trauma

Trauma, Crisis, Disaster, and Related Disorders

Learning Objectives

  • Impact of Trauma, Crisis, and Disaster: Describe how these factors affect a client’s overall health.
  • Epidemiological and Etiological Risk Factors: Explore the factors that increase the likelihood of clients experiencing trauma, crisis, or disaster.
  • Clinical Presentation Differentiation: Differentiate among the clinical presentations of clients experiencing trauma, crisis, or disaster.
  • Nurse's Role: Explore the responsibilities of nurses in caring for clients affected by trauma, crisis, or disaster.
  • Application of Nursing Process: Apply the nursing process using clinical judgment functions in the context of trauma, crisis, or disaster care.

Overview

  • Definitions:
    • Trauma
    • Crisis
    • Disaster
    • Types of disasters:
    • Natural disasters
    • Human-caused disasters

Examples of Adverse or Traumatic Events or Experiences

  • Natural Disasters: Events like earthquakes, floods, hurricanes.
  • Human-Caused Disasters: Events such as terrorist attacks, industrial accidents.
  • Other Adverse Experiences:
    • Poverty
    • Racism, discrimination, and oppression (citing American Psychiatric Association, 2020a; Trauma-Informed Care: Implementation Resource Center, 2021; SAMHSA, 2021)

Trauma-Related Disorders

  • Effects of Trauma: Understand the various manifestations arising from exposure to trauma, including:
    • Intense fear
    • Feelings of confusion
    • Dissociation
    • Disruptive emotions (according to American Nurses Association, American Psychiatric Nurses Association, 2015; American Psychiatric Association, 2022; Trauma-Informed Care: Resource Center, 2021)

Types of Trauma

  • Various Types of Trauma:
    • Acute Trauma: Short-term trauma response.
    • Chronic Trauma: Prolonged exposure to traumatic events.
    • Complex Trauma: Exposure to varied forms of trauma, often in childhood.
    • System-induced Trauma: Trauma resulting from systemic issues.
    • Vicarious Trauma: Trauma experienced through exposure to the trauma of others.
    • Historical Trauma: Cumulative emotional and psychological wounds that are passed through generations (citing CT.gov, 2021; Trauma-Informed Care in Behavioral Health Services, 2014; Gone et al., 2019; Garner et al., 2021).

Theoretical Framework: Bowlby’s Attachment Theory

  • John Bowlby’s Perspective (1969): Highlights the significance of attachment relationships formed with caregivers (typically parents) during infancy to early childhood as essential for survival and brain development.

Early Childhood and Attachment Relationships

  • Key Points:
    • Development of a child's brain relies on healthy attachment relationships.
    • These relationships act as protective factors against stress and trauma.
    • Crucial in providing support and safety, modeling positive social-emotional skills and effective responses to needs.
    • Important for developing self-regulation (sources: Garner et al., 2021; Forkey, 2019; Herringa, 2017).

Bowlby’s Attachment Theory: Stages of Attachment

  • Stages of Attachment Development:
    • Birth to 3 months: Pre-attachment stage
    • 6 weeks to 7 months: Indiscriminate attachment
    • 7 months to 11 months: Discriminant attachment
    • 24 months and beyond: Attachment continues to evolve (citing Esteves et al., 2020; Garner et al., 2021; Marshall & Frazier, 2019).

Polyvagal Theory: Nervous System and Trauma

  • Response Mechanism During Trauma: Interaction between various parts of the nervous system following a traumatic event:
    • Sympathetic Nervous System Activation: Triggers flight or fight response.
    • Dorsal Vagus Nerve Activation: Leads to fainting or freezing.
    • Ventral Vagal Nerve Activation: Calls for social engagement and safety (citing Porges, 2009; Huttunen & Mednick, 2018; Kolacz et al., 2019).

Trauma Response and Polyvagal Theory

  • Responses to Trauma:
    • Fight or Flight (Sympathetic Nervous System): Initial defense mechanism.
    • Faint or Freeze (Dorsal Vagus): Secondary defense mechanism characterized by shutdown behavior.
    • Fawn or Social Engagement (Ventral Vagus): Unconsciously using social skills to appease or protect oneself (citing Huttunen & Mednick, 2018; Kolacz et al., 2019).

Pathophysiology of Trauma: When the Past Becomes the Present

  • Types of Stress:
    • Chronic Exposure: Continuous stress leading to long-term adverse effects.
    • Toxic Stress: Prolonged activation of stress response hindering recovery of brain and body, leading to biological and genetic changes, particularly in the absence of protective factors (citing Forkey, 2019; Garner et al., 2021).

Toxic Stress

  • Consequences: Prolonged stress activation:
    • Prevents recovery of the body and brain.
    • Results in increased vulnerability and instability, impacting mental and physical health (Forkey, 2019; Garner et al., 2021).

Impact on Brain and Body

  • Hypothalamic-Pituitary Axis (HPA):
    • Chronic stress leads to hyperarousal.
    • Can be acute with temporary symptoms or chronic with ongoing perception of threat (citing Center on the Developing Child, 2021; CT.gov, 2021; Forkey, 2019).

Manifestations of Toxic Stress: Children and Adolescents

  • Developmental Changes:
    • Developmental delays as a consequence of toxic stress.
    • Behaviors such as engaging in risky activities.
    • Increased risk for autoimmune diseases and mental health concerns like suicide attempts (citing Center on the Developing Child: Harvard University, 2021; SNOHMIS Health District, 2021; Felitti et al., 1998).

Manifestations of Toxic Stress: Adults

  • Common Behavioral Manifestations:
    • Increased risk of intimate partner violence.
    • Social challenges such as financial stress.
    • Physiological effects including ischemic heart disease and increased risk of infections.
    • Mental health challenges demonstrated through substance use, suicidal thoughts, or depression (sources: Center on the Developing Child: Harvard University, 2021; SNOHMIS Health District, 2021; Felitti et al., 1998).

Impact of Repeated Toxic Stress

  • Neuroplasticity and Neurological Changes:
    • Trauma leads to changes in brain architecture and function.
    • Adverse childhood experiences (ACEs) can adversely affect brain structure, impacting both physical and mental health (citing Center on the Developing Child, 2021; Crouch et al., 2019; Luby et al., 2019; de Oliveira, 2020; Mateos-Aparicio & Rodriguez-Mareno, 2019).

Fear Learning

  • Significance of the Amygdala:
    • Functions as the brain’s fear detection system; dysfunction can lead to altered fear learning, which modifies nerve pathways, impacting emotional responses.
    • Mechanisms such as fear conditioning and fear extinction are important to understand traumatic re-experiencing (citing Stahl, 2021; Terranova et al., 2019; McLeod, 2021; Shalev et al., 2017).

Genetic Implications

  • Protective and Risk Factors:
    • Stress response activation and resilience can change through mechanisms such as epigenetics, affecting health and behavior across generations (citing Stahl, 2021; van Rooij et al., 2020; Estevez et al., 2019; Jiang et al., 2019).

Historic Trauma

  • Concept of Generational Trauma:
    • Trauma that manifests across generations, often seen in vulnerable populations, can lead to inherited predispositions affecting future generations (Jiang et al., 2019).

Trauma-Related Disorders in Children

  • Impact of Childhood Trauma:
    • Exposure and absence of protective factors can lead to developmental changes and difficulties in interpersonal functioning, potentially increasing chronic health issues and risk for trauma-related disorders (citing Felitti et al., 1998; Claypool et al., 2021; Crouch et al., 2019; Zhou et al., 2020).

Common Risk Factors: Mental Health and Trauma Related

  • Examples of Risk Factors:
    • Family history of mental health issues.
    • Current health and well-being concerns.
    • Individual experience of traumatic events (citing Felitti et al., 1998; Forkey, 2019; American Wellness Association, 2022; Kimberg & Wheeler, 2019).

Common Protective Factors: Mental Health and Trauma Related

  • Notable Protective Factors:
    • Social/Developmental: Secure attachment in childhood.
    • Physiological/Physical Health: Healthy diet, exercise, adequate sleep.
    • Mental Health: Positive learned coping skills.
    • Behaviors/Practices: Effective emotional self-regulation (citing Felitti et al., 1998; Forkey, 2019; American Wellness Association, 2022; Kimberg & Wheeler, 2019).

PACES: Protective and Compensatory Experiences in Children

  • Importance of PACES:
    • Proves a protective factor for physical or mental issues, thereby increasing resilience and promoting well-being (citing Ratliff et al., 2020).

DSM-5-TR Categories: Trauma- and Stress-Related Disorders

  • Disorders Include:
    • Reactive attachment disorder (RAD)
    • Disinhibited social engagement disorder (DSED)
    • Post-traumatic stress disorder (PTSD)
    • Acute stress disorder (ASD)
    • Adjustment disorder
    • Other specified trauma- and stressor-related disorder
    • Unspecified trauma- and stressor-related disorder.

Disaster Management Cycle

  • Phases Include:
    • Pre-Disaster phase: Prevention/mitigation and preparedness.
    • Disaster phase: Impact assessment.
    • Post-Disaster phase: Recovery and response.

Crisis Emergency Model of Care

  • **Adaptation from Brennaman’s Theory of Crisis Emergencies (2021):
  • Framework emphasizes a structured response to crisis situations in care settings.

Impact of Disaster

  • Types of Disasters:
    • Human-caused disasters.
    • Natural disasters.
  • Effects: Emotional and physical impacts on affected populations.

Trauma Related Disorders: Prevalence

  • Common Disorders:
    • PTSD and adjustment disorder.
  • Population Groups at Higher Risk:
    • Women
    • Adolescents
    • Black Americans, Hispanic Americans, and Indigenous peoples
    • LGBTQ+ individuals
    • Military personnel and first responders.

Etiology and Risk Factors

  • General Risk Factors for Trauma:
    • Experiencing or witnessing trauma.
    • Childhood maltreatment.
    • Interpersonal violence.
    • Chronic exposure to adverse childhood events.
    • Witnessing the loss of life or limb (WHO, 2020, APA, 2022).

Adverse Childhood Experiences (ACEs)

  • Impact of ACEs:
    • Genetic vulnerabilities can arise from harmful childhood experiences leading to lifelong consequences including chronic illness and mental health issues (citing CDC, ACEs Pyramid, n.d.; Felitti et al., 1998; WHO, 2020; Shalev et al., 2017; Jiang et al., 2019).

Cultural Considerations

  • Generational Impact of Trauma:
    • Epigenetic changes experienced by vulnerable populations affected by historical trauma result in inequitable health outcomes, presenting higher rates of mental health problems and social inequity (citing Gone et al., 2019; Bhatt & Bathija, 2018).

Historical Trauma

  • Definition and Characteristics:
    • Represented as "invisible soul wounds" on the collective psyche of populations, leading to persistent inequalities and health disparities (citing Gillson & Ross, 2019; Joo-Castro & Emerson, 2020; Salerno et al., 2020).

Comorbidities: Trauma-and-Stress Related Disorders

  • Related Conditions:
    • Mental health disorders like bipolar disorder and alcohol use disorder, which may manifest as anxiety or aggression.
    • Physical health issues such as cardiovascular disease or type 2 diabetes may present as obesity (American Psychiatric Association, 2022).

Acute Stress Disorder and Post-Traumatic Stress Disorder: Shared Characteristics

  • Common Symptoms:
    • Intrusive manifestations and negative alterations in cognition/mood.
  • Distinguishing Feature:
    • Timeline:
    • Acute stress disorder: Occurs 3 days to 1 month post-trauma.
    • PTSD: Symptoms persist longer than 1 month (American Psychiatric Association, 2022).

Significant Trauma-Related Disorders

  • Diagnostic Categories:
    • Reactive attachment disorder (RAD)
    • Disinhibited social engagement disorder (DSED)
    • Acute stress disorder (ASD)
    • Adjustment disorder (AD)
    • Post-traumatic stress disorder (PTSD) (citing American Psychiatric Association, 2022).

Criteria for PTSD: Individuals Younger Than 6 Years

  • Event Exposure: Must be exposed to, witness, or experience learning about a traumatic event.
  • Manifestations:
    • Intrusive manifestations
    • Avoidance manifestations or changes in thoughts/mood
    • Arousal or reactive manifestations (American Psychiatric Association, 2022).

Criteria for PTSD: Individuals Older Than 6 Years

  • Event Exposure: Definition remains similar to younger individuals.
  • Manifestations Include:
    • Intrusive behavior
    • Avoidance behavior or cognitive/mood alterations
    • Negative alteration in cognition or mood
    • Arousal or reactive behaviors (American Psychiatric Association, 2022).

Additional Manifestations of PTSD

  • Common Symptoms in Adults and Adolescents:
    • Depersonalization and derealization experiences.
  • Children's Unique Symptoms:
    • Time skew, omen formation, and post-traumatic reenactment (citing American Psychiatric Association, 2022; Hamblen et al., 2019).

Nursing Role in Trauma, Crisis, and Disaster

  • Primary Goal: Structure client care to address needs and promote positive health outcomes.
  • Trauma-Informed Nursing Practice: Avoid practices that could lead to re-traumatization (citing Fleishman et al., 2019).

Cultural Humility: Cultural-Ecological Model of Health

  • Shift in Perspective: Moving from asking, "Why are you here?" to "What has happened to you?" (citing Ranjbar et al., 2020).

Creating Equitable, Client Sensitive Care

  • Implementing Peplau’s Phases of Therapeutic Interventions: Focus on safety, equity, and inclusion while preventing traumatic re-experiencing and enhancing communication (citing SAMHSA, 2014; Fleishman et al., 2019; Olson, 2020).

Universal Trauma Precautions

  • Key Considerations for Care:
    • Acknowledge the impact of crisis, utilize therapeutic communication, uphold non-judgment, create a healing environment, and practice self-care (adapted from Rutgers Biomedical and Health Sciences, 2022).

Bias in Healthcare

  • Consequences of Bias: May result in health inequities and disparities.
  • Types of Bias:
    • Explicit bias
    • Implicit bias
  • Addressing Bias: Implementation of trauma-informed care to move beyond biases (National Center for Cultural Competence, n.d.a).

4 Cs of Trauma-Informed Care

  • Four Core Principles:
    • Calm
    • Contain
    • Care
    • Cope (Kimberg & Wheeler, 2019; Trauma-Informed Behavioral Care, 2014).

Crisis Interventions

  • Focus: Utilize therapeutic responses, de-escalation techniques, and support from team members (The National Institute for Occupational Safety and Health, 2020).

Disaster Management: Role of Mental Health Nurse

  • Key Responsibilities:
    • Provide psychological first aid and both physical and emotional support.
    • Identify problems and prioritize steps/actions needed (State of Indiana, n.d.).

Behaviors and Manifestations Requiring Further Assistance

  • When to Seek Additional Support:
    • Disorientation
    • Significant depression or anxiety
    • Pre-existing mental illness
    • Suicidal or homicidal ideations/plans.
    • Problems with substance use
    • Interpersonal violence or abuse
    • Prolonged disruptive behaviors/emotions related to disasters (State of Indiana, n.d.).

Post Disaster: Mental Health Risks

  • Possible Disorders Post-Disaster:
    • Adjustment disorders
    • Acute stress disorders
    • Mood disorders, including depression
    • PTSD
    • Anxiety disorders
    • Non-specific somatic symptoms or disorders
    • Substance use disorders (American Psychiatric Association, 2022).

Age-Related Manifestations After Disaster

  • Behavioral Symptoms:
    • Regression behaviors typical in children.
    • Isolation and withdrawal common among adolescents and adults.
  • Physical Symptoms:
    • Eating and sleep disturbances ubiquitous across age groups.
  • Psychological Symptoms:
    • Depression and anxiety prevalent in adolescents and adults, while sadness and angry outbursts may be observed more in children (State of Indiana, n.d.).

Trauma: Disease & Illness Prevention

  • Prevention Strategies Broken Down:
    • Primordial prevention
    • Primary prevention
    • Secondary prevention
    • Tertiary prevention.

Nursing Process and Plan of Care (1 of 3)

  • Initial Steps: Collect data and recognize clinical cues using a trauma-informed perspective.
  • Key Questions: What has happened? Assess current manifestations, evaluate life stressors, and consider functional impairments.

Recognizing Cues (Assessment)

  • Importance: Acknowledge the cues exhibited by clients to provide proper assessment and intervention using trauma-informed approaches (Trauma-Informed Care in Behavioral Health Services, 2014; Ranjbar et al., 2020).

Screening Tools

  • Purpose and Usage:
    • Not for diagnosis but to guide treatment and safety interventions.
    • Steps involve explaining the screening tool and ensuring active listening and support for client's discomfort (Trauma-Informed Care in Behavioral Health Services, 2014).

Nursing Process and Plan of Care (2 of 3)

  • Analyzing Cues: Assess and validate each symptom indicated, searching for evidence of hopelessness or helplessness in the client’s condition.
  • Prioritize Hypotheses: Focus on critical areas like risk for self-harm or harm to others, including command hallucinations (Trauma-Informed Care in Behavioral Health Services, 2014).

Nursing Process and Plan of Care (3 of 3)

  • Developing Solutions (Planning):
  • Client-Centered Care: Building effective relationships focused on safety and collaboration.
  • Execution Steps (Implementation): Implement strategies to enhance coping and diminish negative manifestations while collaborating with health care teams for medication and therapies.

Nursing Process and Plan of Care: Evaluation

  • Response to Interventions: Regularly evaluate the effectiveness of the plan of care and collect feedback from interprofessional teams to adjust resources and support accordingly.

Trauma-Informed Care: Key Principles

  • Core Principles:
    • Safety
    • Trustworthiness and transparency
    • Peer support
    • Collaboration and mutuality
    • Empowerment, voice, and choice
    • Attention to cultural, historical, and gender issues (SAMHSA, 2014).

Pharmacology and Therapies

  • Common Therapeutic Approaches:
    • Cognitive Behavioral Therapy (CBT)
    • Prolonged Exposure Therapy (PE)
    • Cognitive Processing Therapy (CPT)
    • Eye Movement Desensitization and Reprocessing (EMDR)
    • Pharmacotherapy.