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Mental Health
Chapter 16 Trauma, Stressor-Related, and Dissociative Disorders
| Term | Definition |
|---|---|
| Trauma-Related Disorders | Traumatic life events associated with a wide range of psychiatric and other medical disorders Understanding of long-term effects of trauma expanded: Effective treatments available People in need of treatments do not always get the care they need Trauma-informed care |
| Types of Trauma-Related Disorders | Attachment Disorders: Reactive attachment disorder Disinhibited social engagement disorder Posttraumatic Stress Disorder (PTSD): PTSD in children PTSD in adults Acute Stress Disorder Adjustment Disorder |
| Attachment Disorders | Reactive Attachment Disorder: Consistent pattern of inhibited, emotionally withdrawn behavior; unresponsive to caregiver efforts to offer comfort in distress Disinhibited Social Engagement Disorder: No normal fear of strangers; seemingly unfazed by separation from primary caregiver Risk Factors: Neurobiology + environment |
| Posttraumatic Stress Disorder in Children & Adolescents | Manifestations • Reduction in play or play reflecting aspects of the trauma • Self-blame, detachment, estrangement, loss of interest in significant activities • Mood changes, sleep disturbances, hypervigilance, loss of concentration |
| Risk Factors | Genetic: How individuals react to trauma Neurobiological: Trauma dysregulates neural pathways that integrate emotional regulation and arousal Triggers hyperarousal state leading to dissociation Polyvagal theory Environmental factors: Children’s neuroplasticity: Dependence on adults and systems External factors that support or add stress Resilience |
| PTSD Affects the Brain | Amygdala (Fight or Flight) Hippocampus (Store memories) Medial Prefrontal Cortex (Executive functioning) |
| Implementation Stages | Stage 1: Provide safety and stabilization Stage 2: Reduce arousal and regulate emotion through symptom reduction and memory work Stage 3: Catch up on developmental and social skills; develop a value system |
| Interventions for Child with PTSD | Use interactive process Establish trust and safety Use developmentally appropriate language Teach relaxation techniques before trauma exploration to restore a sense of control Use art and play to promote expression of feelings Involve caretakers in 1:1s, unless they are the cause of trauma Educate child and caretakers about grief process and response to the trauma Assist caretakers in resolving their own emotional distress about the trauma Coordinate with social work for protections |
| Evaluation for Child with PTSD | Treatment is effective when: Safety is ensured. Anxiety is reduced, and stress handled adaptively. Emotions and behavior are appropriate for the situation. Child achieves normal developmental milestones. Child is able to seek out adults for nurturance and help |
| Treatment Modalities: Biological Treatments | Pharmacotherapy combined with EMDR therapy or CBT Target symptoms and comorbidities like ADHD or MDD |
| Treatment Modalities: Psychological Therapies | CBT EMDR |
| Trauma-Related Disorders in Adults | Examples of PTSD-Inducing Events Military combat or hostage situations Crime-related events Natural disasters Human disasters (accidents) Experience: Flashbacks: Re-experiencing the trauma Avoidance of stimuli associated with trauma Persistent symptoms of increased arousal (hypervigilance) Alterations in mood |
| Application of the Nursing Process: Assessment | Primary Care PTSD Screen (PC-PTSD) PTSD Checklist (PCL-5) |
| Application of the Nursing Process: Nursing Diagnoses | Post-trauma response Anxiety (moderate, severe, panic) Ineffective coping Social isolation Insomnia Sleep deprivation Hopelessness Chronic low self-esteem Self-care deficit |
| Application of the Nursing Process : Outcome Identification | Manages anxiety Experiences enhanced self-esteem Exhibits an enhanced ability to cope |
| Application of the Nursing Process : Implementation | Use same stage model of treatment used for children Health teaching & promotion |
| Application of the Nursing Process: Evaluation: | Recognizes symptoms as related to the trauma Uses learned strategies to manage anxiety Has no flashbacks or intrusive thoughts Sleeps adequately without nightmares Assumes usual roles Has satisfying interpersonal relationships |
| Treatment Modalities: Biological Treatment: Pharmacotherapy: Antidepressants: SSRIs | Selective serotonin reuptake inhibitors (SSRIs) (treat depressive disorders and anxiety disorders) • First-line therapy • Rare risk of serotonin syndrome (Elevated BP, fever, cardio shock, abd pain) • Takes 4-6 weeks to work • Black box warning for SI under the age of 24 • Help with symptoms of depression • Side effects: Lowers sex drive, GI issues, H/A *** Can activate Mania or Hyper mania*** Block the synaptic reuptake of serotonin Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Proz |
| Psychological Therapies | Components of exposure and/or cognitive restructuring and EMDR therapy |
| Acute Stress Disorder | Develops after exposure to a highly traumatic event Diagnosed 3 days to 1 month after traumatic event |
| Acute Stress Disorder Diagnosis | Diagnosis: 8 or more of the following, during or after traumatic event A subjective sense of 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 |
| Acute Stress Disorder Diagnosis cont. | Avoidance of thoughts or feelings about the event Sleep disturbances Hypervigilance Irritable, angry or aggressive behavior Exaggerated startle response Agitation or restlessness |
| Application of the Nursing Process : Nursing Diagnoses | Post-trauma response Impaired adaptation Anxiety (specify level) |
| Application of the Nursing Process: Outcomes Identification | Reduced response to trauma Improved adaptation Decreased anxiety |
| Application of the Nursing Process: Implementation | Establish therapeutic relationship Assist to problem solve Connect person to supports Educate about ASD Collaborate for coordination of care Ensure and maintain safety Monitor response and/or adherence to treatment |
| Treatment Modalities: Psychological Therapies: | CBT: Exposure therapy - Confront memories in a safe environment until they feel distress. In Vivo exposure - Gradually confront situation, people or places they have been avoiding. Cognitive Therapy - Address unhealthy beliefs & assumptions associated with the trauma. Specialized protocols for EMDR therapy |
| Adjustment Disorder | A milder, less specific version of ASD and PTSD Precipitated by stressful event Symptoms may include all forms of distress (guilt, depression, anxiety, anger) These feelings may be combined with other manifestations of distress (physical complaints, social withdrawal, impaired occupational function, academic decline) |
| Dissociative Disorders | Disconnection or Lack of continuity between the individual & their own thoughts, memories, actions and identify. -Dissociation is a defense mechanism using separate parts of the personality that are not fully integrated, each becoming dominant depending on the situation These are the different types of dissociative disorders - On a Spectrum from High to Low: Dissociative Amnesia (Middle) Depersonalization/Derealization Disorder (Low) Dissociative Identity Disorder (High) |
| EMDR therapy | Eye movement desensitization & Reprocessing (EMDR). -Individuals move their eye back & forth across the field of vision; while recalling traumatic memories -It evolved over time to incorporate aspects of cognitive and exposure therapy. |
| Dissociative Disorders : Clinical Picture | Occur after significant adverse experiences/traumas Individuals respond to stress with severe interruption of consciousness Unconscious defense mechanism Protects individual against overwhelming anxiety through emotional separation Results in disturbances in memory, consciousness, self-identity, perception |
| Dissociative Amnesia | Inability to recall important personal information Often of traumatic or stressful nature Dissociative fugue : Subtype characterized by sudden, unexpected travel and inability to recall one’s identity/information about the past |
| Depersonalization/ Derealization Disorder | Persistent or recurrent episodes of… Depersonalization—focus on self: extremely uncomfortable feeling of being an observer of one’s own body or mental processes Derealization—focus on outside world: recurring feeling that one’s surroundings are unreal or distant. Person feels as if walking around in a fog, bubble, or dream. |
| Depersonalization | focus on self: extremely uncomfortable feeling of being an observer of one’s own body or mental processes |
| Derealization | focus on outside world: recurring feeling that one’s surroundings are unreal or distant. Person feels as if walking around in a fog, bubble, or dream. |
| Dissociative Identity Disorder | Presence of two or more distinct personality states Each alternate personality (alter) has own pattern of: Perceiving Relating to and Thinking about the self and environment Cognitive distortion an insistence that the “alters” inhabit separate bodies and are unaffected by the actions of one another |
| Application of the Nursing Process: Assessment | Memory assessment History (especially of self-harm) Mood Impact on patient and family Suicide risk Self-assessment |
| Application of the Nursing Process : Nursing Diagnosis | Disturbed personal identity Impaired role performance Anxiety (specify level) |
| Application of the Nursing Process :Outcomes Identification (personality integration) | Improved personal identity Improved role performance Reduced anxiety |
| Application of the Nursing Process: Planning | Phase 1: safety, stabilization, symptom reduction Phase 2: confronting and integrating traumatic memories Phase 3: Identify integration and rehabilitation |
| Application of the Nursing Process : Implementation | Implementation Process of integration and linking previously disconnected neural networks Interventions offering emotional presence Health Teaching and Promotion • Normalize experiences by explaining symptoms are adaptive responses to past overwhelming events • Teach grounding techniques |
| Application of the Nursing Process : Evaluation | Treatment effectiveness for dissociative identity disorder is “integration” Treatment considered successful when outcomes are met: • Patient safety maintained • Anxiety reduced • Integration of fragmented memories • New coping strategies • Stress is handled adaptively, without use of dissociation |
| Treatment Modalities: Pharmacotherapy | No specific medications Medications for hyperarousal and intrusive symptoms -Naltrexone - Improve disassociative symptoms -Lamotrigine - Mood stabilizer.: Used for Depersonalization/Derealization |
| Psychological Therapies | CBT (Change Harmful thinking patterns, feelings and behaviors) Exposure therapy, Modified EMDR therapy(Diminish negative feelings associated with traumatic events) Somatic Therapy |
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bonitasoul
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