Trauma, Stressor Related and Dissociative Disorders

Complicated Grieving/Prolonged Grief Disorder

• Loss of a loved one must have occurred at least one year ago for adults or at least six months ago for children and adolescents.
• Experienced at least 3 symptoms nearly every day for at least the last month prior to the diagnosis.
  • Identity disruption (feeling as though part of oneself has died).
  • Marked sense of disbelief about the death.
  • Avoidance of reminders that the person is dead.
  • Intense emotional pain (anger, bitterness, sorrow) related to the death.
  • Difficulty with reintegration (problems engaging with friends, pursuing interests, planning for the future).
  • Emotional numbness (absence or marked reduction of emotional experience).
  • Feeling that life is meaningless.
  • Intense loneliness - feeling alone or detached from others.
  • Functional Impairment: Significant difficulty in social, occupational, or other important areas of functioning. This could manifest as an inability to maintain relationships, poor performance at work, or neglecting personal care.
  • Cognitive Impairment: Difficulty concentrating, making decisions, or remembering things related to the deceased or the circumstances of their death.
  • Behavioral Changes: Noticeable changes in behavior such as social withdrawal, restlessness, or engaging in self-destructive behaviors.

Stages of Grief

• Denial- Client has difficulty believing a terminal diagnosis or loss.
  • Example: A patient might refuse to accept their cancer diagnosis or insist there was a mistake in the lab results.
• Anger- Anger is directed toward self, others, or objects.
  • “Why is this happening to him?” “This isn't fair.”
  • Example: A person may express anger at the doctors for not providing better care, at themselves for not detecting the illness sooner, or at the deceased for leaving them.
• Bargaining- Client negotiates for more time or a cure.
  • “If I can just make it to my daughter’s wedding.”
  • “I just want my dad to be here for my wedding.”
  • Example: Someone might promise to quit smoking or start exercising if they can have more time with their loved ones.
• Depression- Client is overwhelmingly saddened by the inability to change the situation.
  • Example: Experiencing deep sadness, loss of interest in activities, changes in appetite or sleep, and feelings of hopelessness.
• Acceptance- May have come to terms with it.
  • Doesn't mean they're okay, but have just accepted it.
  • Example: Acknowledging the reality of the loss and finding ways to live with it, even though it is painful. This might involve making plans for the future, cherishing memories, and focusing on new aspects of life.

Intervention

• Determine the stage of grief in which the patient is fixed.
• Explain to the patient the normal stages of grief and the behaviors associated with each stage.
  • Provide educational materials: Offer pamphlets, books, or online resources that describe the grieving process and what to expect. This helps normalize their experience and provides reassurance.
• Allow the patient to express anger.
  • Create a safe space: Encourage the patient to express their anger without judgment. Let them know that it’s okay to feel angry and that you are there to listen.
• Assist the patient to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercises, volleyball, exercise bike).
  • Physical outlets: Suggest activities that help release physical tension and aggression, such as hitting a punching bag or engaging in a high-intensity workout.
• Encourage the patient to review their perception of the loss or change.
  • Guided discussions: Facilitate conversations where the patient can talk about their loss from different perspectives. Encourage them to explore the positive and negative aspects of their relationship with the deceased or the situation they are grieving.
• Communicate to the patient that crying is acceptable.
  • Validate emotions: Reassure the patient that crying is a normal and healthy response to loss. Provide tissues and a comfortable environment.
• Help the patient to solve problems as attempts are made to determine methods for more adaptive coping with the stressor.
• Encourage support groups: Recommend grief support groups where the patient can connect with others who have experienced similar losses. Sharing experiences and strategies can be incredibly helpful.
  • Promote self-care: Emphasize the importance of taking care of oneself during the grieving process. This includes getting enough rest, eating well, staying hydrated, and engaging in activities that bring comfort and joy.

Acute Stress & Post Traumatic Stress Disorder

• Exposure to actual or threatened death, serious injury, or sexual violation, in one (or more) of the following ways:
  • Directly experiencing the traumatic events
  • Witnessing (in person), the event as it occurred to others.
  • Learning that the events occurred to a close family member or close friend
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event
• Fear, hopelessness, horror.
• Precipitating Event:
  • BOTH involve witnessing or experiencing an event that threatens severe injury or death
• Onset
  • Acute Stress= begin immediately
  • PTSD= occur at any time, often within delays (days, weeks, months, or years)
• Duration
  • Acute stress= less than 30 days
  • PTSD= over 30 days
• When experiencing the event
  • BOTH= dreams, images, flashbacks
  • PTSD adds delusions and hallucinations
• Manifestation
  • BOTH= irritability, sleep disturbances
  • Acute stress= dissociative ness (amnesia) , absent emotional response, decreased awareness of surroundings
  • PTSD= difficulty concentrating, avoid stimuli associated with the trauma (avoiding person, place), and inability to show feelings
• D= Detachment (to others)
• R= Re-experience
• E= Emotional effects (emotional distress)
• A= Avoidance (avoiding stimuli)
• M= Medication (pt with PTSD may self medicate with alcohol or other drugs)
• S= Sympathetic hyperactivity (hypervigilant & hyperarousal state)

Interventions

• Assign the same staff as often as possible.
  • Rationale: Consistency in care providers can create a sense of safety and predictability, which is crucial for individuals who have experienced trauma.
• Use a nonthreatening, matter-of-fact but friendly approach.
  • Communication: Keep your tone calm and neutral. Avoid being overly sympathetic, as this can sometimes be overwhelming for the patient.
• Respect the patient’s wishes regarding interaction with individuals of the opposite gender at this time.
  • Cultural and personal sensitivity: Be aware that some individuals may have specific cultural or personal preferences regarding interactions with people of different genders, especially after a traumatic event.
• Be consistent; keep all promises; convey acceptance; spend time with the patient.
  • Building trust: Consistency in actions and words helps to build trust. Keeping promises shows the patient that you are reliable and supportive.
• Stay with the patient during periods of flashbacks and nightmares.
  • Safety and reassurance: Staying with the patient provides a sense of safety and can help ground them in reality during a flashback or nightmare.
• Encourage the patient to talk about the trauma at their own pace.
  • Empowerment: Allowing the patient to control the narrative and timing of their story empowers them and prevents re-traumatization.
• Discuss coping strategies used in response to the trauma as well as those used during stressful situations in the past.
  • Identifying strengths: Exploring past coping strategies can help the patient recognize their own resilience and identify what has worked for them in the past.
• Assist the individual to comprehend the trauma.
  • Psychoeducation: Provide information about trauma and its effects on the brain and body. This can help the patient understand their reactions and reduce self-blame.
• Acknowledge feelings of guilt or self-blame that the patient may express.
  • Validation: Acknowledge that these feelings are common but not necessarily based on reality. Help the patient challenge these thoughts and replace them with more rational ones.

Treatment Modalities

• Cognitive Behavioral Therapy
• Prolonged exposure therapy
  • Reduce their anxiety and reduce avoidance
• Group and family therapy
• Eye movement desensitization and reprocessing (EMDR)
  • Following the therapist hand movement with their eyes
• Digital therapeutics
  • Smart watches?
• Psychopharmacology
  • Antidepressant → SSRI
  • Anxiolytics
  • Antihypertensive
  • Other Medications

Dissociative Identity Disorder

• Multiple Personality Disorder (old name).
• Characterized by the existence of 2 or more personality states in a single individual (alter identities or alters).
• Only one alter is evident at any given moment.
• One alter is dominant most of the time over the course of the disorder.
• Each alter is unique and has its own set of memories, behavior patterns, and social relationships.
• Transition from one alter state to another is sudden or gradual and sometimes dramatic.
• Denial, acting out, sublimation, regression, suppression, projection, etc. are all forms of defense mechanisms. Mostly unconscious and maladaptive coping mechanisms.
• Dissociation is another form of defense mechanism.
  • A mental process where they disconnect from their thoughts, feelings, memories, or even identities. An extreme method of coping with stress.
• Some switches are rapid, some noticeable, while others are gradual

Treatment

• Achievement of integration
  • Blending of all the personality states into one.
• Intensive long-term psychotherapy
  • Insight-oriented psychotherapy
• Cognitive behavior therapy
• Trauma informed treatment approaches

Child, Older Adult, and Intimate Partner Violence

Statistics

• 10% of children have been sexually abused
• Intimate partner violence
  • \frac{1}{3} woman
  • \frac{1}{4} men
• Older adults- 1 in 10 people over the age of 60

The Cycle of Battering

• Profile of the VICTIM
  • Largest % are women
• Profile of the VICTIMIZER
  • Largest % are men
• Female victim have low self- esteem and adhere to feminine stereotypes
• For men, they also have low self-esteem and are pathologically jealous and dual personalities, and also easily stressed with limited coping abilities. Possessive, and threatened when women express independence. Ignore children at first but can abuse them when they get older. Like using threats to take kids away.
• All ages, races, religion, cultures, and socioeconomic backgrounds can fit here. No discrimination when it comes to violence.

Tension-Building Phase (Phase I)

• Abusers are edgy with minor explosions. Pushing, punching, slapping etc.
• Victims are tense and afraid, walking on eggshells. Feels helpless, becomes compliant, and accepts blame. Victims rationalize abuse and actions.
  • “Of only he doesn't drink, he wouldn't hit me”

Serious Battering Phase (Phase II)

• Most violent
• The abuser loses control.
• Victims can provoke incidents to get it over with, and usually cover up injuries or look for help ONLY if there will be death to her and/or her kids. Dissociates often. Help is unfortunately not sought.

Honeymoon Phase (Phase III)

• Abusers give loving behaviors such as gifts, flowers, and special events. Promises to change
• Victims trust, hope for change, and want to believe promises.
• Unfortunately this will be a cycling because victim will not change
• Victim is 75% more to be killed post relationship.

Types of abuse

• Physical- When physical harm or pain is involved
• Sexual- When sexual contact takes place w/out consent, whether vulnerable person is able to give consent or not
• Emotional- Behavior that minimizes an individual's feelings of self- worth or humiliates, threatens or intimidates a family member
• Economic/ Financial- Failure to provide for the needs of a vulnerable person when adequate funds are available

Assessment

• Establish trust; non threatening and supportive
• Person who experienced violence should be allowed to tell the story without interruptions
• Be direct, hones, and professional
• Use language patient understand
• Inform patient if you must make a referral to children or adult protective services and explain process
• Do not display horror, anger, shock, or disapproval of the perpetrator or situation
• Do not allow the pt to feel “at fault” or “in trouble”
• Do not display horror, anger, shock, or disapproval of the perpetrator or situation
• Do not probe or press for answers the patient is not willing to give

Physical Abuse

• Infants- Shaken baby syndrome ( intracranial hemorrhage)
• Preschoolers to adolescents- Assess for unusual bruising, mechanism of injury, burns, fractures, human bite
  • Marks, head injuries
• Older adults- Assess for bruises, laceration, abrasions, or fractures, in which appearance doesn't match the Hx or mechanism of injury
• If the explanation DOES NOT match the injury seen or if the patient minimizes the seriousness of the injury, you should suspect abuse

Trauma Informed Care

• Foundational to all treatment modalities when responding to survivors of abuse and neglect
• The 4 R’s
  • Realize- The victim needs to understand the trauma and what is happening to them
  • Recognize- Identifying the signs of trauma
  • Responding- Integrating trauma informed practices
  • Resist- Preventing retraumatization
• Patient Centered Care
  • Mandatory reporting
• Document subjective and objective data obtained during assessment
• Provide basic care to treat injuries
• Make appropriate referrals
• Help client develop a safety plan
• Make sure clients are physically and psychologically safe from harm

Prevention

• Primary- Identifying individuals and families at risk
  • Providing health teaching
  • Coordination with support services
• Secondary- Screening programs for individuals at risk, participate in the medical treatment of injuries resulting from violent episodes, coordinating community services
• Tertiary- Occurs in mental health setting
  • Legal advocacy programs for survivors

Sexual Assault

Sexual Violence

• Any act of sexual coercion, including penetration, unwanted sexual contact, and noncontact unwanted sexual experiences

Sexual Assault

• Any type of sexual act in which an individual is threatened or coerced to submit against their will

Rape

• The expression of power and dominance by means of sexual violence
• Ranges from surprise attack by a stranger to insistence on sexual intercourse by acquaintances or spouse
• Rape is an act of AGGRESSION not one os passion

Acquaintance Rape (date rape)

• If the encounter is a social engagement agreed to by the victim
• Is a term applied to situations in which the rapist is acquainted with the victim
  • Such as first date, dating for a few months, school mates
• College campuses are the locations for staggering numbers of these rapes

Marital Rape

• Case in which a spouse may be held liable for sexual abuse directed at a marital partner against that persons will

Statutory Rape

• Defined as unlawful intercourse between a person who is over the age of consent with a person who is under the age of consent
  • Ranges from 16-18 years old to legally consent to sexual consent

Profile the victimizer

• Seeking out vulnerable person
• Violate or ignore others rights
• Use of drugs

Rape Trauma Syndrome

• Form of PTSD that happens after sexual assault

Expressed response pattern

• Emotional outburst
  • Crying, laughing, hysteria, anger, incoherence (book)
  • Feeling of fear, anger, and anxiety

Controlled response pattern

• Feelings are masked or hidden
• Appear calm and have blunted affect but can also be confused, have difficulty making decisions and feel numb (book)

Compound rape reaction

• Depression, suicide, substance abuse, psychotic behaviors

Silent Rape Reaction

• Tell NO ONE!!
  • Can abrupt changes in relationships with partners
  • Nightmares
  • Increased anxiety during interviews
  • Marked changes in sexual behaviors
  • Sudden onset of phobic reactions
  • No verbalization of the occurrence of sexual assault

Evident in days and weeks after attack (somatic reaction?)

• Contusion and abrasions
• Headaches, fatigue, sleep disturbances
• Stomach pains, N/V
• Vaginal discharge and itching
• Rage, humiliation, embarrassment, desire for revenge, and self blame
• Fear of physical violence and death

Drugs associated with Date rape

GHB (gamma-hydroxy-butric acid)

• liquid, white powder, pill
  • Street name = “G” and “liquid ecstasy”
  • When consumed with alcohol, the ONSET is within 5- 20 min
  • duration= 1-12 hours
  • Produces relaxation, euphoria, incoordination, confusion, deep sedation, and amnesia

Flunitrazepam (Rohypnol)

• Pill dissolves in liquids
  • Street names= “roofies” “club drug” “roachies”
  • Onset = 10-30 min
  • duration= 2-12 hours
  • More potent when combined with alcohol
  • Causes sedation, psychomotor slowing, muscle relaxation, amnesia

Ketamine

• Liquid or white powder
  • Onset IV= 30 sec, PO= 20 min
  • duration= 30-60 min
  • Amnesia effects may last longer
  • Can become paranoid or delirious with jeweling or hallucinations
  • With dye to detect the drug on drinks…(SPIKED)
  • Light drink = turns bright blue
  • Dark drinks = turns cloudy

Acute Stress

• Manifestations appear and persist at least 3 days and can extend to 1 month. If longer than 1 month, then it is classified as PTSD

PTSD

• Can occur beyond 1 month after the attack
• Reliving the moment (flashbacks, dreams, intrusive thoughts)
• Increased activity due to fear of assault to reoccur (visiting friends, moving residence)
• Hyperarousal and increased emotional responses (easily startled, anxiety, angry outburst, difficulty falling asleep/ concentrating)
• avoidance , fears and phobias
  • Fear of being alone, fear of sexual encounters,
  • Avoiding triggers of event, memory problems of trauma, emotional numbness, guilt, depression
• Difficulties with daily functioning, low self esteem, depression, sexual dysfunction, and somatic reports
  • Headache or fatigue

Interventions

• It is important to communicate the following to the individual who has been sexually assaulted
  • “You are safe here”
  • “I’m sorry that it happened”
  • I’m glad you survived”
  • “It’s not your fault. No one deserves to be treated this way”
  • “You did the best that you could”
• Explain every assessment procedure that will be conducted & why is it being conducted
• Ensure that the patient has adequate privacy for all immediate post- crisis interventions
• Encourage the patient to give an account of the assault. Listen, but do not probe.
• Discuss with the patient whom to call for support or assistance. Provide information about referrals for aftercare

Sexual Assault Nurse Examiner (SANE)

• Perform self-assessment
  • Be empathetic, objective, and non judgmental
• Assist SANE with physical examination and the collection, documentation, and preservation of forensic evidence in a private environment
  • Collection kit= collecting blood, oral swabs, hair samples, nail swabs, or scrapings and genital, anal, or penile swabs
• Document subjective data using patients verbatim statements
• Obtain informed consent to collect data that can be used as
  • Legal evidence (phots, pelvic exam)
• Assess for indications of emotional and/ or physical trauma
• Assess for suicidal ideation
• Administer prophylactic treatment for STI’s as outlined by the CDC and prevention
• Evaluate for pregnancy risk and provide for prevention (contraception)

Nursing Actions

• Provide numbers for 24hr hotlines for sexual assault survivors
• Promote self care activities. Give follow-up instructions in writing, because client might be unable to comprehend or remember verbal instructions
• Initiate referrals for needed resources and support services. Individual psychotherapy and group therapy can be helpful to increase coping skills and prevent long term disability (depression or SI)
• Schedule follow up calls or visits at prescribed intervals after the assault
• Emphasize importance of after care as sexual assault pt’s historically have a poor compliance rate with follow-up visits

Somatic Symptom Disorder

• The psychological and emotional expression of stress shown with physical symptoms.
  • Instead of feeling anxiety, depression, or irritability…
  • you may experience head, back, or chest pain, paralysis, unexplained skin rashes and other symptoms
• There is NO ORGANIC PATHOLOGY TO BE FOUND FOR THESE PAINS. Diagnostic procedures, assessments, and labs will find nothing wrong.

Types of Disorders:

• Somatic symptom disorder:
  • A combo of distressing symptoms with excessive or maladaptive response or associated health concerns, without significant physical findings and medical diagnosis
  • Patients’ suffering is authentic, and they typically experience a high level of functional impairment.
  • Symptoms may be initiated, exacerbated, or maintained by combinations of biological, psychological, and sociocultural factors.
  • Symptoms can affect any body part or system, be vague or exaggerated
  • Symptom unexplained medically lead to patient stress and “doctor shopping”
  • Symptoms are usually present for longer than 6 months
  • Target system is: gastrointestinal, but multiple systems as well (very vague).
  • Difficult to distinguish from physical disorders with organic causes.
  • Anxiety and depression are often comorbidities
  • Use SSRIs.
  • To target worry and anxiety
• Illness anxiety disorder:
  • Characterized by extreme worry and fear about the possibility of having a disease, used to be called hypochondriasis.
  • Actual symptoms and complaints of symptoms are either mild or absent.
  • Thoughts about illness may be intrusive and hard to dismiss even when patients realize the fear is unrealistic.
  • Reassurance seekers make frequent medical appointments to be sure that their “symptoms” are nothing.
  • Clients research their suspected disease excessively and examine themselves repeatedly
  • Primary issue is intense anxiety about potential physical illness
  • Example: worrying a rash might be cancerous despite medical reassurance
  • 0
  • Use SSRIs.
• Conversion disorder/ Functional Neurological Symptom Disorder
  • Manifests itself as neurological symptoms in the absence of a neurological diagnosis. (Functional Neurological Symptom disorder)
  • Symptoms often unrecognized by client
  • Difficulty speaking or swallowing for example.
  • Arms feeling numb when you can’t manifest anger physically.
  • Thought to help resolve internal conflicts.
  • Cannot be medically explained.
  • Marked by the presence of deficits in voluntary motor or sensory functions.
  • Blindness, paralysis, seizures, gait disorders, hearing loss
  • Motor(neurological) = paralysis, movement/ gait disorders, seizure-like movement
  • Sensory= blindness, inability to speak, inability to smell, numbness, deafness, tingling/ burning sensation
  • Attributed to channeling of emotional conflicts or stressors into physical symptoms, especially when trying to repress them.
  • Patients truly believe in the presence of the symptoms; they are not fabricated or under voluntary control.
  • La belle indifference: An associated symptom where a client’s apparent indifference to symptoms that seem very serious to others. Being curious or having a unique reaction to a symptom as an example, and is considered a maladaptive defense mechanism.
  • Might get worse d/t an underlying psychological disorder.
• Psychological factors affecting medical condition:
  • Psychodynamic Theories:
  • Psychogenic complaints of pain, illness, or the loss of physical function are related to repression of a conflict.
  • Behavioral Theories:
  • People with somatic symptoms learn methods of communicating helplessness and that these methods help the individuals to manipulate others. (such as Factitious disorder)
  • Cognitive Theories:
  • Patients with somatic symptoms focus on body sensations, misinterprets their meaning, and become alarmed by them.
  • Environmental Theories:
  • Childhood events can result in lifelong problems, including somatization disorders.
  • Childhood trauma exposure accounts for negative outcomes across a variety of diagnoses in later life, including somatic symptoms.
• Factitious Disorder:
  • Also known as “Munchausen Syndrome”
  • People with a factitious disorder consciously pretend to be ill to get emotional needs met and attain the status of “patient”.
  • They want the emotional care and attention that patients get. Actions are conscious but the motivation is unconscious.
  • Patients with this disorder artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury, with the goal of assuming a sick role.
  • Results in disability and immeasurable costs to the health care system.
  • A compulsion, it’s very difficult for them to resist doing this, and patients are very skillful at making their symptoms appear real.
  • Before taking a temperature, they may drink hot water to maintain the illusion, or even harm themselves to produce symptoms.
• Factitious Disorder Imposed on Another:
  • Munchausen syndrome by proxy
  • A caregiver deliberately falsified illness in a vulnerable dependent.
  • The diagnosis is imposed on the perpetrator and not the victim.
  • Purpose of attention and excitement and to perpetuate the relationship within the healthcare provider.
  • A famous example of this disorder is Dee Dee Blanchard, who subjected her daughter, Gypsy Rose to a childhood of horrendous abuse. Dee Dee claimed that her daughter had muscular dystrophy, apnea and seizures. Gypsy Rose was confined to a wheelchair in public, was fed with a feeding tube, slept with a breathing machine, and was given anticonvulsants for non-existent seizures.
• Malingering
  • A consciously motivated act to deceive based on the desire for material gain (monetary or otherwise; avoiding work or punishment).
  • It involves a process of fabricating an illness or exaggerating symptoms in order to
  • Become eligible for disability compensation
  • Commit fraud against insurance companies
  • Obtain prescription medications
  • Evade military service
  • Example; feigning illness to get a sick day for pay or exaggerating a foot injury to get a handicap parking pass
• Psychological factors affecting medical condition:
  • Psychodynamic Theories:
  • Psychogenic complaints of pain, illness, or the loss of physical function are related to repression of a conflict.
  • Behavioral Theories:
  • People with somatic symptoms learn methods of communicating helplessness and that these methods help the individuals to manipulate others. (such as Factitious disorder)
  • Cognitive Theories:
  • Patients with somatic symptoms focus on body sensations, misinterprets their meaning, and become alarmed by them.
  • Environmental Theories:
  • Childhood events can result in lifelong problems, including somatization disorders
  • Childhood trauma exposure accounts for negative outcomes across a variety of diagnosis in