Chapter 12: Trauma, Stress-Related, and Dissociative Disorders
Trauma Informed Care
 Difficult or unpleasant experience that causes someone to have mental or emotional
problems for a long time
 Disordered psychic or behavioral state resulting from mental or emotional stress of
physical injury
Trauma-Related Disorders in Children
 Posttraumatic stress disorder
 Reduction in play
 Play that includes re-enactment of traumatic event
 Social withdrawal
 Negative emotions
 Problems w/ sleep, concentration, hypervigilance (hyper alertness)
 Regress to previous level of functioning (wet bed after being potty trained)
 Reactive Attachment Disorder (RAD)
o Consistently inhibited (not being part of the moment)
o Emotionally withdrawn
o Difficulty w/ attachment
 Disinhibited Social Engagement Disorder
o Lack “Stranger Danger”
Posttraumatic Stress Order
 Implementation:
o Protect child from panic levels of anxiety
o Provide emotional support to help child progress developmentally
o Increase child’s self-esteem and feelings of competence
o Help child work through traumatic event
o Teach coping skills (relaxing, breathing)
o Cognitive therapy—focused on underlying fears and concerns
 Thoughts—Feelings—Actions & Bx (behavior)
 If we have thoughts and feelings, it correlates with their bx
 Pos. thoughts and pos. feelings = pos. actions
Evaluation
 Child’s safety maintained
 Anxiety reduced and stress handled adaptively
 Emotions and behavior appropriate for circumstances
 Child reaches appropriate developmental milestones for age
 Child seeks out adults for nurture and help
PTSD in Adults
 Constant re-experiencing of a traumatic event for individual (flashbacks)
 Avoidance of stimuli associated w/ trauma
 Persistent symptoms of increased arousal—hypervigilance
 Alterations in mood
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One month of symptoms to fit criteria
55-90% of people have experienced one or more traumatic events
Approx. 8% of people will develop PTSD
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?
o YES/NO
 Tried hard not to think about it or went out of your way to avoid situations that
reminded you of it?
o YES / NO
 Were constantly on guard, watchful, or easily startled?
o YES / NO
 Felt numb or detached from others, activities, or your surroundings?
o YES/NO
 Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems
the event(s) may have caused?
o YES / NO
 Current research suggests that the results of the PTSD screen should be considered
“positive” if a patient answers “yes” to any three items
Interventions
 Strategies to manage anxiety (may include animal assisted therapy)
 Increase support groups, friends, family
 Story of event (poetry) and the meaning of the event to the person (may reduce guilt by
realizing they weren’t responsible)
 Psychoeducation—normal reaction to abnormal event
 Meds—antidepressants, alpha agonists
o Clonidine prazosin (nightmares), beta-blocker (Inderal), MDMA (ecstasy)
Advance Practice Interventions (No need to memorize)
 EMDR (eye movement desensitization retraining)
 Exposure therapy
 Cognitive restructuring
 Psychotherapy
 Group therapy
Outcomes/Goals
 Person can manage anxiety positively—use of relaxation, increased sleep, increased
ability to work/play
 Self-esteem is improved
 Enhanced ability to cope decreases physical symptoms
Acute Stress Disorder
 May develop after exposure to a traumatic event—usually 3 days to 1 month after event
 Follow guidelines of Crisis Intervention
Dissociative Disorders (DD)
 May occur after adverse experiences or trauma
 Defined as an unconscious defense mechanism that protects the person against
overwhelming anxiety through an emotional separation
 Dissociation results in disturbances in memory, consciousness, self-identity, and
perception
 Etiology
o Genetic vulnerability may have some influence, DD mostly due to extreme
stress/environmental factors
o Neurological findings show the limbic system is involved in the development of DD
 Traumatic memories are processed in the limbic system and the hippocampus
stores this info
o Psychological by use of the defense mechanism of dissociation
o Environmental traumas include:
 Combat, emotional/verbal abuse, incest, neglect/abuse, imprisonment, and
accidents
Depersonalization Disorder
 Exceptionally painful sense of being an observer of one’s own physical (body) or
emotional function
o Recurring sensation that what is happening in the “here and now” is not real
o Feeling of “detached” from body
Derealization Disorder
 Focus is on the outside world
 Recurring feeling that one’s surroundings are distant/unreal
 Can be intermittent or constant
Dissociative Amnesia
 Inability to remember what occurred after a traumatic or stressful event that is not
explained by normal forgetfulness
 Dissociative fugue is a subtype of this disorder
o Sudden, unplanned travel to another location
o No recall or identity or past events in life
o May live out a diff identity indefinitely and then remember the past
Dissociative Identity Disorder (DID)
 Used to be labeled Multiple Personality Disorder
 A person has 2 or more alternate personality states
 Each personality has own likes, beliefs, views of world
o Can present w/ diff race, sex, values
 Person’s primary personality is usually not aware that there is/are alter personalities
 Primary personality may not remember events when an alter personality is “in charge”
and is confused, with loss of memory and being called by a diff name
 May experience “black-outs”
Assessment of Dissociative Disorders
 Lapses of memory
 Assess for safety which includes suicide risk
 Has patient had a recent head injury
 History of trauma and sexual abuse
 Assess for mood shifts
 Family and work problems
 Assess anxiety level and signs of DD
 Assess support systems
Nursing Diagnoses
 Overall goals for DD focus on personal identity role performance and anxiety
 Diagnoses: disturbed personal identity, ineffective role performance
Planning
 Three phases of treatment
o Establishing safety, stabilization, and symptom reduction (most often the focus
for the nurse as patient is seen because of a crisis or depression)
o Confronting, working through, and integrating traumatic memories
o Identity integration and rehabilitation
Interventions
 Provide undemanding, simple routine
 Ensure patient safety
 Encourage patient to ADL’s and routine tasks
 Teach stress reduction, deep breathing and relaxation methods
 Confirm identity of patient and orientation to time and place
 PROVIDE SUPPORT THROUGH EMPATHETIC LISTENING
Evaluation
 Effective treatment for DD is long-term psychotherapy and focuses on personality
integration
Chapter 15: Anxiety and Obsessive-Compulsive Disorders (EXAM II)
Anxiety and Fear
 Anxiety is defined as a feeling of apprehension, uneasiness, uncertainty, or dread
resulting from a real or perceived threat
 Fear is defined as a reaction to a specific
 Body reacts the same to both fear and anxiety
Amygdala
 Set of neurons located deep in the brain’s medical temporal lobe
 Key role in processing emotions
 A threat stimulus triggers a fear response in the amygdala, which activates fight or flight
 Test anxiety can initiate this reaction
Statistics
 40 million or 18% of adults in U.S. have an anxiety disorder
 8% of children and teenagers experience anxiety
Risk Factors
 Genetics
o First degree biological relatives
 Neurotransmitters
 Psychological
Neurotransmitters
 GABA:
o General Function: reduce neuronal excitability by inhibiting nerve transmission =
relaxation and sedation
o Deficit: anxiety, irritability, hostility, seizures
o Excess: over sedation, hypersomnia, respiratory depression
 GABA is low
 Serotonin helps to regulate anxiety, so serotonin is theorized to be LOW as well
Psychological Factors
 Behavioral theories: anxiety is a learned response
 Cognitive theories: anxiety is caused by distortions in a person’s thoughts or perceptions
 Interpersonal theories: early needs went unmet or constant disapproval is experienced
in early years
Levels of Anxiety (Peplau)
 Mild
o Occurs in everyday life
o See, hears and grasps more info and problem solving becomes more effective
o Learning comes at ease because you are focused
o This is a good thing
 Moderate
o Sees, hears and grasps less information, details become excluded from
observations (tunnel vision)
o Learning can still take place, but not at optimal levels
o SNS kicks in, may experience tension, pounding heart, increase HR, RR, sweating,
and GI distress
 Severe
o Perceptual field reduces even more
o Focus usually on one detail or scattered details and has difficulty noticing things
in the environment even when it’s pointed out to them
o Learning and problem solving usually are not possible
 Panic
o Unable to process what is going on in the environment and may lose touch w/
reality
o Pacing, running, shouting, screaming, or withdrawal
o May experience hallucinations and become impulsive
o “NOT” possible to learn during this level
Anxiety Disorders
 Generalized Anxiety Disorder
 Separating anxiety disorder
 Specific phobia
 Body dysmorphic disorder
 Social anxiety disorder
 Panic disorder
 Agoraphobia
Generalized Anxiety Disorder
 Females to males 2:1
 Excessive worrying
o Common worries: job performance, relationships, finances, family
o Symptoms: feeling easily fatigued, restless, irritable, muscle tension, and
headaches
o Dx with GAD-7 (General Anxiety Disorder Questionnaire)
 Diagnosing
o Practitioners use GAD-7
o Score 0-4: minimal anxiety
o Score 5-9: mild anxiety
o Score 10-14: moderate anxiety
o Score greater than 15: severe anxiety
Separation Anxiety
 Peeks at 18 months and should decline after
 If it does not decline, people w disorder present w/ great concern and distress over
being away from a significant other
 Interferes w/ daily functioning, disrupts sleep, causes nightmares, headaches and GI
issues
 Diagnosed before age 18 after month 1 of symptoms
Specific Phobias
 Persistent irrational fear of a specific object, activity, or situation
o Ex: water, dogs, closed spaces
o Will go to great lengths to avoid specific object, activity or situation
Social Anxiety Disorder
 AKA: Social Phobia
o Severe anxiety or fear provoked by social or performance issues
 Speaking in class, fear of negative feedback
o Fear of public speaking is most common form
o Risk factors: childhood, trauma, or having shy or timid caregivers
Panic Disorder
 Key feature: panic attacks
o Panic attack = sudden onset of extreme apprehension or fear, sometimes w/
feelings of impending doom
o May feel like they are losing their minds or having heart attack
o Children usually will not verablize needs like adults and may become avoidant
o Self-medicate w/ substances
Agoraphobia
 Derived from Greek term agora = pen space

Type of anxiety disorder in which you fear and avoid places or situations that might
cause you to panic and make you feel trapped, helpless, or embarrassed
 Most common is fear or public places
 May feel unable to leave their home
Obsessive Compulsive Disorders
 Trichotillomania
 Excoriation
 Hoarding
 Obsessions: thoughts, impulses or images that persist and reoccur that are very difficult
to dismiss from the mind even if the person tries to do so
 Compulsion: ritualistic behaviors a person feels driven to perform to reduce anxiety and
stress
DSM 5 Criteria for OCD
 Presence of obsessions and/or compulsions
 Obsessions:
o Unwanted and intrusive thoughts, impulses or images that the client reports they
cannot dismiss or ignore
 Compulsions:
o Repetitive behaviors or mental acts that occur in response to the obsession,
aimed to prevent or reduce anxiety
 Symptoms take up at least 1 hr. of the day
 Symptoms not explained by medical dx, psychosis, or substance use
Hoarding Disorder
 Persistently difficulty discarding or parting w/ possessions because of a perceived need
to save them
 Person w/ hoarding disorder experiences distress at the thought of getting rid of the
items
 Excessive accumulation of items regardless of actual value
Trichotillomania
 Cannot resist the urge to pull hair out
 Some people may consume the hair which is called trichophagia
Excoriation Disorder
 Cannot resist urge to pick at skin
Body dysmorphic Disorder
 Mental disorder that includes the follow criteria
o Preoccupation w/ perceived physical defect
o Repetitive, compulsive behaviors in response to perceived defect
o Causes significant distress or impairment in social, occupational or other
important areas of functioning
o Does not focus on being overweight considered an eating disorder
o Stats: 1:50 people in the U.S
Treatment Options
 Assessment
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CBT
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o Assessment needs to be patient centered and empathetic
o Always assess before intervening to ensure intervention appropriate
 Objective: VS, numerical rating for anxiety, EKG may be ordered to rule
out cardiac issues
o Mostly subjective
Planning
o Patient is the center of the treatment plan
o When you include the patient in decision making, the patient is more likely to be
compliant w/ treatment
o Consider culture
Interventions
o Coping skills; identify triggers
o Inpatient: SAFETY FIRST, use calm consistent care and low stimulation when
possible
o Self-care activities: proper nutrition and food intake (decrease caffeine and high
sugar intake), elimination, sleep hygiene
o Fluids and rest to prevent exhaustion
Helps to reframe negative thinking or thought patterns that can further increase anxiety
Anxious thoughts, trigger the fear response, which increases fight or flight
Calming thoughts, lets the mind know you are safe, has a calming effect on your mind
and body
Behavioral Therapy
 Modeling—Therapist of significant models appropriate behavior in a feared situation
and the patient models it
o Therapist goes in elevator first, models comfort
o Pt models what the therapist does
 Systemic Desensitization—takes baby steps to learn how to deal w/ feared situation
o Ex: agoraphobia—opens door, goes on lawn, gets in car
Antidepressants
 SSRI are first line of therapy for anxiety disorders
 Why? Less side effects and non-addictive
 Increases serotonin levels which helps w/ the overall feeling of well-being
 SSRI’s helps to treat chronic anxiety and therefore can decrease panic attacks overtime
Benzodiazepines (for panic disorder)
 Lorazepam, diazepam, alprazolam
 MOA: binds to GABA receptors to enhance the inhibitory effects of GABA
 Calming effect on the CNS
 S/E: drowsiness, confusion, dizziness, impaired coordination
 “Should” be prescribed and taken PRN to prevent panic attacks, since it known to be
addictive
 Education for clients:
o Sedatives: risk for fall, consider the elderly population
o Do not take w/ other CNS depressants such as ETOH or opioids
Noradrenergic Drugs
 Used for short-term relief od social or performance anxiety
o Lowers both HR and BP, do not give with HR 60 or BP 90/60
o Ex: propranolol used for short term relief of social and performance anxiety and
Clonidine used for anxiety disorders and panic attacks
Buspirone
 Trade name: Buspar
 MOA: helps to enhance serotonin receptors in the body
 Considered to be non-addicting
 S/E: dizziness, drowsiness, headache, n/v, trouble sleeping
 Can cause serotonin syndrome if taken in excess or taken along w/ other medications
that increase serotonin
Evaluation
 Anxiety management and reduction is the goal of treatment
o Does the client know their triggers?
o Is the client able to implement coping skills?
Defense Mechanisms
 Psychological ways we can deal w/ stress and anxiety
o Adaptive: helps the person achieve goals in an acceptable way
o Maladaptive: interferes w/ function, relationships, and orientation to reality
 Two types of defense mechanisms that are always healthy and adaptive:
o Altruism: dealing w/ anxiety by reaching out to others
o Sublimation: dealing w/ unacceptable feelings of impulses by unconsciously
substituting acceptable forms of expression
 Ex: a person who has feelings of anger and hostility toward their work
supervisor sublimates those feelings by working out vigorously at the gym
during their lunch