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ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
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Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
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COURSE OBJECTIVE: To provide information about posttraumatic stress disorder: its history, symptoms, underlying concepts, diagnostic features, treatment, prevention, and resources.
Upon completion of this course, you will be able to:
History is replete with accounts of individuals who have experienced or witnessed terrifying events; felt intense fear, helplessness, and horror; and suffered ongoing emotional distress.
Even though PTSD has been described throughout human history, veterans groups and healthcare providers have been slow to acknowledge its existence or explore its dimensions. This reticence may have been due to the sigma of cowardice and weakness, or perhaps to the variability of symptoms. For whatever the reason, the disorder has been ill defined and its treatment inconsistent.
Recently, scientists have begun to understand that people respond to terrifying events in different ways, intensities, and time frames. This response varies, not because of faint-heartedness or mental illness, but because of the complexity of the human brain as it adapts to internal and external stressors. Several complex factors are involved, namely trauma, stress and stressors, memory, and emotions.
Trauma is the direct personal experience of an event that involves actual or threatened death or serious injury to one’s physical integrity (APA, 2000). Trauma can alter the very foundations of a person’s life and cause profound emptiness, loss of hope, trust, or caring for oneself or others. It can produce all manner of disorders, including depression, anxiety, somatoform disorders, substance abuse, psychosis, and personality disorders.
There are two primary categories of traumatic events: widespread devastation and interpersonal terror.
Widespread devastation affects many people all at the same time. These calamities include natural disasters such as earthquakes, hurricanes, and tsunamis; large-scale transportation accidents; explosions and fire; motor vehicle accidents; life-threatening epidemics; and radiation, terrorist attacks, and wars.
Interpersonal terror includes such things as torture, rape, sexual assault, partner battery, stranger physical assault, kidnap/hostage prey, and child abuse—either as victim or witness.
People respond to trauma in remarkably different ways. When a group of unrelated individuals is exposed to the same traumatic event, one person may develop a full-blown stress disorder lasting for months or years, one may become depressed and suicidal, and another may experience only mild, transient symptoms. Researchers identify such variation of symptoms as risk factors and resilience factors for traumatic distress.
The presence of any risk factors makes people more vulnerable and more likely to develop severe symptoms. Risk factors fall into at least three categories: (1) variables specific to the victim, (2) characteristics of the trauma, and (3) social response, support, and resources available to the victim after the event.
As more is learned about PTSD, leaders in traumatic high-risk occupations are beginning to pay attention to the need for resilience in those who carry out the duties of their occupation. These include such professions as firefighters, emergency care providers, and police and military officers. The National Institute of Mental Health (2011) has suggested five specific actions and personal characteristics that increase resistance to PTSD, as follows:
The concept of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to threat and noticed that the body responds in a predictable sequence. Hans Selye (1991) carried on the work of Cannon, defining stress as the “rate of wear and tear on the body” and stressors as “causative agents of stress.” He found that stressors might be physical (such as extreme cold, infection, injury, and pain) or psychological (such as fear, sadness, anger, and disgust). He identified what he called a general adaptation syndrome (GAS) whereby the body maintains homeostasis, or balance (see box).
GENERAL ADAPTATION SYNDROME
Exhaustion sets in as the individual fails to adapt to stressors and becomes exhausted.
Source: Adapted from Selye, 1991.
Memory is the retention of and ability to recall information, personal experiences, and procedures. It comprises a diverse set of cognitive capacities by which we retain information and reconstruct past experiences (Stanford Encyclopedia, 2010). Although the structure and function of the brain has been studied extensively, there is still no universal agreement about just how memory works. However, research-supported evidence tells us that:
Emotions play an important role in the memory of traumatic events. For this reason, caregivers of those who suffer from PTSD need to understand just what emotions are, how they are experienced, and what purpose they serve in the survival of human beings.
An emotion is “a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior; it is a feeling that accompanies an adaptive behavior for survival” (Plutchik, 1991).
Studies of the emotions have identified four positive and four negative emotions relative to the pleasure or displeasure they bring.
|Primary Emotions||Degrees of Feeling||Life-Preserving
|Source: Adapted from Plutchik, 1991.|
Each emotion has varying degrees of intensity and may combine with other emotions to form more complex emotions, such as to jealousy (sadness, anger, fear) and optimism (joy and anticipation).
Emotions serve life-preserving functions for the survival of the human species, including: incorporation of what is helpful, exploration of the environment, orientation for the sake of safety, reproduction for continuation of the species, protection against harm, destruction of danger, rejection of what may be harmful, and reintegration to wholeness when wounded.
Though emotions may be called positive or negative, in themselves they are neither good nor bad. However, the actions people take when they experience an emotion can be harmful or helpful to others or themselves. For example:
Fear is a normal, protective response to a specific danger, such as an attack by an armed assailant or the sight of a black widow spider. When individuals recognize danger (cognition), feel the emotion of fear (feeling), and have an urge to act (impulse), then they take protective action (behavior) either to fight or take flight.
When an event creates an intense experience of the emotion of fear, the event is encoded in memory and acute stress disorder or posttraumatic stress disorder may result.
Anxiety is “free-floating” fear of a nonspecific danger. It creates the same physiological response as fear, yet because individuals do not know who or what is threatening them, they cannot take protective action. As a result, the fear response continues, following the physiological sequence described earlier as General Adaptation Syndrome, and in time individuals become exhausted.
At milder levels, anxiety keeps humans alert and focused, which aids in the work of living. However, when anxiety increases, adaptive behaviors decrease, physical symptoms increase, social adaptation and occupational functioning decline, and anxiety disorders follow. Thus, PTSD is classified as one of the anxiety disorders.
Plotted in an ascending scale of severity, the continuum of anxiety disorders identified by the American Psychiatric Association (APA) is shown below. Note the relative intensity of posttraumatic stress disorder and acute stress disorder as they relate to other anxiety disorders.
|Source: Adapted from Shoemaker & Varcarolis, 2006.|
Alex Moore was brought to the ED by his sister. She had found him writing a suicide note at the kitchen table. The smell of alcohol was on his breath, and there were bottles of both pain and sleeping pills beside him. Five weeks earlier, Alex had left his wife in Texas and driven to his sister’s home in California. Three weeks after that he wrecked his truck and became dependent on his sister for transportation. When she confronted him at the kitchen table, he said, “I’m no damn good to anyone. You’ll all be better off without me.” After much pleading, his sister talked Alex into going with her to the ED.
In the ED Alex’s manner was subdued but somewhat hostile, especially when the staff decided to admit him to the hospital as a “danger to self.” His sister gave further history: For several years Alex had been a fireman. His best friend and fellow fireman died in an explosion and fire that Alex survived. On the one-year anniversary of his friend’s death, Alex walked off the job and never went back. Since then, he has not been able to “settle down” or keep a job, has had frequent outbursts of anger, “woman problems,” troubled sleep, nightmares that he refused to discuss, inability to concentrate, and chronic fatigue.
In the hospital Alex was passive, withdrawn, and irritable. He sat stone-faced in group meetings, refusing to participate. He was easily startled by sounds, avoided news programs and movies of violence, and wandered around the ward checking doors and windows.
Although there is an increasing awareness of PTSD in servicemen and women returning from combat overseas, it is important to remember that many other individuals may be suffering from the disorder. These survivors may include the diabetic octogenarian in an extended-care facility, a new mother in a postpartum clinic, a non-English-speaking immigrant on dialysis, a high school teacher having a routine physical examination, or a firefighter visiting the emergency department. All patients should be assessed for symptoms of PTSD.
Typically, the symptoms of posttraumatic stress disorder fall into three categories: (1) reliving the traumatic event, (2) detachment and avoidance, and (3) exaggerated responses (NCBI, 2010).
Reliving the event to a degree that it interferes with normal life activities:
Detachment and avoidance:
The most common method for assessing individuals for PTSD is the clinical interview. In settings such as emergency departments and clinics, the interview focuses on the individual’s immediate safety, emotional stability, and possible exposure to further trauma. The following guidelines may be helpful:
The mnemonic ERRAND may be helpful when assessing for the specific criteria identified by the American Psychiatric Association in the DSM-IV-TR.
|Source: Adapted from Kaiman, 2003.|
|E||Exposure to a traumatic event that occurred more than one month before assessment and involved intense fear, helplessness, or horror and was not merely an “upsetting” event. (If trauma occurred less than four weeks before assessment, diagnosis may be acute stress disorder.)|
|R||Re-experiencing of a traumatic event in frightening nightmares; restless sleep wit diaphoresis.|
|R||Reliving or describing the traumatic event causes extreme distress. Various sights and sounds remind survivor of traumatic event. Flashbacks of trauma, with visual, olfactory, tactile, and auditory hallucination.|
|A||Autonomic hyperarousal with exaggerated startle response. Angry outbursts for little reason, impatience, intolerance of crowds. Hypervigilance, sitting with back to walls, inspecting exits, patrolling at night.|
|N||Numbing and avoidance. Lack of interest in hobbies or activities. Poor concentration. Emotionally numb, detached, unable to endure strong emotional reactions. Feels hopeless, helpless, and worthless; suicidal ideation. Unable to recall important aspects of trauma. Avoids thoughts of people and places associated with trauma.|
|D||Duration of symptoms.
Although informal mental status interviews can reveal many posttraumatic stress symptoms, their unstructured nature may overlook important symptoms. For this reason, some clinicians prefer more structured assessment tools.
Other trauma-specific tests include:
Generic tests include:
Although it may seem obvious to healthcare professionals, people with acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) should have a complete physical examination to check for endocrine, cardiovascular, and neurologic disorders. Furthermore, patients should be asked what over-the-counter drugs and mood-altering substances they are taking (e.g., alcohol, marijuana).
A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The box below gives the American Psychiatric Association diagnostic criteria for PTSD. When individuals develop similar symptoms lasting 2 days within 4 weeks of a traumatic event, the diagnosis is acute stress disorder (ASD).
APA DIAGNOSTIC CRITERIA FOR PTSD
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Copyright 2000, American Psychiatric Association.
Nursing diagnoses are words or phrases that describe an actual or potential human response to health conditions and life processes (NANDA International, 2011).
Meeting with Alex in the ED, the nurse learns more about his case. She develops some likely nursing diagnoses:
Planning care involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.
The number one, over-arching goal of treatment for people suffering from PTSD is reintegration, by which the traumatized person metabolizes or internally resolves distressing feelings, thoughts, and memories. This goal influences all therapeutic interventions. The intrinsic function of reliving these experiences appears to be the processing and integrating of disturbing material. This internal working-through activity builds on the innate tendency of humans to process trauma-related memories, adapt to new realities, survive, and even thrive.
From the perspective that posttraumatic stress is adaptive, symptoms such as flashbacks, recurring images, and dreams can be considered “recovery procedures,” not pathological symptoms. Thus, nurses and other clinicians see traumatized individuals not as collections of pathological symptoms but as people who are “at some level attempting to recover, albeit not always successfully” (Biere & Scott, 2007).
The second most important goal of treatment is personal growth. This is not to be interpreted as some platitude about “growing stronger through testing” or “making lemonade from lemons.” It does mean that not all traumatic events are inevitably tragic. Adversity can cause people to develop in ways they never would have imagined, such as acquiring new levels of resilience, greater self-knowledge, additional survival skills, increasing empathy for others, and a broader view of life. At first, people who have suffered great trauma need safety, attention to life support, and help with painful symptoms. Later in the recovery process, personal growth becomes evident (Biere & Scott, 2007).
In planning for Alex’s treatment, the most urgent problem is his risk for suicide, followed by a disturbed sleep pattern that impairs thinking. His dysfunctional grieving, ineffective coping, and anxiety should be addressed as he works through and resolves the distressing feelings and memories of the explosion, fire, and death of his friend.
The goals and outcomes for each of Alex’s nursing diagnoses are as follows:
To achieve reintegration and personal growth—the primary goals of treatment for traumatized individuals—clinicians follow these basic principles:
A review of existing literature suggests that, regardless of the theoretical stance of therapists, effective treatment for PTSD includes: (1) provision of a healing environment; (2) education about trauma; (3) distress reduction and emotion regulation; (4) cognitive interventions; (5) emotional processing; (6) increasing identity and relational functioning; and (7) psychopharmacology.
A healing environment is a place of safety from physical and emotional assault. It is a haven of stability and order with a predictable schedule; adequate food and shelter; and an environment of human kindness, respect, and safety. It is a place where survivors of trauma receive unconditional positive regard, nonpossessive warmth, genuineness, and accurate empathy (Rogers, 1961; Carkhoff, 1977). In such a sanctuary, a consistent, therapeutic relationship is established where every individual is respected and taken seriously. Survivors are commended for the strength and courage they demonstrate by their mere presence and willingness to confront painful memories.
Education about trauma and its symptoms greatly facilitates healing. It not only gives survivors information about the nature of trauma and its effects, but it also validates their experience and helps them integrate relevant information into their overall perspective. Education about trauma is especially valuable for victims of interpersonal violence because their reality may have been distorted by their abusers, making them believe they deserved the abuse and are to blame for its consequences. Education for survivors of trauma focuses on the following topics:
When education is imbedded in the therapeutic context, it becomes more relevant and better integrated into the understanding of survivors. In addition to planned education from clinicians, survivors learn from fellow members of a support group and from well-chosen, timely handouts and self-help books. Regardless of the source, all educational material should be monitored and evaluated for:
(Sources of handouts and books are listed in the “Resources” section below.)
Survivors of trauma often suffer chronic levels of anxiety and arousal and strong negative emotional responses to trauma-related memories. Such memories are easily triggered and difficult to manage. Because these feelings are so vivid and painful, survivors may rely on avoidance strategies, including substance abuse, dissociation, and unhealthy tension-reducing behaviors (such as binge eating, promiscuous sex, and self-mutilation).
Avoidance measures hinder recovery and may cause survivors to drop out of therapy and give up. To help people cope with distress and increase their capacity to regulate negative emotions, clinicians use and teach stress-reduction activities, including grounding, breathing-relaxation exercises, and emotional regulation.
In therapy sessions, when clients experience sudden panic, flashbacks, intrusive negative thoughts, dissociative states, or psychotic symptoms, the therapist may use a technique called grounding. At these times the clinician changes the subject from whatever was being discussed to the immediate therapeutic process. To reduce such overwhelming distress, the therapist may lead the person in breathing or other relaxation exercises, or just sit quietly, acknowledging their pain. Grounding should be used judiciously to avoid implying that something has gone wrong.
Slow, deep breathing lowers tension and leads to inadvertent muscle relaxation. When trauma survivors learn how to breathe deeply and relax, they have a tool they can use at any time and in almost any place. Such knowledge is empowering. Many therapists begin each session with breathing or relaxation exercises to foster a sense of control and safety in survivors.
This simple breathing-relaxation exercise can be led and modeled by a therapist, who asks survivors to:
With relatively little practice, survivors can learn this deep breathing, self-relaxation exercise and by so doing gain a sense of empowerment and control.
In addition to grounding and relaxation, therapists have identified several techniques to help trauma survivors tolerate and reduce negative emotions. These skills include learning to (1) identify and discriminate between emotions, (2) recognize and counter thoughts that trigger intrusive emotions, (3) notice triggers and intervene, and (4) resist harmful tension-reducing behaviors.
Survivors of trauma, especially those who have suffered interpersonal violence, are prone to harbor negative beliefs and perceptions about themselves, such as shame and guilt. Cognitive therapy involves reevaluating those beliefs and perceptions and replacing them with more affirming and empowering views. The central goal of cognitive therapy is to assist clients to explore and “think through” their beliefs within the context of when and how those beliefs developed. The process involves talking about a traumatic event and gaining a better understanding of their reasoning.
As they describe a traumatic event chronologically and analytically and place it in a larger context, clients experience an increased sense of perspective and reduced feelings of chaos (Meichenbaum & Fong, 1994). The retelling and the rethinking of a traumatic event somehow provides a degree of closure so that the event does not require further rumination and preoccupation. In this way, survivors develop a coherent narrative(logical story) of the trauma that upset them and are able to incorporate it into their ongoing life.
Emotional processing of traumatic events involves exposure to traumatic memories at the same time the survivor is experiencing safety. Over time, the expectation of treatment is that the extreme fear and horror of the original trauma (the conditioned emotional response) lessens and gradually is extinguished. Eventually, the survivor is able to remember the event without re-experiencing the fear and horror associated with it. Emotional processing is said to follow a five-stage sequence: exposure, activation, disparity, counter-conditioning, and desensitization.
Alex’s healthcare provider believes that emotional processing is an appropriate treatment for him. In a group therapy session with other survivors, Alex talks about the fire and explosion that killed his best friend (exposure). Alex remembers his frantic efforts to see through the flames and smoke. He feels again the intense fear and frustration (anger) of entrapment and helplessness as he tries to find his way out of the debris (activation).
Unlike during his traumatic experience, Alex is now sitting in a comfortable chair in a nonthreatening, well-ventilated, safe place with people who accept and care for him (disparity). He is not restrained and is free to move about as he wishes. The fear and anger Alex felt at the time of the explosion is directly opposite the safety, positive regard, acceptance, validation, and genuineness he now feels from the environment and fellow survivors (counter-conditioning).
Over time, with repeated experiences of safety and emotional support, even as he tells his narrative of horror, Alex gradually experiences less and less fear, anger, and guilt. He no longer needs to avoid the triggers he once did, nor does he need drugs and alcohol to quell his emotional pain (desensitization).
Because exposure of survivors to the horror of a traumatic event can be extremely upsetting, therapists seek to control the intensity of emotions within a therapy session. Ideally, at the beginning of a session survivors are not aroused. In the safety of the therapeutic setting, they may become aroused as they process the traumatic event. As the session draws to a close, the therapist seeks to lower the level of emotionality so that survivors can leave the session in as calm an affective state as possible.
Exposure to traumatic memories may be contraindicated for some survivors, including clients who are severely depressed, extremely anxious, acutely psychotic, or overwhelmed by guilt or shame. Interventions for these clients include the affect regulation and cognitive interventions discussed earlier, psychiatric medication, and hospitalization.
Many survivors of multiple traumas have great difficulty with self-identity and interpersonal relationships. This is particularly true of survivors of early and severe childhood trauma who have problems recognizing their own needs and entitlements, maintaining a consistent sense of self, and establishing an internal reference point in times of stress (Allen, 2001). As abused children, they may have concluded that all people are dangerous and that they themselves are intrinsically unacceptable and deserve punishment or disregard. Because of these entrenched problems with personal identity and interpersonal functioning, untreated survivors are more likely to fall victim to multiple abusers, compounding their issues and leading them into further difficulties.
Interventions for survivors with personal identity and interpersonal relationship issues are the same as for all victims of trauma, however a safe and nurturing environment in the presence of beneficent others is especially important. From caring relationships, they are able to gain a sense of personal identity and dignity and learn how to communicate assertively without submission or domination by anyone. Eventually, relating to others no longer triggers the same level of fear, anger, distrust, and avoidant behavior it once did and survivors are able to sustain positive interpersonal relationships.
While supportive therapy is of enormous value for sufferers of PTSD, individuals may be so overwhelmed by the disorder they are unable to participate in therapy. In addition, they may suffer from other psychological conditions, such as depression, other anxiety disorders, and psychotic conditions. For this reason, psychotropic medications can be useful adjuncts to trauma-focused therapies, especially in the early phase of treatment.
Several classes of medications are effective in the treatment of anxiety disorders, including antidepressants, anxiolytics, and others. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment (Simon & Rosenbaum, 2003; National Center for PTSD, 2011). Results of many randomized, double-blind, placebo-controlled studies of SSRIs indicate that these drugs reduce symptoms in the three core symptom clusters of PTSD, namely re-experiencing, hyperarousal, and avoidance. SSRIs are preferable to tricyclic antidepressants because they have more rapid onset of action and fewer side effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if clients eat food containing tyramine.
Sufferers of PTSD often self-medicate as a means to avoid or nullify their symptoms, misusing prescribed drugs or self-medicating with alcohol, marijuana, and various herbal preparations. For this reason, PTSD treatment centers advise their clients to refrain from use of nonprescribed substances. When medications are prescribed for clients, clinicians assume the responsibility to monitor both their symptom relief and their overall health status.
|Class||Generic (trade) name||Usual daily dose (mg/day)|
|Selective serotonin reuptake inhibitors (SSRI)||Citalopram (Celexa)||10–60 mg|
|Duloxetine (Cymbalta)||40-60 mg|
|Fluoxetine (Prozac)||10–80 mg|
|Fluvoxamine (Luvox)||100–300 mg|
|Paroxetine (Paxil)||10–60 mg|
|Sertraline (Zoloft)||50–200 mg|
|Other serotonergic agents||Venlafaxine XR (Effexor XR)||75–225 mg|
|Mirtazapine (Remeron)||15–45 mg h.s.|
|Trazodone (Desyrel)||150–600 mg|
|Bupropion (Wellbutrin)||150–300 mg|
|Monoamine oxidase inhibitors (MAOIs)||Phenelzine (Nardil)||15–19 mg|
|Tranylcypromine (Parnate)||30–60 mg|
|Tricyclic antidepressants||Amitriptyline (Elavil)||50–300 mg|
|Clomipramine (Anafranil)||100–250 mg|
|Desipramine (Norpramin)||100–300 mg|
|Imipramine (Tofranil)||75–300 mg|
|Nortriptyline (Pamelor)||74–150 mg|
|Benzodiazepines||Alprazolam (Xanax)||0.25–2.0 mg|
|Chlordiazepoxide (Librium)||15–75 mg|
|Diazepam (Valium)||2.5–10 mg|
|Lorazepam (Ativan)||0.5–6.0 mg|
|Nonbenzodiazepine||Buspirone (BuSpar)||30–60 mg|
Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. Evaluation questions include:
Six months after he began treatment, Alex meets with his healthcare provider. In evaluating his treatment, she determines that he has achieved most of his goals:
Although natural disasters cannot be prevented, the damage they cause can be anticipated and sometimes mitigated. When such disasters do occur, official and charitable agencies can provide tangible assistance and emotional support.
Some occupations, by their very nature, expose individuals to terrifying traumatic events. These include such dangerous professions as military service, firefighting, underground mining, and deep-sea exploration. To prevent or at least reduce the number of individuals who develop posttraumatic stress disorder, leaders in these professions have begun assessing potential candidates for risk of posttraumatic stress disorder. In addition, they are now providing resilience education for those who are accepted. (See also “Risk and Resilience” above).
As the medical profession becomes aware of the widespread instance of posttraumatic stress disorder in the general population, greater attention will be paid to its prevention and to effective treatment for its victims.
International Society for Traumatic Stress Studies
Office for Victims of Crime, U.S. Department of Justice
David Baldwin’s Trauma Information Pages
United States Department of Veterans Affairs, National Center for PTSD
Allen J. (2001). Traumatic relationships and serious mental disorder. Chichester, UK: Wiley.
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