Stress and Trauma-Related Disorders W. CHANCE NICHOLSON, PHD, MS, PMHNP-BC **IMPORTANT STRESS CONCEPTS • Stress: response to any change, situation, unknown or known stimulus that automates (autonomic) a systematic adjustment from one’s current (default) state to a different physiological state • A person reacts to these changes with physical (e.g., respiratory, cardiovascular, immune), motor, cognitive, and emotional responses that serve a physiological goal of “regulation” • Stress, time-limited and/or modifiable in nature, is a normal part of life and is important to our development (e.g., coping skills) IMPORTANT STRESS CONCEPTS • Acute Stress: intense, autonomic, immediate reaction (i.e., fight or flight) of one’s physiology to a significant threat, challenge, unpredictability • Is time-limited due to stressor(s) being neutralized • Can have negative impact on health pending event, duration, and intensity (e.g., co-occurring with other compounding or chronic stressors) • Chronic Stress: persistent physiological response (sympathetically primed default) to ongoing stressors • Promotes wear and tear on body (e.g., accelerated aging) • Increases susceptibility to mental health disorders • “Toxic-Stress” IMPORTANT STRESS CONCEPTS • Homeostasis: (homeo = similar; stasis = balance): • Optimal (free-energy) physiological functioning when balancing predictable internal and external environment • Physiological resistance to state changes, which keeps body in a well-coordinated or “similar” state to maintain our set-point (e.g., blood glucose levels, pH, O2): “Stability without change” • Allostasis (allo = different; stasis = balance): • Regulatory process that dynamically adapts (“different state”) to unpredictable internal/external environment (i.e., stressor), which can modify or maintain homeostasis: “Stability with change” • Allostatic load (AL): physiological burden of adjusting or maintaining homeostasis (energy expenditure). • Chronically increased AL corresponds to a variety of physiological problems (e.g., metabolic syndrome) Primary Stress Systems System 1 System 2 Sympathetic-Adrenal Medullary (SAM) System Hypothalamic-Pituitary-Adrenal (HPA) Axis Adrenal Medulla Adrenal Cortex Adrenaline Release (Fight or Cortisol Release (maintaining stress Flight) response) Cardiometabolic SNS Immune Activation and Response activation Modulates Future Response Body Mobilized for Action Physiology (long-term) (short-term capacity) Chronic Stress Response Acute Stress Response Metaphor: Drip Metaphor: Injection **ADAPTATIBILITY TO STRESS • Person’s capacity to survive and flourish during unpredictable or novel conditions (How is this different than resiliency?) - Biophysiological Definition: Ability to restore functional homeostasis after stress exposure (allostatic shift), identification, & neutralization - Cognitive/Affective Definition: Ability to learn from stress & change emotives, thoughts, and behaviors towards healthier future responses - Social Definition: Ability to rely on “others” for stress reduction via family, friends, or community engagement - Examples of positive adaptation? Stress Response: Adaptive vs Maladaptive Exercise: Acute Stressor Neurotrophic factor production (BDNF) Endorphin release Activation of reward Bullying: Acute Stressor > HPA axis activity > Cortisol release > SNS activity synaptogenesis > Attention, memory pathways (dopamine) Chronic Exercise (Adaptive) Lung volume, plasma, blood volume, capillary density, mitochondrial density SNS/HPA activity (<) Vascular health (>) Concentration of growth factors (> nerve, BDNF) Dopamine synthesis, replenishment, release Glucose tolerance, > insulin response anti-oxidant activity and memory capacity (>) Hyperactivation of serotonin receptors Decreased dendritic branch length (toxic neuroexcitability: dysregulated glutamate release) Chronic Bullying (Mal-Adapative) Sustained cortisol circulation Increased cell death Decreased prefrontal, hippocampal volume and coordination (altered learning, memory formation) Suppression of growth factors (e.g., nerve, BDNF) Glucose tolerance, insulin resistance oxidative stress **QUESTION #1 A nurse educating a group of local parents correctly defines stress in which of the following statements? A. Stress can be either beneficial or dysfunctional depending on the context it is being experienced B. Stress is defined as a dysfunctional state that always contributes to negative mental health outcomes C. Stress is always beneficial when experienced acutely, but never when experienced chronically D. All types of stress increase the susceptibility to mental health disorders regardless of context NURSING MANAGEMENT: COGNITIVE-AFFECTIVE Emotions Severity Reactions to emotion • Validate, help process Coping Strategies • Problem-focused • Emotion-Focused Coping Centered in Emotion (Reduces Stress by Reinterpretation or Temporarily Removing Self) Coping Centered in Emotion Example of Items Evasive distraction I get away from the problem temporarily (change of environment) Reduction of anxiety and avoidance I practice some kind of sport in order to reduce my anxiety of tension Preparing for the worst I prepare myself for the worst Emotional discharge and isolation I act irritable and aggressive towards others Resigned acceptance I accept the problem as it is, since I cannot do anything to solve it Coping Centered on the Problem (Directly Confronts the Stress-Source) Coping Centered on the Problem Example of Items Search for help and family advice I talk with people I know who can do something to solve my problem Self-instruction I set down a plan of action and try to carry it out I try to see positive aspects of the situation that could help this problem in the future I can approach the problem differently when I explain my problems to friends or family members Positive re-appraisal Communication of feelings and social support NURSING MANAGEMENT: SOCIAL ASSESSMENT • Recent life changes • Why is this important? • Social Network (e.g., community, friends, family) Size and extent of the network Functions that the network serves (intimacy, support, social integration) Degree of reciprocity/interconnectedness between patient and other persons within network (e.g., is the relationship one of give-and-take, or one-sided) NURSING MANAGEMENT: BIOLOGIC DOMAIN Assessment Sex-based differences Acute vs chronic (interventions could differ) Review of systems • Mental status exam • Health Physical functioning • Sleep, activity level Pharmacologic assessment • Medications, substance use Figure 18.1 Diathesis: “vulnerability” or predisposition to mental health disorders OVERVIEW OF TRAUMA- AND STRESSORRELATED DISORDERS • Not everyone who experiences a traumatic event will be emotionally injured • May be delayed • May be lifelong • Traumas and abuse influence the current experience EPIDEMIOLOGY • PTSD: about 8% of men and 20% of women in general population • Risk factors • Prior diagnosis of Acute Stress Disorder • Extent, duration, and intensity of trauma • Environmental factors (e.g., socioeconomic, acculturative stress) • The lifetime prevalence of PTSD in U.S. is statistically similar across Hispanic (5.9%), Black (7.1%), and White (6.8%) adults • LGBTQ individuals are more likely to be exposed to childhood abuse and traumatic events; and have a 1.6 to 3.9 times greater risk of PTSD compared with their nonLGBTQ peers • PTSD prevalence estimates after Iraq and Afghanistan • 0.5% to 48% in males • 2% to 68% in women TRAUMA EVENTS AND VULNERABILITIES Pre-Traumatic Factors Traumatic Event Examples Neglect, Assault, Abuse, Rape Sudden death of a loved one War, Car/Plane Crashes, Natural disasters Medical Complications, Procedures Bully, Racism, Discrimination, Stigma Peritraumatic Factors Posttraumatic Pre-existing psychiatric/medical comorbidities (family history) Severity of trauma (e.g., duration, intensity) Perceived or actual lack of social support Hx of substance abuse Decreased sense of safety or perceived threat to life Dysfunctional social interactions, isolation Lower socioeconomic, education status Emotional dysregulation (decreased resilience) Compounding stressors Discrimination, stigma, racism Dissociative tendencies Adverse childhood events (neglect, abuse) Previous trauma High-risk occupation (e.g., military, EMT, police officers) TRAUMA-BASED DISORDERS (TBD) • Despite TBD’s all resulting from trauma, unique and diagnostic clusters of symptoms emerge from differences in timing of exposure, type of exposure, perpetrator of exposure, etc. Ex: Trauma-avoidance (phobia vs natural disaster vs abuse) TBD behavior’s represent a physiological interaction between the unique trauma-coding of any given stressor (e.g., specific inflammatory marker clusters, context) and Self-Other-Environment attempts driven by predictions about the stressor DIAGNOSTIC CRITERIA FOR PTSD • A- Exposure to actual or threatened death, serious injury, or sexual violence • B- Intrusion symptoms (need at least one symptom in this category) • C- Avoidance (need at least one symptom in this category) • D- Negative alterations in cognition and mood (need at least two symptoms in this category) • E- Alterations in arousal/Hyperarousal (need at least two symptoms in this category) PTSD SYMPTOMS CORE FEATURES OF PTSD, CONT. • A. Exposure to actual or threatened death/ injury/ sexual violence • Directly experienced OR witnessed • Natural disaster, serious accident, terrorist act, refugee, war, rape or other violent personal assault • Learning it occurred to close family/ friend • Repeated exposure to details of trauma (e.g., first responders) • B. Intrusion symptoms (re-experiencing) • Memories, dreams, flashbacks • Cognitive or physical distress when exposed to cues/ symbols • Dreams may be similar content OR similar affect r/t the trauma • Why does this occur? • C. Avoidance • Avoid places, people, activities that are associated • Avoid thoughts, feelings, memories associated with the event • Internal and external triggers • Why does this occur? CORE FEATURES OF PTSD, CONT. • D. Negative alterations in cognition and mood (numbing) • Lost memories r/t the event • Exaggerated negative beliefs, self-blame, survivor guilt • Negative emotional state (depression) • Inability to experience or process emotions (e.g., alexithymia) • Reduced interest/ participation in activities • Feeling detached from others • Why does this occur? • E. Alterations in arousal (Hyperarousal): Constant Threat • Anger or irritability • Reckless or self-destructive behavior • Startle response, hypervigilance • Decreased concentration, decreased sleep • Why does this occur? ADDITIONAL CRITERIA FOR PTSD • Duration at least 1 month • No onset criterion • Clinically significant impairment in personal, occupational, social domains • Not attributable to another disorder, substance use disorder, medical ADDITIONAL CRITERIA FOR PTSD • Specifiers • With delayed expression • If greater than 6 months, and may take years for symptoms to appear ACUTE STRESS DISORDER • A. Exposure to actual or threatened death/ injury/ sexual violence • Directly experienced OR witnessed • Learning it occurred to close family/ friend • Repeated exposure to details of trauma (first responders) • B. 9 or more from any category • 1. Intrusion (re-experiencing) • 2. Negative mood • 3. Dissociative symptoms • 4. Avoidance • 5. Arousal ACUTE STRESS DISORDER, CONT. • C. Duration of 3 days to 1 month immediately following trauma • Typically begin immediately after and resolve within one month • D. Clinically significant impairment • E. Not attributable to another disorder, Substance use disorder, medical DIAGNOSTIC CRITERIA: PTSD IN A CHILD 6 YEARS OR YOUNGER • Predisposing event • Symptoms persisting beyond 1 month • Intrusive symptoms • Avoidance of reminders of traumatic event • Hyperarousal (irritable, angry) • Negative mood, feelings, thoughts • Not attributable to medication, substance use, illness TRAUMA AND CHILDREN AND ADOLESCENTS • Higher likelihood of more extreme response • May depict the event in drawings • May exhibit traumatic themes during play • Repetitive play seen in those older than six • Regressive behaviors: bedwetting, tantrums • Clingy with parents or other caregivers • Sleep disturbances • Nightmares may not have specific trauma content (monster imagery common) • Withdrawal, irritability, disruptive or destructive behaviors • Can manifest with conduct or oppositional behaviors, ADHD, reactive attachment, disinhibited social engagement QUESTION #2 A person with PTSD startles easily and reacts irritably to small annoyances. The nurse interprets this as which of the following? A. Hyperarousal B. Intrusion C. Avoidance D. Numbing ANSWER TO QUESTION #2 A. Hyperarousal is manifested by being hypervigilant for signs of danger, becoming easily startled, reacting irritably to small annoyances, and sleeping poorly. QUESTION #3 The nurse is talking with a client who just had a beautiful bouquet of roses delivered. Suddenly the client becomes tearful and stares out the window. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client? A. Tell the client that the sexual abuse was in the past B. Tell the client to relax and enjoy the roses C. Assess if the client is having a flashback D. Give the client some alone time and return later ANSWER TO QUESTION #3 C. Clients who have experienced a traumatic event such as sexual abuse may experience flashbacks. The triggers for these flashbacks may be visual, auditory, tactile, or olfactory. TRAUMA-RELATED COMORBIDITIES • Substance Use ■ Sleep Disorders (e.g., Insomnia, Apnea) • ETOH, Benzodiazepines ■ Self-harm; Suicidality; Depression • Opioids ■ Traumatic Brain Injury; Chronic Pain Co-Symptoms Chronic pain with no medical basis Stress-related conditions such as chronic fatigue syndrome or fibromyalgia Stomach pain or other digestive problems (e.g., IBS, diarrhea/constipation) Breathing problems or asthma Headaches Neuropathy Metabolic Disorders Alterations in taste or smell Cardiovascular problems • **Protective factors • Social support, good social network • Effective coping skills • Good premorbid functioning • Resiliency: • The capacity to withstand stress and catastrophe • Increases psychophysiological flexibility to negative stressors • It develops over time & increases ability to recover from negative stressors • Culmination of multiple internal and external factors Treatment • Medications: SSRI’s • Sertraline and Paroxetine only FDA approved • Prazosin not FDA-approved, but gold-standard for nightmares • Clinical Diagnosis • Most Common: PTSD Checklist (PCL, civilian and military version) • Clinician-Administered PTSD Scale (CAPS-5 • Most Common Therapies • Trauma-Focused Cognitive Behavioral Therapy • Exposure Therapy • Eye Movement Desensitization Reprocessing (EMDR) • www.tfcbt.org • www.emdr.org • www.emdria.org QUESTION #4 All of the below are among the most common trauma-related comorbidities except which of the following? A) Traumatic Brain Injury B) Alcohol, benzodiazepine, and opioid substance use C) Sleep Apnea D) Chronic Pain E) Thyroid Dysfunction • Cognitive behavioral therapy • Cognitive Processing Therapy (CPT) • Brief Eclectic Psychotherapy, Narrative Exposure Therapy • Biofeedback and virtual reality therapy THERAPIES • Body-based psychotherapy (Sensorimotor, Somatic Experiencing, Trauma Resiliency Model) • Stellate Ganglion Block (SGB) • Neuromodulation (e.g., deep brain stimulation, transmagnetic stimulation, vagus nerve stimulation, electroconvulsive therapy) • Stabilization-safety concerns? NURSING MANAGEMENT • PTSD screen • Symptom management: sleep, pain • Education about stress management: • relaxation techniques, meditation, mindfulness, resiliency skills, prayer, gratitude, Community Resiliency Model (ichill app or www.ichillapp.com) • PTSD Coach Online • https://www.ptsd.va.gov/apps/ptsdcoachonline/handouts. htm • Group therapy • Family therapy • Social support and support groups PTSD Screen In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you . . . •Have had nightmares about it or thought about it when you did not want to? YES NO •Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO •Were constantly on guard, watchful, or easily startled? YES NO •Felt numb or detached from others, activities, or your surroundings? YES NO Current research suggests that the results of the PTSD screener should be considered “positive” if a patient answers “yes” to any three (3) items. NURSING CARE GENERAL APPROACH • Trauma-informed care • Safety and trust • Therapeutic relationship • Trauma and resiliency competencies/certifications TRAUMA-INFORMED TENETS • Safety • Trustworthiness and Transparency • Peer support and mutual self-help • Collaboration and mutuality • Empowerment, voice, and choice • Cultural respect DISSOCIATIVE DISORDER’S • Necessary features of dissociation: • Responses to extreme external or internal events or stressors • failure to integrate identity, memory, and consciousness • Types (See Table 27.2) • Dissociative amnesia: inability to recall • Depersonalization disorder: being detached from one’s body • Derealization: being detached from reality • Dissociative identity disorder (formerly called multiple personality disorder):at least two distinct personality or identity states THANK YOU! QUESTIONS?
