CHAPTER VII

TRAUMA AND STRESS-RELATED DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain the
following Intended Learning Outcomes:
 Discuss the characteristics, risk factors and dynamics of trauma related
disorder
 Identify factors leading to PTSD
 Describe responses of clients with PTSD
 Provide health education associated to trauma and stress among patients,
families and concerned individuals
 Prepare your books and notebooks. Highlight concepts that need to be reinforced. Jot
down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of this
chapter is also provided along with other resources to facilitate better understanding of
the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Acute stress disorder
 Adaptive disorder
 PTSD
 Depersonalization
 Derealization
 Dissociation
 Hyperarousal
 Falshbacks
 Intrusive thoughts

POSTTRAUMATIC STRESS DISORDER (PTSD)

- disturbing pattern of behavior
demonstrated by someone who has
experienced, witnessed or been
confronted with a traumatic event (ex.
natural disaster)
- The patient was exposed to the event
which caused intense fear or terror
LI: What is “Life Events Checklist” and
“PTSD Checklist”?
- Signs and symptoms:
o Re-experiencing the trauma
through memories, dreams,
“flashbacks”
o Avoidance
 o Negative cognition
o Being on guard “HYPERAROUSAL”
o Hyperarousal: insomnia, hypervigilance, irritability, angry outburst
o Numbing or general unresponsiveness
o Losing a sense of connection and control over his life
o Seeks comfort, safety but can become isolated over time
- Symptoms occur 3 months or more after the trauma/event (Acute stress disorder
lasts 3 days up to 1 month)
- PTSD is chronic; onset maybe delayed for months or even years
- Patients often develop psychiatric disorders (depression, anxiety disorders, substance
abuse)
- Can occur at any age
- Prevalence: increased in combat veterans and victims of natural disasters
- 50% of patients recover within 3 months

 DSM-5 DIAGNOSTIC CRITERIA

- Applicable to adults, adolescence and children older than 6 years
Criterion A: stressor (one required)
The person was exposed to: death, threatened death, actual or threatened serious
injury, or actual or threatened sexual violence, in the following way(s):
 Direct exposure
 Witnessing the trauma
 Learning that a relative or close friend was exposed to a trauma
 Indirect exposure to aversive details of the trauma, usually in the course of
professional duties (e.g., first responders, medics)
Criterion B: intrusion symptoms (one required)
The traumatic event is persistently re-experienced in the following way(s):
 Unwanted upsetting memories
 Nightmares
 Flashbacks
 Emotional distress after exposure to traumatic reminders
 Physical reactivity after exposure to traumatic reminders
Criterion C: avoidance (one required)
Avoidance of trauma-related stimuli after the trauma, in the following way(s):
 Trauma-related thoughts or feelings
 Trauma-related external reminders
Criterion D: negative alterations in cognitions and mood (two required)
Negative thoughts or feelings that began or worsened after the trauma, in the following
way(s):
 Inability to recall key features of the trauma
 Overly negative thoughts and assumptions about oneself or the world
 Exaggerated blame of self or others for causing the trauma
 Negative affect
 Decreased interest in activities
 Feeling isolated
 Difficulty experiencing positive affect
Criterion E: alterations in arousal and reactivity
Trauma-related arousal and reactivity that began or worsened after the trauma, in the
following way(s):
 Irritability or aggression
 Risky or destructive behavior
 Hypervigilance
  Heightened startle reaction
 Difficulty concentrating
 Difficulty sleeping
Criterion F: duration (required)
Symptoms last for more than 1 month.
Criterion G: functional significance (required)
Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion (required)
Symptoms are not due to medication, substance use, or other illness.

RELATED DISORDERS
 Adjustment disorder:
o Reaction to a stressful event (financial, work-related stressors) that causes
problems for the individual.
o Symptoms develop within a month lasting for no more than 6 months
o Treatment: outpatient counseling
 Acute Stress Disorder:
o Occurs after a traumatic event
o Re-experiencing, avoidance, hyper arousal
o Symptoms occur 3 days to 4 weeks after the event
o Treatment: Cognitive behavioral therapy to prevent progression to PTSD
 Reactive attachment disorder (RAD)/ Disinhibted social engagement
disorder (DSED)
o Occur before 5 years old
o Result of trauma (child abuse or neglect)
o S/sx: disturbed inappropriate social relatedness; exhibits minimal social
and emotional responses to others, lacks positive effect, sad, irritable,
afraid

Etiology/Occurrence:
- Exposure to trauma
- Adolescents are more likely to develop PTSD than children; they are at increased
for suicide, substance abuse, poor social support, academic problems and poor
physical health
- Children: they develop PTSD if with a history of parental major depression and
abuse

Treatment/Interventions:
**usually outpatient treatment
- Counseling (individual or group)
- CBT
- Exposure therapy: help the client face troubling thoughts and regain control over
it.
o Confronts the feared emotions associated with the trauma
o While doing so, the nurse uses various relaxation techniques to help the
client tolerate and manage the anxiety response
o Ex: returning to where the incident happened, imagined confrontation
- Adaptive Disclosure: specialized CBT approach developed by the military to offer
an intense, specific, short-term therapy for active-duty military personnel
o Incorporates explosive therapy + empty chair technique (the patient says
what he/she wants to anyone whether dead or alive)
 o The therapy consists of six sessions
- Cognitive processing therapy: successful in treating rape victims with PTSD
o Involves structured sessions that focus on examining beliefs that interfere
with daily functioning (shame, guilt, self-blaming)
- Psychopharmacology: Give SSRI as prescribed; second generation antipsychotic
(Risperidone)

Nursing Interventions:
- Be nonthreatening and professional when approaching the client
- Assign the same staff member to the client to respect his/her fears and feeling.
Then, gradually increase the number and variety of staff members interacting
with the client
- Educate yourself and other staff members about the client’s experience
- Promote self-awareness
- Remain nonjudgmental
- Be consistent with the client; convey acceptance
- Encourage verbalization of feelings
- Give positive regard for every task done
- Help the client practice stress management and relaxation techniques,
assertiveness and self-defense

DISSOCIATIVE DISORDERS
- Dissociation: a subconscious defense mechanism that helps a person protect her
emotional help or reduce anxiety
o Allows mind to forget or remove itself from the painful sensation
- Dissociative disorders: disruption in the usually integrated functions of
consciousness, memory, identity and environmental perception
- Dissociative amnesia: client cannot remember important personal information
(traumatic or stressful nature). Includes a fugue experience where the client
suddenly moves to a new geographic location without memory in the past and
assume a new identity
- Dissociative identity disorder (DSM IV: multiple identity disorder): displays two or
more distinct identities or personality; involves inability to recall personal
information
- Depersonalization/derealization disorder: persistent feeling of being detached
from his mental process or body (depersonalization); sensation of being in a
dream-like situation (derealization)
- D.O are usually rare but prevalent in population where there is a history of child
abuse (physical and sexual)

Significant assessment:
- Hyperalert/ hyperarousal
- Anxious and agitated
- Displays a wide range of emotions
- Patient may appear frightened (screams, cries, attempts to run or hide)
- Flashbacks
- Some reports hallucination
- Self-destructive thoughts and impulses
- Fantasies of taking revenge against abusers
- Client is oriented to reality except during flashbacks or dissociation episode
(memory gap)
- Low self-esteem
 - Difficulty dealing with others
- Disturbance in sleep patterns

Priority nursing diagnoses:

- Risk for self-mutilation
- Risk for suicide
- Ineffective coping
- Chronic low self-esteem
- Powerlessness
- Disturbed sleep pattern
- Spiritual distress
- Social isolation

Interventions:
- Promoting client’s safety: CLOSE MONITORING!
o Initiate SUICIDE PRECAUTION
o Discuss self-harm thoughts
- Help client cope up with stress and emotions
o Use grounding techniques to help the client who is dissociating or having
flashbacks
o Validate client’s feelings
o Dissociation: client may assume a body position – do not attempt to grab
or reposition him/her
o Use supportive touch
o Reach deep breathing and relaxation techniques
o Use distraction techniques (physical exercise, listening to music, writing
journals)

Teacher’s Insight:
Traumatic events may be horrific. Nurses must remain nonjudgmental of the client. They
must facilitate effective coping skills to help the client regain control and independence

Chapter Assessment
Critical thinking:
1. Have you experienced a traumatic situation/event in your life that caused drastic
change on how you deal with daily dealings?

1. Judy is assigned in the emergency department with a woman who was raped 1 hour ago. In planning care,
it is important for Judy to remember which of the following?
A. Angry feelings need to be set aside until physical care is completed.
B. Evidence collection according to procedures is the priority.
C. The nurse will need to make decisions for this client.
D. The woman may feel threatened by some of the procedures.
2. . Nurse Lila is assessing an elderly female in the emergency department. There are many bruises present
on her body in varying stages of healing. After documenting the bruising in the assessment, what should Lila
do next?
A. Ask the client when and how the bruises occurred
 B. Call the nursing supervisor immediately
C. Follow the facility's policy and procedures for reporting abuse
D. Notify the physician that abuse is suspected
3. A coherent elderly woman has been financially and emotionally abused by her adult children for the past
several years, but has failed to report the abuse to anyone. The most likely reason for neglecting to report
the abuse includes which of the following?
A. She cannot claim abuse if there is no evidence of physical harm
B. Laws do not provide protection against abuse when the suspect(s) is/are family members
C. She has no financial resources to hire legal representation against her children
D. She is emotionally close to her children and does not want to bring them harm
4. Lila is collecting assessment data on a patient who is suspected to be a victim of violence. She would note
which assessment data to support the suspicion that the patient is a victim of abuse? (Select all that apply)
1. Has few friends
2. Holds a dominant role in the family
3. Is in charge of the family finances
4. Moderate amount of alcohol use in the home
5. Reports father was abusive during childhood
A. 1, 3, 4 C. 1, 3
B. 1, 4, 5 D. 2, 5
5. Lila is caring for a 16-year-old boy with a history of sexual abuse. Lila might expect this adolescent to:
A. Experience nightmares and flashbacks
B. Have no ill effects due to his age
C. Reject his mother for not protecting him
D. Want to confront the perpetrator
6. Which of the following behaviors would first alert Nurse Lila or teacher to suspect sexual abuse in a 7-year-
old child?
A. Extreme friendliness to peers
B. Learning problems and shyness
C. Telling sexually explicit stories to peers
D. Withdrawn behavior and enuresis
7. A frightened young woman calls the emergency department and tearfully tells Nurse Rhoda, “I've been
raped! Please help me!” Before telling the client what to do, Rhoda would need to know if:
A. If the client was injured, was in a safe place, and had transportation available
B. If the client knew her assailant, knew her location, and had notified the police
C. If she has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility
D. If she had bathed, douched, or changed clothes
8. The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a fractured femur.
Which of the following data obtained during the assessment would raise the nurse’s suspicion that the child
has suffered physical abuse?
A. The parents appearing overprotective of the child
B. Bruises over the child’s boney prominences
C. The injury occurring several days before the parents sought treatment
D. Both parents reporting the exact same details pertaining to the injurious event