Psychiatric Nursing: Trauma, Stressor-Related, and Dissociative Disorders
Recovery from Stressors and General Psychological Functioning
The majority of individuals, after experiencing a significant stressor, exhibit the capacity to return to their baseline level of normal functioning once the stressor subsides or is removed.
A specialized category within this domain is known as adjustment disorder.
Adjustment disorder is characterized by a development that may occur slowly, though the symptoms typically do not persist for longer than a duration of months. This period of approximately months is considered an adequate timeframe for most individuals to adjust to significant life changes or stressors.
Post-Traumatic Stress Disorder (PTSD): Diagnostic Criteria and Origins
Formal Definition and Diagnosis: To receive a clinical diagnosis of Post-Traumatic Stress Disorder (PTSD), an individual must have either personally experienced or witnessed a traumatic event.
Criterion of Physical Integrity: A core component of the diagnosis is that the individual must have felt that their life was in immediate danger, or they witnessed a situation where others' lives were threatened.
Examples of Traumatic Events: Typical traumatic triggers include being a victim of assault, experiencing combat, or surviving natural disasters.
Emotional Response Profile: The psychological response to the trauma is often characterized by three primary emotional states: intense fear, a sense of total helplessness, and sheer terror.
Symptoms of PTSD: Re-experiencing, Avoidance, and Hyperarousal
Re-experiencing the Trauma: Individuals often suffer from intrusive recollections of the event. - Nightmares and Dreams: Reoccurring nightmares or dreams are identified as the number trigger and indicator of PTSD. - Intrusive Thoughts: Continuous, unwanted thoughts regarding the traumatic event.
Avoidance Behaviors: Sufferers frequently engage in avoidance to prevent the psychological distress of reliving the event. - Environmental Assessment: An individual may constantly assess their surroundings, checking every exit, looking at every lock, and monitoring the perimeter of a space. - Psychological Rationale: These behaviors are often linked to specific past traumas, such as being held captive or kidnapped, where monitoring exits was previously a survival necessity.
Hyperarousal and Hypervigilance: This state involves being "on guard" or hyper-focused on possible threats. - Examples include being extremely reactive to specific stressors or being unable to relax even in safe environments (e.g., following a fire or other life-threatening incident).
Related Trauma and Stressor Disorders
Acute Stress Disorder: This condition is considered the precursor to PTSD. - Timeframe: It occurs between days and month following the traumatic event. - Progression: If the symptoms—such as re-experiencing the trauma or hyperarousal—persist beyond the one-month mark, the diagnosis may transition from Acute Stress Disorder to PTSD.
Childhood Disorders (Age Under ): These disorders typically manifest in children under the age of and are rooted in a lack of healthy bonding or connection with caregivers. - Etiology: These reactions arise from trauma and the failure to form a secure attachment. - Behavioral Manifestations: Children may display abnormal reactions to people, such as being completely unresponsive to a hug or showing an inappropriate level of intensity in their interactions.
Risk Factors and Manifestations of Trauma
Predisposing Factors: - Support Structure: A lack of a solid support system increases the risk of developing long-term trauma disorders. - Age: The age at which trauma occurs significantly impacts the psychological outcome. - Pre-existing Health: A previous mental health condition makes an individual more predisposed to trauma-related disorders. - Coping Skills: Individuals with poor established coping skills or those who lack resilience are at higher risk.
Manifestations in Children and Adolescents: - Behavioral Issues: Acting out at home or in social settings. - Severe Indicators: Presence of suicidal ideation. - Complex Trauma: Traumas related to sexual abuse or human trafficking have profound impacts on development. - Childhood Amnesia: Some individuals may not remember large portions of their childhood due to the severity of the trauma and the mind's use of dissociation as a defense mechanism.
Dissociative Disorders
Dissociation as a Defense: Dissociation is often seen in patients with PTSD. It involves a detachment from reality or self. The more an individual dissociates, the easier it becomes for the brain to utilize this mechanism in the future.
Impact on Activities of Daily Living (ADLs): Chronic dissociation negatively impacts relationships and the ability to perform basic ADLs.
Dissociative Amnesia: A specific type of dissociative disorder involving memory loss for personal information that is not explained by ordinary forgetfulness.
Dissociative Identity Disorder Case Study (Longwood): - A patient at a facility in Longwood presented with a belief that he was God or Jesus. - The patient would state, "I am God, and I need my meds." - Post-stabilization through medication, the patient experienced a return to his standard identity, reporting that he realized he "couldn't take the burden of being Jesus."
Depersonalization: This involves a detachment from one's own body. - Description: It is often described as an "out-of-body experience," where the person feels as though they are floating above themselves, watching the event happen to someone else while they remain detached. - Protective Factor: It serves as a psychological barrier that allows the person to remember the event without feeling that it is happening to "them" directly.
Nursing Assessment and Care Management
Comprehensive Assessment: Nurses must document a full history of trauma and identify current symptoms.
Safety Assessment Questions: - "Do you feel like harming yourself?" (Assessing for suicidal or self-harm ideation). - "Are you engaging in unhealthy behaviors?" (Checking for substance use, such as alcohol).
Risk Factors for Self-Harm: - Physical behaviors such as cutting or burning the skin. - Eating habits: Overeating or not eating, which are often used as mechanisms to exert control over one's environment or emotions.
Goal of Care: Safety: The primary and absolute reward/goal of nursing care in these cases is always maintaining physical and psychological safety.
Suicide Prevention and Safety Planning
Intention and Means: Clinical assessment must distinguish between the idea of self-harm and the actual intention or means to carry it out. For inpatient units, specific plans (e.g., "I am going to use curtains") must be identified.
Safety Plan Components: - Identifying specific people to call for help. - Placing physical barriers to prevent lethal action (e.g., keeping a gun in one location and locking the ammo in another). - Mobilizing resources to allow more people to intervene before a crisis occurs.
Nurse-Patient Relationship: Supportive interventions often include simple presence, such as "sitting quietly" with the patient or "walking with" the patient to provide a grounding force.
Treatment and Professionalism
Evidence-Based Treatments: - Individual Therapy: One-on-one psychological counseling. - Group Therapy: Shared therapeutic experiences with others who have similar traumas. - Pharmacology: Selective Serotonin Reuptake Inhibitors (SSRIs) are the primary class of medication used.
Goals of Treatment: The main objectives are to improve the overall quality of life and reduce the prevalence of triggers and symptoms.
Nurse Self-Awareness: Nurses must be aware of their own triggers. Past personal traumas (e.g., experiences with hurricanes or household events during natural disasters) can impact the quality of care provided if a nurse is triggered by a patient's situation.
Academic and Examination Requirements
Required Reading: Students must carefully study Chapter , Chapter , and Chapter .
ATI Resource: Students should utilize the ATI book to identify "key test" concepts.
Exam Format: The upcoming test consists of questions.
Pacing: Each student is permitted only minute per question ( seconds per item).