Trauma, Stressor-Related, and Dissociative Disorders Chp.
16
ATI Chapter 12
LLU SCHOOL OF NURSING
Nursing 217
Psychiatric Mental Health Nursing
Tony Dharmaraj RN, MSN
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Trauma Informed Care
A very difficult or unpleasant
experience(s) that causes someone to
have mental or emotional problems
usually for a long time
A disordered psychic or behavioral
state resulting from mental or
emotional stress or physical injury
Merriam-Webster Dictionary
See DSM-5 Box in Halter
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Trauma-Related Disorders
Posttraumatic stress disorder
(PTSD) Below is link to ACE test
https://www.npr.org/sections/healthshots/2015/03/02/387007941/take-theace-quiz-and-learn-what-it-does-anddoesnt-mean
• Reduction in play
• Play that includes re-enactment of
traumatic event
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Trauma-Related Disorders
in Children
• Social withdrawal
• Negative emotions (sadness, guilt, fear,
anger shame)
• Problems with sleep, concentration,
hypervigilance
• Regress to previous level of functioning
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Trauma-Related Disorders
in Children
Reactive Attachment Disorder (RAD)
•consistently inhibited
•emotionally withdrawn
•difficulty with attachment
Disinhibited Social Engagement Disorder
•lack “Stranger Danger”
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Posttraumatic Stress Disorder
Implementation:
• Protect child from panic levels of anxiety
• Provide emotional support to help child
progress developmentally
• Increase child's self-esteem and feelings of
competence
• Help child work through traumatic event (art
of play)
• Teach coping skills i.e. relaxation, breathing
• Cognitive therapy--Focused on underlying
fears and concerns
See Box 16.1 in Halter
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Evaluation
• Child’s safety maintained
• Anxiety reduced and stress handled
adaptively
• Emotions and behavior appropriate for
circumstances (can they accept “no”)
• Child reaches appropriate developmental
milestones for age
• Child seeks out adults for nurture and help
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Posttraumatic Stress Disorder
(PTSD) in Adults
• Constant re-experiencing of a traumatic
event for individual (Flashbacks)
• Avoidance of stimuli associated with
trauma
• Persistent symptoms of increased
arousal –hypervigilance
• Alterations in mood
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Posttraumatic Stress Disorder
(PTSD) in Adults
• 55-90% of people have experienced one
or more traumatic events
• Approximately 8% of people will
develop PTSD
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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
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
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PTSD Screen
• 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
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PTSD Screen
• Felt guilty or unable to stop blaming
yourself or others for the event(s) or
any problems the event(s) may have
caused?
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.
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Interventions
• Strategies to manage anxiety (may
include animal assisted therapy)
• ↑Support groups, friends, family
• Story (may include journaling) of the
event and the meaning of the event to
the person (may reduce guilt)
• Psychoeducation—normal reaction to
abnormal event
• Meds—antidepressants, alpha agonists
ie: clonidine and prazosin (nightmares),
beta-blocker (Inderal), MDMA (ecstasy)
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Advance Practice Interventions
• EMDR (eye movement desensitization
retraining)
• Exposure therapy
• Cognitive restructuring
• Psychotherapy
• Group therapy
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Outcomes/Goals
• Person can manage anxiety positively—
use of relaxation, ↑ sleep, ↑ ability to
work/play.
• Self-esteem is improved
• Enhanced ability to cope ↓ physical sx.
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Acute Stress Disorder
• May develop after exposure to a
traumatic event—usually 3 days to 1
month after event.
Follow Guidelines of Crisis Intervention
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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.
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Etiology
• Genetic vulnerability may have some
influence, DD mostly due to extreme
stress/environmental factors.
• Neurobiological 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 information
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Etiology
• Psychological by use of the defense
mechanism of dissociation
• Environmental traumas include:
– Combat
– Emotional/verbal abuse
– Incest
– neglect/abuse
– Imprisonment
– Accidents
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Depersonalization Disorder
• Exceptionally painful sense of being an
observer of one’s own physical (body)
or emotional functions
– Recurring sensation that what is happening
in the ‘here and now” is not real.
– Person feel “detached” from own body
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Derealization Disorder
• Focus is on the outside world
• Recurring feeling that one’s
surrounding are distant/unreal.
• Can be intermittent or constant
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Dissociative Amnesia
• The 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
– Sudden, unplanned travel to another
location
– No recall or identity or past events in life
– May live out a different identity indefinitely
and then remember the past
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Dissociative Identity Disorder (DID)
• This used to be labeled Multiple
Personality Disorder.
• A person has 2 or more alternate
personality states. One alter personality
functions in day to day life and usually
has no recall of trauma experiences.
The other alternate personality deals
with the trauma memories.
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DID, Cont.
• Each alter personality has own likes,
beliefs, views of the world. Can present
with different race, sex, values.
• The person’s primary personality is
usually not aware that there is/are alter
personalities
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DID, Cont.
• The primary personality may not
remember events when an alter
personality is “in charge” and is
confused, with loss of memory an being
called by a different name. May
experience time “black-outs.”
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Assessment of Dissociative Disorders
• Lapses of memory
• Assess for safety which includes
suicide risk
• Has patient has a recent head injury
• History of trauma and sexual abuse
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Assessment, Cont.
• Assess for mood shifts (may also have
depression r/t DD)
• Family and work problems
• Assess anxiety level and signs of DD
• Assess support systems
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Nursing Diagnoses
• Overall goals for DD focus on
personal identity, role performance
and anxiety
Halter (2018) suggests several Nursing
Diagnoses:
Disturbed personal identity
Ineffective role performance
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Planning
• Halter (2018) lists three phases of
treatment (p. 311).
– 1. Establishing safety, stabilization, and
symptom reduction (most often the focus
for the nurse as patient is seen because of
a crisis or depression, etc.)
– 2. Confronting, working through, and
integrating traumatic memories
– 3. Identity integration and rehabilitation
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Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Interventions
• Halter, Table 16-2 page 311
– 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 an place
– PROVIDE SUPPORT THROUGH
EMPATHETIC LISTENING
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Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Evaluation
• Effective treatment for DD is long-term
psychotherapy and focuses on
personality integration.
• As you watch the link below, identify the
following:
– Different personalities
– Reasons for personalities
– How was the therapist therapeutic?
Split movie therapist scene
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Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.