MENTAL HEALTH: CHAPTER 13: TRAUMA & STRESSOR-RELATED DISORDERS:

Dissociative Disorders: Dissociative Identity Disorder:

- (Formerly multiple personality disorder) - The client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. - This is accompanied by the inability to recall important personal information.

Individual Trauma/Stressors:

- Abuse - Illness

Assessment/Treatment For PTSD:

- Assessment/treatment for PTSD can be culturally tailored

PTSD Treatment Options: CBT & Specialized Therapy:

- 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. - Self-help groups offer support and a safe place to share feelings.

Trauma and Stressor-Related Assessment: Roles & Relationships:

- Clients generally report a great deal of difficulty with all types of relationships. - Problems with authority figures often lead to problems at work, such as being unable to take direction from another or have another person monitor performance. - Close relationships are difficult or impossible because the client's ability to trust others is severely compromised. - Often the client has quit work or has been fired, and he or she may be estranged from family members. Intrusive thoughts, flashbacks, or dissociative episodes may interfere with the client's ability to socialize with family or friends, and the client's avoidant behavior may keep him or her from participating in social or family events.

Exposure Therapy:

- Combats avoidance behaviors associated with PTSD - Helps survivors regain feelings of power and control

PTSD Treatment Options:

- Counseling and therapy (individual or group) - Medications (especially targeting specific issues) - CBT and specialized therapy - Exposure therapy - Relaxation techniques - Adaptive disclosure - Cognitive processing therapy - Community-based care - Mental health promotion

PTSD Treatment Options: Counseling & Therapy (Individual Group):

- 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. - There are some medications that may also contribute to successful resolution, especially when targeting specific issues, such as insomnia. - A combination of both therapies produces the best results - Inpatient treatment is not indicated for clients with PTSD; however, in times of severe crisis, short inpatient stays may be necessary. - This usually occurs when the client is suicidal or is being overwhelmed by re-experiencing events, such as flashbacks.

Derealization:

- Disconnects from reality - Dream-like state where environment seems foggy/unreal - Things are not real

Depersonalization:

- Disconnects from self

PTSD: OUTLINE:

- Disturbing pattern of behavior by someone who has experienced, witnessed, or been confronted with a traumatic event that posted actual or threatened death, serious injury, and response of fear/terror/helplessness - Occurs 3 + months after event - Chronic condition - Complete recovery within 3 months occurs for 50% of people affected - Victims of rape have highest rates of PTSD - Can be diagnosed at any age

Trauma and Stressor-Related Assessment: Sensorium & Intellectual Processes:

- During assessment of sensorium and intellectual processes, the nurse usually finds that the client is oriented to reality except if the client is experiencing a flashback or dissociative episode. - During those experiences, the client may not respond to the nurse or may be unable to communicate at all. - The nurse may also find that clients who have been abused or traumatized have memory gaps, which are periods for which they have no clear memories. - These periods may be short or extensive and are usually related to the time of the abuse or trauma. - Intrusive thoughts or ideas of self-harm often impair the client's ability to concentrate or pay attention.

Nursing Interventions For PTSD:

- Express feelings directly and openly in a non-destructive way - Convey acceptance while setting/maintaining limits regarding behavior - Set limits/consequences to substance abuse behaviors - Involve client and group in setting these limits - If control becomes too much an issue, may need to refer to a treatment program - Encourage ID of relationship/experiences that were positive in the past

Therapy For Survivors W/ Dissociation:

- Focus on RE-association or putting the consciousness back together

Cognitive Processing Therapy:

- Focuses on examining beliefs that are erroneous - ("it was my fault for not fighting harder", "I should've died along with them")

Dissociative Amnesia:

- Forget personal details associated with fuge state in which person moves to new geographic location and assumes a new identity

PTSD Treatment Options: 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. - It incorporates exposure therapy as well as the empty chair technique, in which the participant says whatever he or she needs to say to anyone, alive or dead. - This is similar to techniques used in Gestalt therapy. - Despite the short six-session format, this approach seems well tolerated and effective in reducing PTSD symptoms and promoting post-trauma growth

Dissociation:

- Is a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. - Dissociation can occur both during and after the event. As with any other protective coping mechanism, dissociating becomes easier with repeated use.

Dissociative Disorder Treatment & Intervention:

- Survivors of abuse who have dissociative disorders are often involved in group or individual therapy in the community to address the long-term effects of their experiences. - Therapy for clients who dissociate focuses on reassociation, or putting the consciousness back together. - This specialized treatment addresses trauma-based, dissociative symptoms. - The goals of therapy are to improve quality of life, improved functional abilities, and reduced symptoms. - Clients with dissociative disorders may be treated symptomatically, that is, with medications for anxiety or depression or both if these symptoms are predominant.

Dissociative Disorders: Dissociative Amnesia:

- The client cannot remember important personal information (usually of a traumatic or stressful nature). - This category includes a fugue experience where the client suddenly moves to a new geographic location with no memory of past events and often the assumption of a new identity.

Depersonalization/Derealization Disorder:

- The client has a persistent or recurrent feeling of being detached from his or her mental processes or body (depersonalization) or sensation of being in a dream-like state in which the environment seems foggy or unreal (derealization). - The client is not psychotic nor out of touch with reality.

Is the following statement true or false? Persons who witness a traumatic event are likely to develop post-traumatic stress disorder (PTSD):

False - Rationale: Not all people, nor even most people, who witness a traumatic event will develop posttraumatic stress disorder (PTSD). Those most likely to develop PTSD are those who were directly involved in the event, not just merely witness to the event; those who experienced physical injury or loss of a loved one; those with a lack of social supports; or those with previous psychiatric history/repeated trauma.

Is the following statement true or false? It may require years for clients who experienced trauma to achieve their outcomes.

True - Rationale: Clients with trauma or stress-related disorders make gradual progress in their treatment. The effects of trauma and abuse can be far reaching and can last a lifetime.

4. Clients from other countries who suffered traumatic oppression in their native countries may develop PTSD. Which is least helpful in dealing with their PTSD? a.Assimilating quickly into the culture of their current country of residence b.Engaging in their native religious practices c.Maintaining a strong cultural identity d.Social support from an interpreter or fellow countryman

a.Assimilating quickly into the culture of their current country of residence

1. Which behavior might the nurse assess in a 3-year-old child with RAD? a.Choosing the mother to provide comfort b.Crying when the parents leave the room c.Extreme resistance to social contact with parents and staff d.Seeking comfort from holding a favorite stuffed animal

c.Extreme resistance to social contact with parents and staff

2. Which intervention would be most helpful for a client with dissociative disorder having difficulty expressing feelings? a.Distraction b.Reality orientation c.Journaling d.Grounding techniques

c.Journaling

3. Which statement is true about touching a client who is experiencing a flashback? a.The nurse should stand in front of the client before touching. b.The nurse should never touch a client who is having a flashback. c.The nurse should touch the client only after receiving permission to do so. d.The nurse should touch the client to increase feelings of security.

c.The nurse should touch the client only after receiving permission to do so.

5. The nurse working with a client during a flashback says, "I know you're scared, but you're in a safe place. Do you see the bed in your room? Do you feel the chair you're sitting on?" The nurse is using which technique? a.Distraction b.Reality orientation c.Relaxation d.Grounding

d.Grounding

6. Nursing interventions for hospitalized clients with PTSD include a.encouraging a thorough discussion of the original trauma. b.providing private solitary time for reflection. c.time-out during flashbacks to regain self-control. d.use of deep breathing and relaxation techniques.

d.use of deep breathing and relaxation techniques.

Intervention: Helping The Client Cope W/ Stress & Emotions:

- Grounding techniques are helpful to use with the client who is dissociating or experiencing a flashback. - Grounding techniques remind the client that he or she is in the present, is an adult, and is safe. - Validating what the client is feeling during these experiences is important: "I know this is frightening, but you are safe now." In addition, the nurse can increase contact with reality and diminish the dissociative experience by helping the client focus on what he or she is currently experiencing through the senses: •"What are you feeling?" •"Are you hearing something?" •"What are you touching?" •"Can you see me and the room we're in?" •"Do you feel your feet on the floor?" •"Do you feel your arm on the chair?" •"Do you feel the watch on your wrist?" - For the client experiencing dissociative symptoms, the nurse can use grounding techniques to focus the client on the present. - For example, the nurse approaches the client and speaks in a calm reassuring tone. - First, the nurse calls the client by name and then introduces him or herself by name and role. - If the area is dark, the nurse turns on the lights. - He or she can reorient the client by saying the following: "Hello, Janet, I'm here with you. My name is Sheila. I'm the nurse working with you today. Today is Wednesday, September 18, 2019. You're here in the hospital. This is your room at the hospital. Can you open your eyes and look at me? Janet, my name is Sheila." - The nurse repeats this reorienting information as needed. - Asking the client to look around the room encourages the client to move his or her eyes and avoid being locked in a daze or flashback. - As soon as possible, the nurse encourages the client to change positions. - Often during a flashback, the client curls up in a defensive posture. - Getting the client to sta

PTSD Treatment Options: Cognitive Processing Therapy:

- Has been used successfully with rape survivors with PTSD as well as combat veterans. - The therapy course involves structured sessions that focus on examining beliefs that are erroneous or interfere with daily life, such as guilt and self-blame; for example, "It was my fault, I should have fought harder" or "I should have died with my fellow Marines;" reading aloud a written account of the worst traumatic experience; recognizing generalized thinking, that is, "No one can be trusted;" and regaining more balanced and realistic ways of appraising the world and themselves

Dissociative Disorders:

- Have the essential feature of a disruption in the usually integrated functions of consciousness, memory, identity, or environmental perception. - This often interferes with the person's relationships, ability to function in daily life, and ability to cope with the realities of the abusive or traumatic event. - This disturbance varies greatly in intensity in different people, and the onset may be sudden or gradual, transient, or chronic. - Dissociative symptoms are seen in clients with PTSD - Dissociative disorders, relatively rare in the general population, are much more prevalent among those with histories of childhood physical and sexual abuse. - Some believe the recent increase in the diagnosis of dissociative disorders in the United States is the result of more awareness of this disorder by mental health professionals. - Whether dissociative identity disorder is a legitimate diagnosis is still a controversy among psychiatrists in the field

Grounding Techniques:

- Helpful with dissociation or flashback. - Remind the person that he or she is present, is an adult, and is safe. - Increase contact with reality. - Diminish the dissociative experience by focusing on current experiences. - Focus the client in the present.

Ground Technique (OUTLINE):

- Helps the survivor remember they're in the present, they're an adult, they're safe AND increase contact with reality by helping client focus on what they're feeling through the 5 senses

Trauma and Stressor-Related Assessment: Mood & Affect:

- In assessing mood and affect, the nurse must remember that a wide range of emotions is possible from passivity to anger. - The client may look frightened or scared or agitated and hostile depending on his or her experience. - When the client experiences a flashback, he or she appears terrified and may cry, scream, or attempt to hide or run away. - When the client is dissociating, he or she may speak in a different tone of voice or appear numb with a vacant stare. - The client may report intense rage or anger or feeling dead inside and may be unable to identify any feelings or emotions.

PTSD Inpatient Treatment:

- Inpatient treatment is NOT usually recommended for PTSD survivors unless they're in an acute crisis (ex: harm to self or others)

Adaptive Disclosure:

- Intense, short-term (6 session) therapy for active duty military personnel with PTSD that incorporates exposure therapy and empty-chair technique (they say whatever's on their mind to the person alive or dead)

Posttrauamtic 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. - In PTSD, the symptoms occur 3 months or more after the trauma, which distinguishes PTSD from acute stress disorder, which may have similar types of symptoms but lasts 3 days up to 1 month. - The onset can be delayed for months or even years. - Typically, PTSD is chronic in nature, though symptoms can fluctuate in intensity and severity, becoming worse during stressful periods. Often, other life events can exacerbate PTSD symptoms. In addition, many clients with PTSD develop other psychiatric disorders, such as depression, anxiety disorders, or alcohol and drug abuse - PTSD can occur at any age, including during childhood. - Estimates are that up to 60% of people at risk, such as combat veterans and victims of violence and natural disasters, develop PTSD. - Complete recovery occurs within 3 months for about 50% of people. - The severity and duration of the trauma and the proximity of the person to the event are the most important factors affecting the likelihood of developing PTSD. - One-fourth of all victims of physical assault develop PTSD. - Victims of rape have one of the highest rates of PTSD at approximately 70%

Related Disorders: Adjustment Disorder:

- Is a reaction to a stressful event that causes problems for the individual. - Typically, the person has more than the expected difficulty coping with or assimilating the event into his or her life. - Financial, relationship, and work-related stressors are the most common events. - The symptoms develop within a month, lasting no more than 6 months. - At that time, the adjustment has been successful, or the person moves on to another diagnosis - Outpatient counseling or therapy is the most common and successful treatment.

PTSD Treatment Options: 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. - The client confronts the feared emotions, situations, and thoughts associated with the trauma rather than attempting to avoid them. - Various relaxation techniques are employed to help the client tolerate and manage the anxiety response. - The exposure therapy may confront the event in reality, for example, returning to the place where one was assaulted, or may use imagined confrontation, that is, mentally placing oneself in the traumatic situation. - Prolonged exposure therapy has been particularly effective for both active military personnel and veterans

Most Affective Way To Avoid Pathologic Response Of Trauma:

- Is to effectively deal with the trauma soon after it occurs

Self-Awareness Issues:

- It is essential for nurses to deal with their own personal feelings to best care for individuals affected by traumatic events. - These events may be horrific in nature. - Natural disasters can affect thousands of people; attacks on individuals or groups are sometimes senseless, random violence; and combat experiences in war can devastate on the individuals involved. - If the nurse is overwhelmed by the violence or death in a situation, the client's feelings of being victimized or traumatized beyond repair are confirmed. - Conveying empathy and validating clients' feelings and experiences in a calm, yet caring professional manner is more helpful than sharing the client's horror. - When the client's traumatic event is a natural disaster or even a random violent attack, the nurse may easily support the client, knowing the client had nothing to do with what happened. - When the traumatized client causes a car accident that injured or killed others, it may be more challenging to provide unconditional support and withhold judgment of the client's contributory. - Remaining nonjudgmental of the client is important but doesn't happen automatically. - The nurse may need to deal with personal feelings by talking to a peer or counselor.

PTSD Treatment Options: Mental Health Promotion:

- It is not possible to avoid many of the traumatic events in life that can potentially cause mental health problems. - Natural disasters such as earthquakes and hurricanes are beyond human control. - It is also not possible to avoid all the man-made traumatic events that occur; people have been victims of trauma while shopping, watching a movie, or during any other ordinary daily activity. - One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs. - In addition to first aid responders for disastrous events, counselors are often present to help people process the emotional and behavioral responses that occur. - Some people more easily express feelings and talk about stressful, upsetting, or overwhelming events. - They may do so with family, friends, or professionals. Others are more reluctant to open up and disclose their personal feelings. - They are more likely to ignore feelings, deny the event's importance, or insist "I'm fine; I'm over it." - By doing that, they increase the risk of future problems such as PTSD. - It is essential to have an accurate diagnosis of PTSD. - Stress immediately after an event is acute stress disorder, while PTSD is delayed in onset. - Some individuals will report "having PTSD" but are self-diagnosed. - They may have autism spectrum disorder, a grief reaction, or any variety of problems. - Effective treatment is possible only with accurate, professional diagnosis.

Intervention: Helping Promote Client's Self-Esteem:

- It is often useful to view the client as a survivor of trauma or abuse rather than as a victim. - For these clients, who may believe they are worthless and have no power over the situation, it helps to refocus their views of themselves from being victims to being survivors. - Defining themselves as survivors allows them to see themselves as strong enough to survive their ordeal. - It is a more empowering image than seeing oneself as a victim.

PTSD Treatment Options: Medications:

- Medications may be used for clients with PTSD to deal with symptoms such as insomnia, anxiety, or hyperarousal. - Studies show that selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor antidepressants are most effective, followed by second-generation antipsychotic, such as risperidone. - Evidence is lacking for the efficacy of benzodiazepines, though they are widely used in clinical practice - A combination of medications and CBT is considered to be more effective than either one alone.

Care Of Trauma Patients:

- Most care of trauma patients is on an outpatient basis whether it's individual, group, or self-help groups

PTSD Treatment Options: Community-Based Care:

- Most care provided to people in the aftermath of traumatic experiences is done on an outpatient basis. - Individual therapy, group therapy, and self-help groups are among the most common treatment modalities. - In addition, both clients and families can implement many self-care interventions to promote physical and emotional well-being.

Trauma and Stressor-Related Assessment: Psychologic Considerations:

- Most clients report difficulty sleeping because of nightmares or anxiety over anticipating nightmares. - Overeating or lack of appetite is also common. - Frequently, these clients use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or memories.

Medications For PTSD:

- Most effective medications for PTSD are: SSRIs and SNRIs: venlafaxine and resperidone

Dissociative Identity Disorder:

- Multiple personality disorder

Factors That Affect PTSD Recovery:

- Severity and duration of the trauma - Proximity of person to the event

Dissociation: OUTLINE:

- Subconscious defense mechanism in which survivors protects his emotional self by allowing the mind to forget or remove itself from the painful memory/situation

Related Disorders: Reactive Attachment Disorder (RAD) & Disinhibited Social Engagement Disorder (DSED):

- Occur before the age of 5 in response to the trauma of child abuse or neglect, called grossly pathogenic care. - The child shows disturbed inappropriate social relatedness in most situations. - Rather than seeking comfort from a select group of caregivers to whom the child is emotionally attached, the child with RAD exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason. - The child with DSED exhibits un-selective socialization, allowing or tolerating social interaction with caregivers and strangers alike. - They lack the hesitation in approaching or talking to strangers evident in most children their age. - Grossly deficient parenting and institutionalization are the two most common situations leading to this disorder

Acute Stress Disorder (OUTLINE):

- Occurs 2 days to 4 weeks after event - Lasts 3 days to 1 month - Can be precursor to PTSD - Treatment to prevent this progression includes cognitive behavior therapy that involves exposure and anxiety management

Related Disorders: Acute Stress Disorder:

- Occurs after a traumatic event and is characterized by re-experiencing, avoidance, and hyperarousal that occur from 3 days to 4 weeks following a trauma. - It can be a precursor to PTSD. Cognitive-behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD

Etiology Of PTSD:

- PTSD and acute stress disorder had long been classified as anxiety disorders, though they differ from other diagnoses in that category; they are now classified in their own category. - There has to be a causative trauma or event that occurs prior to the development of PTSD, which is not the case with anxiety disorders - PTSD is a disorder associated with event exposure, rather than personal characteristics, especially with the adult population. - In other words, the effects of the trauma at the time, such as being directly involved, experiencing physical injury, or loss of loved ones in the event, are more powerful predictors of PTSD for most people. - This is particularly true of single-event trauma, or triggering event, such as natural disasters. - However, lack of social support, peri-trauma dissociation, and previous psychiatric history or personality factors can further increase the risk of PTSD when they are present pre-trauma - In addition, people who participate in post-trauma counseling right after the event decrease their risk of PTSD. - Studies of adolescents with PTSD indicate they are more likely to develop PTSD than children or adults. - Age, gender, type of trauma, and repeated trauma are related to increased PTSD rates. - Adolescents with PTSD are at increased risk for suicide, substance abuse, poor social support, academic problems, and poor physical health. - Trauma-focused CBT is beneficial and can be delivered in school or community-based settings. - It also has positive long-term effects both with PTSD and other comorbid conditions - PTSD may disrupt biologic maturation processes contributing to long-term emotional and behavioral problems experienced by adolescents with this disorder that would require ongoing or episodic therapy to deal with relevant issues. - Children are more likely to

PTSD Causation:

- PTSD needs to have a causative event which is what separates it from anxiety

Many People Experience Traumatic Events Or Stressors:

- People may experience events in their lives that are extraordinary in intensity or severity, well beyond the stress of daily life - These traumatic events or stressors would be expected to disrupt the life of anyone who experienced them, not just individuals at risk for mental health problems or issues. - The trauma or event may affect a single individual, such as a person with a history of childhood abuse, a child newly diagnosed with type 1 diabetes, or an adult with an acute coronary syndrome such as a myocardial infarction or unstable angina. - Large numbers or groups of people may be affected by a traumatic event, such as war, terrorist attacks, or a natural disaster like a flood, hurricane, or tsunami. Posttraumatic stress disorder (PTSD) is seen in countries around the world - While all persons experiencing events such as these manifest anxiety, insomnia, difficulty coping, grief, or any variety of responses, most work through the experience and return to their usual levels of coping and equilibrium, perhaps even enhanced coping as a result of dealing with the event. - However, some individuals continue to have problems coping, managing stress and emotions, or resuming the daily activities of their lives. - They may develop an adjustment disorder, acute stress disorder, PTSD, or a dissociative disorder.

Cultural Considerations:

- Research indicates that PTSD is a universal phenomenon, occurring in countries around the world. - There is less information about the meaning of one's culture on PTSD, treatment, and recovery. - People leaving their countries for reasons of political oppression experience mental defeat and alienation and lower levels of resilience, which are associated with PTSD as well as poorer long-term outcomes - People with a stronger sense of self and cultural identity are less frequently diagnosed with PTSD and have better long-term outcomes when PTSD was present. - This may indicate that strong cultural identity and allegiance to culture contribute to resilience and are therefore highly positive factors. - The assessment and treatment of PTSD can be culturally tailored to patients - Specifically, therapists should try to understand the patients' help-seeking behaviors as well as their expectations for treatment. - Effective treatments, such as CBT, should be strengths-based, client-driven, and include the patient's culturally relevant beliefs about the illness, its symptoms, and how that intrudes in daily life.

Intervention: Establishing Social Support:

- The client needs to find support people or activities in the community. - The nurse can help the client prepare a list of support people. - Problem-solving skills are difficult for these clients when under stress, so having a prepared list eliminates confusion or stress. - This list should include a local crisis hotline to call when the client experiences self-harm thoughts or urges, and friends or family to call when the client is feeling lonely or depressed. - The client can also identify local activities or groups that provide a diversion and a chance to get out of the house. - The client needs to establish community supports to reduce dependency on health care professionals. - Local support groups can be located by calling the county or city mental health services or the Department of Health and Human Services. - A variety of support groups, both online and in person, can be found on the internet.

Trauma and Stressor-Related Assessment: Judgement & Insight:

- The client's insight is often related to the duration of his or her problems with dissociation or PTSD. - Early in treatment, the client may report little idea about the relationship of past trauma to his or her current symptoms and problems. - Other clients may be quite knowledgeable if they have progressed further in treatment. - The client's ability to make decisions or solve problems may be impaired.

Intervention: Promoting The Client's Safety:

- The client's safety is a priority. - The nurse must continually assess the client's potential for self-harm or suicide and take action accordingly. - The nurse and treatment team must provide safety measures when the client cannot do so -. To increase the client's sense of personal control, he or she must begin to manage safety needs as soon as possible. - The nurse can talk with the client about the difference between having self-harm thoughts and taking action on those thoughts; having the thoughts does not mean the client must act on them. - Gradually, the nurse can help the client find ways to tolerate the thoughts until they diminish in intensity. - The nurse can help the client learn to go to a safe place during destructive thoughts and impulses so that he or she can calm down and wait until they pass. - Initially, this may mean just sitting with the nurse or around others. - Later, the client can find a safe place at home, often a closet or small room, where he or she feels safe. - The client may want to keep a blanket or pillows there for comfort, and pictures or a tape recording to serve as reminders of the present.

Trauma and Stressor-Related Assessment:

- The health history reveals that the client has a history of trauma or abuse. - It may be abuse as a child or in a current or recent relationship. - It is generally not necessary or desirable for the client to detail specific events of the abuse or trauma; rather, in-depth discussion of the actual abuse is usually undertaken during individual psychotherapy sessions.

Repressed Memories:

- The media has focused much attention on the theory of repressed memories in victims of abuse. - Many professionals believe that memories of childhood abuse can be buried deeply in the subconscious mind or repressed because they are too painful for the victims to acknowledge and that victims can be helped to recover or remember such painful memories. - If a person comes to a mental health professional experiencing serious problems in relationships, symptoms of PTSD, or flashbacks involving abuse, the mental health professional may help the person remember or recover those memories of abuse. - Some mental health professionals believe there is danger of inducing false memories of childhood sexual abuse through imagination in psychotherapy. - This so-called false memory syndrome has created problems in families when clients made groundless accusations of abuse. - Fears exist, however, that people abused in childhood will be more reluctant to talk about their abuse history because, once again, no one will believe them. - Still other therapists argue that people thought to have dissociative identity disorder are suffering anxiety, terror, and intrusive ideas and emotions and therefore need help, and the therapist should remain open-minded about the diagnosis.

Trauma and Stressor-Related Assessment: Thought Process & Content:

- The nurse asks questions about thought process and content. - Clients who have been abused or traumatized report reliving the trauma, often through nightmares or flashbacks. - Intrusive, persistent thoughts about the trauma interfere with the client's ability to think about other things or to focus on daily living. - Some clients report hallucinations or buzzing voices in their heads. - Self-destructive thoughts and impulses as well as intermittent suicidal ideation are also common. - Some clients report fantasies in which they take revenge on their abusers.

Trauma and Stressor-Related Assessment: General Appearance & Motor Behavior:

- The nurse assesses the client's overall appearance and motor behavior. - The client often appears hyperalert and reacts to even small environmental noises with a startle response. - He or she may be uncomfortable if the nurse is too close physically and may require greater distance or personal space than most people. - The client may appear anxious or agitated and may have difficulty sitting still, often needing to pace or move around the room. - Sometimes the client may sit very still, seeming to curl up with arms around knees.

Trauma and Stressor-Related Assessment: Self-Concept:

- The nurse is likely to find these clients have low self-esteem. - They may believe they are bad people who somehow deserve or provoke the abuse. - Many clients believe they are unworthy or damaged by their abusive experiences to the point that they will never be worthwhile or valued. - Clients may believe they are going crazy and are out of control with no hope of regaining control. - Clients may see themselves as helpless, hopeless, and worthless.

Group Trauma/Stress:

- War - Terrorist attack - Natural disaster

2 Effective Ways Of Dealing With Dissociation:

1. Grounding technique 2. Reality orientation

3 Major Elements Of PTSD:

1. Re-experiencing event 2. Emotional numbing 3. Hyperarousal - This can lead to avoidance behaviors (maladaptive)

Which person is most likely to experience a dissociative disorder? A. A survivor of a car accident B. A survivor of childhood sexual abuse C. A survivor of a natural disaster D. A client with a sudden, severe illness

B. A survivor of childhood sexual abuse - Rationale: Dissociative disorders are most prevalent among persons with a history of childhood physical and/or sexual abuse. Dissociative disorders are relatively rare in the general population.

Data Analysis:

Nursing diagnoses commonly used in the acute care setting when working with clients who dissociate or have PTSD related to trauma or abuse include: •Risk of self-mutilation •Risk of suicide •Ineffective coping •Posttrauma response •Chronic low self-esteem •Powerlessness In addition, the following nursing diagnoses may be pertinent to clients over longer periods, although not all diagnoses apply to each client: •Disturbed sleep pattern •Sexual dysfunction •Rape-trauma syndrome •Spiritual distress •Social isolation

PTSD: Clinical Course: Hyperarousal:

The four subcategories of symptoms in PTSD include: - Re-experiencing the trauma through dreams or recurrent and intrusive thoughts, avoidance - Negative cognition or thoughts - Being on guard - Hyperarousal - The person persistently re-experiences the trauma through memories, dreams, flashbacks, or reactions to external cues about the event and therefore avoids stimuli associated with the trauma. - The victim feels a numbing of general responsiveness and shows persistent signs of increased arousal such as insomnia, hyperarousal or hypervigilance, irritability, or angry outbursts. - He or she reports losing a sense of connection and control over his or her life. - This can lead to avoidance behavior or trying to avoid any places or people or situations that may trigger memories of the trauma. - The person seeks comfort, safety, and security, but can actually become increasingly isolated over time, which can heighten the negative feelings he or she was trying to avoid.

Trauma and Stressor-Related Outcomes:

Treatment outcomes for clients who have survived trauma or abuse may include: 1. The client will be physically safe. 2. The client will distinguish between ideas of self-harm and taking action on those ideas. 3. The client will demonstrate healthy, effective ways of dealing with stress. 4. The client will express emotions nondestructively. 5. The client will establish a social support system in the community.

Points To Consider When Working With Abused Or Traumatized Patients:

•Clients who participate in counseling, groups, and/or self-help groups have the best long-term outcomes. It is important to encourage participation in all available therapies. •Clients who survive a trauma may have survivor's guilt, believing they "should have died with everyone else." Nurses will be most helpful by listening to clients' feelings and avoiding pat responses or platitudes such as "Be glad you're alive," or "It was meant to be." •Often clients just need to talk about the problems or issues they're experiencing. These may be problems that cannot be resolved. Nurses may want to fix the problem for the client to alleviate distress but must resist that desire to do so and simply allow the client to express feelings of despair or loss.