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Mental Health

Chapter 16 Trauma, Stressor-Related, and Dissociative Disorders

TermDefinition
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Attachment Disorders Reactive Attachment Disorder: Consistent pattern of inhibited, emotionally withdrawn behavior; unresponsive to caregiver efforts to offer comfort in distress Disinhibited Social Engagement Disorder: No normal fear of strangers; seemingly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
Created by: bonitasoul
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