock" trauma that has been compartmentalized (put in a box and key thrown away). It forces the patient to reprocess the trauma.     * Vulnerability: It can put the patient in a very vulnerable and "weird" position as it uncovers deep-seated trauma.
• Importance of Coping Mechanisms: Proper treatment helps prevent maladaptive behaviors such as burnout, drug diversion, and suicide among healthcare workers and victims of trauma.

Adjustment Disorder

• Definition: A disorder similar to PTSD and ASD but precipitated by a less stressful (though still significant) event.
• Examples of Triggers: Retirement, breakups, chronic illness, moving to a new location where you know no one (e.g., moving across town in a Toyota Camry), or becoming a mother (changes in sleep-wake cycles and roles).
• Progression: It can be diagnosed immediately or may take a few months to manifest.
• Impact: Stress occurs because a specific role (like a job) that served as a person's identity is now gone.

Dissociative Disorders Overview

• Mechanism: An unconscious defense mechanism where the patient separates themselves from significant trauma to protect the self.
• Effects: Leads to an interruption of consciousness, causing disturbances in memory, self-identity, and perception of the world.
• The "Autopilot" Example: A minor form of dissociation everyone experiences, such as driving home on a routine route and not remembering the turns or the drive itself.
• Symptom Classification:     * Positive Symptoms: Unwanted additions to mental activity (e.g., flashbacks).     * Negative Symptoms: Deficits in mental activity (e.g., memory problems/loss).
• Cultural Considerations: Certain cultural behaviors must be ruled out before diagnosing a dissociative disorder. For example, among the Navajo people, a trance-like state is a cultural belief/practice and should not be mistaken for a psychiatric disorder.

Specific Dissociative Disorders and DID

• Dissociative Amnesia: The inability to recall important personal information. Often precipitated by a traumatic or stressful event.
• Dissociative Fugue: A rare psychiatric state related to amnesia where patients wander or travel away from home, forget their identity, and sometimes assume a new one with no recollection of previous events. This can last for days or months.
• Depersonalization/Derealization Disorder:     * Depersonalization: Detaching from oneself.     * Derealization: Detaching from the environment.     * Treatment: Can be short-lived and resolve as anxiety lessens, or may require CBT, hypnosis, and pharmacotherapy (antianxiety agents or antidepressants).
• Dissociative Identity Disorder (DID):     * Presence of $2$ or more distinct personality states (alters).     * Involuntary switching between personalities.     * Each personality can have different names, voices, and mannerisms (e.g., one might be a child, another might wear high heels).     * Risk Factors: Severe physical or sexual abuse.     * Differential Diagnosis: Often misdiagnosed as Schizophrenia.

Nursing Implementation for Dissociative Disorders

• Assessment: Roll out other causes (dementia, cognitive issues, drug-induced states, electrolyte abnormalities) using lab work and urine samples. Use specific screening scales.
• Safety: High risk for self-harm and suicide.
• Nurse Self-Assessment: Nurses must be aware of their own feelings.     * Patience: Nurses may have "paper thin" patience or get short with patients in crisis.     * Transference/Countertransference: Being "too nice" or being mean in response to a disrespectful patient.     * Skepticism: Questioning if the patient is "playing possum" or using the diagnosis to get out of jail.
• Phases of Planning:     1. Safety: Establish stability.     2. Memory Confrontation: Dealing with the traumatic memories.     3. Rehabilitation: Integrating identities and reaching optimal functioning.
• Grounding Techniques: Used to bring the patient back to the "here and now" during dissociative episodes:     * Walking barefoot on the grass.     * Counting beads.     * Box breathing (inhaling for a specific count).     * Yoga-related techniques (plugging specific nostrils to bridge right/left brain).     * Journaling and physical exercise.     * Cuddling a pet.

Questions & Discussion

• Question regarding Derealization:     * Question: "Why do you think choice C was the correct answer for the question?"     * Response: "Because she wasn't in the moment. She was thinking about the guy who escaped… derealization is unrelated to the environment itself… it's a protective mechanism used sometimes unconsciously."
• Question regarding the lady driving aimlessly:     * Question: "Can we relate to this situation where I read a story from a book that a lady was just driving for very long hours, days, not knowing where they are going?"     * Response: "Maybe. But you have to think about… what if they had dementia or other cognitive [issues]? You have to rule out and troubleshoot everything: lab work, urine sample, identity, electrolyte abnormality… it could also be drug-induced."
• Question regarding DID Risk factors:     * Question: "What is choice B for the question regarding dissociative identities?"     * Response: "B is correct… there's usually some sort of abuse… it's a protective response, often from physical or sexual abuse."
• Nursing Self-Awareness Discussion:     * Nelson's Perspective: Noted that it is tough not to treat patients the same way they treat you when they are super disrespectful. He mentioned needing to "simmer down" and remember they have a mental illness.     * Student Perspective: Mentioned being "too nice" and needing to be cautious with boundaries and safety, especially since patients might try to find staff on social media like Facebook.