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Posttraumatic Stress Disorder

7 min read

References:

  1. Psychiatric-Mental Health Nursing, 8th Edition, 978-1-975116-37-8, by Sheila L. Videbeck

Posttraumatic stress disorder (PTSD) is a disturbing pattern of behavior demonstrated by someone who has experienced, witnessed, or been confronted with a traumatic event such as a natural disaster, combat, or an assault. A person with PTSD was exposed to an event that posed actual or threatened death or serious injury and responded with intense fear, helplessness, or terror.

  • PTSD can occur at any age, including childhood. Common demographics that are at risk include combat veterans, victims of natural disorders, victims of physical abuse (25% develop PTSD), and victims of rape (70%; highest rates of PTSD).

Clinical Course

PTSD symptoms appear 3 months or more after the trauma, which distinguishes PTSD from acute stress disorder (lasts 3 days to 1 month). The onset can be delayed for months or even years— PTSD is chronic in nature, though symptoms can fluctuate in intensity and severity, becoming worse during stressful periods.

  1. Re-experiencing the trauma through dreams or recurrent and intrusive thoughts. Memories, dreams, flashbacks, or reactions to external cues about the event and therefore avoids stimuli associated with the trauma.
  2. Avoidance: the person reports losing a sense of connection and control over their life. This can lead to avoidance behavior or trying to avoid any places or people or situations that may trigger memories of the trauma.
  3. Negative cognition or thoughts: the person seeks comfort, safety, and security, but can actually become increasingly isolated over time, which can heighten negative feelings he or she was trying to avoid.
  4. Being on guard; hyperarousal: insomnia, hypervigilance, irritability, or angry outbursts.

Adjunct psychiatric disorders, such as depression, anxiety disorders, or alcohol and drug abuse, can appear.

  • Acute stress disorder occurs after a traumatic event (3 days to 4 weeks after) and may be a precursor to PTSD. Intervention in this stage (e.g., CBT) can prevent the progression to PTSD.
  • Adjustment disorder involves a heightened difficulty in coping with or assimilating the event into his or her life. Financial, relationship, and world-related stressors are commonly implicated.
  • Reactive attachment disorder and social engagement disorder occur before the age of 5 in response to the trauma of child abuse or neglect (grossly pathogenic care). The child exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason. They socialize unselectively, lacking the hesitation in approaching or talking to strangers.

Etiology

PTSD and acute stress disorder, previously considered as anxiety disorders, are now in their own category. There has to be a causative trauma or event that occurs (event exposure) prior to the development of PTSD, which is not the case with anxiety disorders, which may be related to (persona.

Diagnostic Criteria (DSM-5)

Posttraumatic Stress Disorder 309.81 (F43.10)

Note

The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the following corresponding criteria.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing in person the event(s) as it (they) occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or a close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: this criterion does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work-related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as though the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame him or herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Treatment

Counseling or therapy, individually or in groups, for people with acute stress disorder may prevent progression to PTSD. Therapy on an outpatient basis is the indicated treatment for PTSD.

  1. In-patient treatment is not indicated; however, in times of severe crisis, short inpatient stays may be necessary, such as in times when the client is overwhelmed by reexperiencing events, such as flashbacks.
  2. CBT and specialized therapy programs incorporating elements of CBT are the most common and successful types of formal treatment. The choice of therapy can depend on the type of trauma, as well as the choice to seek formal individual or group counseling.
  3. Exposure therapy is a treatment approach designed to combat the avoidance behavior that occurs with PTSD, help the client face troubling thoughts and feelings, and regain a measure of control over his or her thoughts and feelings.
  4. Adaptive disclosure is a specialized CBT approach developed by the military to offer an intense, specific, short-term therapy for active-duty military personnel with PTSD. This involves exposure therapy and the empty chair technique— the participant says whatever he or she needs to say to anyone, alive or dead.
  5. Medications may be used, especially for targeting specific issues, such as insomnia. Studies show that selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake antidepressants are most effective, followed by second-generation antipsychotic, such as risperidone. This in combination with therapy produces the best results.

Nursing Interventions

  1. Promote client safety
  2. Help client cope with stress and emotions
  3. Help promote client’s self-esteem

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