Chapter 10
Trauma and Stress-Related Disorders
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Objective 1: Discuss four examples of how eustress has
helped you in your life and two examples of how distress
has affected you in your life.



Stress and our responses to it are central to psychiatric
disorders and the provision of mental health care.
Eustress
Distress
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Objective 2: Describe some of the common symptoms
people experience when they are stressed.
When individuals feel stressed out, they may have trouble:
 Sleeping
 Eating
Or may:
 Experience headache or back pain
 Lose interest in favorite activities
 Feel tense and become irritable
 Feel powerless
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Long-term chronic stress can cause
physiologic harm
and
emotional difficulties.
Explain!
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Physiologic and Emotional Sequelae
(Results) of Prolonged Stress
Eczema and
other skin
disorders
Heart
disease
Stomach
ulcers
Cancer
Depression
Asthma
Colds
and
influenza
Prolonged
Stress
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Posttraumatic
stress
disorder
5
Objective 3: Describe the physiologic manifestations of the
fight-or-flight response of the autonomic nervous system
when triggered by a stressor.
Fight or Flight
Rest and Digest
Sympathetic Nervous
System (SNS)
Parasympathetic Nervous
System (PNS)
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Stress Operationally Defined
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Stress Signaling System
Alertness Heightened
Circulating adrenaline = ↑ heart rate, ↑ blood
pressure, ↑ respirations, ↑ blood flow
Pituitary gland
releases ACTH
Epinephrine (adrenalin)
is released
SNS signals adrenal glands
Hypothalamus stimulates autonomic
nervous system
Brain signals hypothalamus
The body prepares for a situation that
threatens survival!
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Stress Signaling System (Cont.)
Sympathetic Nervous System
Pituitary gland releases adrenocorticotropic hormone (ACTH),
and adrenal cortex secretes cortisol.
Hormones Secreted
Adrenal medulla secretes stress
hormones (e.g., epinephrine).
Stress hormones travel via bloodstream
to organs (e.g., heart, intestines).
Stress Response
Smooth muscles or glands activate
(e.g., pupils dilate).
Fight or Flight
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Objective 4: Describe, physiologically, the role of the
hypothalamus-pituitary-adrenal (HPA) gland in chronic
stress.
Epinephrine
• Subsides
as the
threat
passes.
Hypothalamus
• Stimulates
the HPA axis.
Corticotropicreleasing
hormone
(CRH)
When stress is prolonged,
chemicals produced by the stress
response (cortisol, adrenaline, and
other catecholamines) can have
damaging effects on the body.
• Travels to the pituitary gland.
Acetylcholine
(ACh)
Travels to the adrenal glands.
Cortisol is
released
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Case Study
Jolene and Kathryn, mathematics professors, discuss work
stress and tiptoe around personal issues.
 Jolene has a good marriage; no children at home; and
chronic, debilitating muscle and joint pain. She grew up
“street smart,” where physical needs were not always
met and harsh physical punishment was common.
 Kathryn is having marital problems (emotional abuse
from husband) and “teenager problems” with 15-year-old
twins. She is a quiet person from a professional family,
went to the best schools, but feels very little love and
emotional support from distant parents.
(Continued)
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Case Study (Cont.)

Based on the information in the previous slide,
describe how the HPA role in chronic stress might
be experienced by each person.

What possible elements do you expect might impact
each person’s coping skills in dealing with chronic
stress?

What physical and psychologic outcomes might you
predict if the stress level does not subside?
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Stress-Reduction Techniques

Eliciting the relaxation response

Physical activity

Social supports (e.g., close family ties,
acquaintances, spouses, friends)

For more on selected stress reduction
techniques, refer to Box 10-1 in the textbook.
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Stress-Related Disorders

Posttraumatic Stress Disorder (PTSD)
Usually occurs after a traumatic event outside
the range of usual human experience.

HPA system is abnormal.

Major depression frequently occurs.

If left untreated or undertreated, painful
repercussions can result.
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Posttraumatic Stress Disorder

Examples of Traumatic Events
Childhood physical abuse, torture, or
kidnapping; military combat; sexual assault;
natural disasters; human disasters

Crime-related events: terror attacks, assault,
mugging, rape, incest, taken hostage

Diagnosis of a life-threatening illness
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Posttraumatic Stress Disorder
(Cont.)
The common element in these experiences
(traumatic events) is extraordinary
helplessness or powerlessness.
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Posttraumatic Stress Disorder
(Cont.)

Flashbacks

Avoidance of stimuli associated with
trauma

Persistent negative alterations in mood
and cognition: guilt; detachment

Persistent symptoms of increased
arousal (angry outbursts, self-destructive
behavior, startling, sleep difficulties)
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Traumatic Brain Injury
Besides PTSD, the military estimates that up to
19%-20% of our combat veterans in both
Afghanistan and Iraq suffer some degree of
traumatic brain injury (TBI).
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Traumatic Brain Injury (Cont.)
TBI is also found in people involved in contact sports,
accidents, and falls, and in patients diagnosed with shaken
baby syndrome and Alzheimer dementia.
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Psychotherapeutic Treatment
Strategies

Cognitive behavioral therapy (CBT)

Selective serotonin reuptake inhibitors (SSRIs)

Group therapy with others who have had
traumatic experiences

Family therapy
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Psychopharmacology

Psychotherapy is the treatment of
choice for individuals with PTSD.

When target symptoms arise and
become serious, medications can be
used and may serve to help the patient gain
emotional control.
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Psychopharmacology (Cont.)
Pharmacology for Target Symptoms of PTSD
Depression
Antidepressants
Intrusive experiences (flashbacks,
avoidance, and numbing)
SSRI antidepressants, secondgeneration antipsychotics
Treatment-resistant PTSD
Second-generation antipsychotics,
anticonvulsants
Panic attacks
Antidepressants, monoamine
oxidase inhibitors (MAOIs), highpotency benzodiazepines
Hyperarousal
Antidepressants, benzodiazepines,
anticonvulsants
Nightmares
Prazosin (Minipress)
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Critical Incident Debriefing

Debriefing—valuable in ameliorating symptoms
of acute stress response

Benzodiazepines—to treat daytime anxiety

Sedative hypnotics—for sleep

Medications—short-term, in conjunction with
crisis intervention and other psychologic
treatments
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Self-Care for Nurses
Compassion Fatigue
and Secondary Trauma
Examples of nurses who are at high risk
include those who work in the following
departments and disciplines:
 Hospice
 Pediatrics
 Emergency
 Oncology
 Forensics
 Psychiatric
The makeup of the nurse can potentiate compassion
fatigue.
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Audience Response Question
Jon, an emergency department (ED) nurse, has just worked an
8-hour shift in the ED. After a five-car wreck during his midshift,
five patients have been transported to the hospital with multiple
injuries and one fatality. Jon looks exhausted, and his hands are
tremulous. He insists that he is scheduled to work another
6 hours. As the nurse manager, what is your best action?
A. Tell him that he needs to end his shift right away.
B. Tell him he needs to nap for 30 minutes and then return to
work.
C. Tell him to go to the cafeteria, relax, and drink strong coffee.
D. Tell him to eat a high carbohydrate snack, take a 30-minute
break, and then return to work.
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Answer
A. Your role as nurse manager of patient care includes
deciding who is safe to work, and Jon is not safe.
B. Sleeping on the job is not an acceptable practice in
a hospital setting.
C. Although food and fluids may help with Jon’s
exhaustion, strong coffee could contribute to further
tremulousness.
D. Although food and a break may help with
exhaustion, it is not a predictor that Jon will be safe
in his work with patients.
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Role-Play Opportunity
Objective 5: Teach a classmate about PTSD,
including:

Symptoms

How it affects veterans coming home from war

Sequelae (results) of untreated PTSD

Potential treatments

How it affects first responders
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Compassion Stress Versus Fatigue
Objective 6: Discuss how health care workers are
vulnerable to compassion stress and compassion fatigue
and describe the steps.
 Compassion fatigue: Same as secondary stress
trauma.
 Cumulative physical, emotional, and psychologic
effect of working closely with those suffering from the
consequences of heart-wrenching/traumatic events.
 “Compassion stress,” when not managed properly,
can lead to compassion fatigue.
 Behaviors: isolation, depression, self-medication.
 Prevention: Practice self-care.
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Traumatic Brain Injury (TBI)
Objective 7: Explain how assessing for traumatic brain
injury (TBI) is best practice when working with returning
war veterans, as well as other members of the population
who are involved in traumatic injury (e.g., head injuries,
sports injuries, physical abuse).
Traumatic Brain Injury (TBI) Sufferers:
 Up to 20% of our combat veterans
 Children and professional athletes in contact sports
 Victims of accidents, falls, shaken baby syndrome
TBI Complications
 Untreated, TBI can result in permanent disability/brain
damage.
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Acute Stress Disorder
As a result of:
 Witnessing or experiencing
a violent or gruesome death
of or by an intimate
 Repeated exposure to
aversive details of the event
 Example: First
responders who collect
body parts, or police
officers repeatedly
exposed to details of
child abuse
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Acute Stress Disorder (Cont.)

Intrusive symptoms

Dissociative symptoms

Avoidance symptoms

Arousal symptoms

By definition, acute stress disorder resolves
within 1 month.
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PTSD Versus ASD
Objective 8: Compare and contrast the differences between
posttraumatic stress disorder (PTSD) and acute Stress
disorder (ASD).

Similarity: Same triggers (violent events or repeatedly
witnessing violent or traumatic events); same or similar
manifestations.

Difference: Only acute stress disorder (ASD) resolves
within 1 month.
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Compassion Fatigue
Objective 9: Describe what is meant by secondary
traumatic stress/compassion fatigue in terms of (a)
symptoms and (b) health care workers who might be the
most vulnerable.
Symptoms
 Feeling overwhelmed physically and mentally exhausted
 Interferes with ability to function
 Intrusive thoughts/images of another’s critical experience
 Difficulty separating work from personal life
 Becoming pessimistic, critical, irritable, prone to anger
 Dread of working with certain individuals
 Depression
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Compassion Fatigue (Cont.)
Symptoms (Continued)
 Ineffective and/or destructive self-soothing behaviors
 Withdrawing socially and becoming emotionally
disconnected from others
 Becoming demoralizing questioning one’s professional
competence and effectiveness
 Becoming easily frustrated
 Insomnia
 Lowered self-esteem in nonprofessional situations
 Loss of hope
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Compassion Fatigue (Cont.)
Nurses and Staff At Risk—those who work in:
 Hospice care
 Pediatrics
 Emergency departments (EDs)
 Oncology
 Forensic nursing
 Psychiatric nursing
 Social workers who work closely with traumatized
individuals
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Audience Response Question
Andrew, a hospice nurse for 5 years and a member of your
nursing team, is demonstrating a blunted affect and is not
completing patient care documentation in the required time
frame. As a peer, what is your best action?
A. Avoid mentioning these observations because you are
only a peer.
B. Ask Andrew what he feels is causing him to fall behind in
his work.
C. Immediately report your concerns to the nurse manager
in charge of your team.
D. Take Andrew to lunch and keep the conversation light
and humorous.
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Answer
A. A practicing nurse has a legal and ethical responsibility
to communicate concerns with peers.
*B. Developing a trusting relationship with peers and being
honest allows for openness and promotes beneficial
dialog.
C. At this point, there is nothing to report to the manager
because you have just noticed a change in affect and a
slower pace than usual.
D. Taking Andrew to lunch may be helpful, but honest
conversation is what is needed.
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