Practice and Learn: Posttraumatic Stress Disorder
As the patient interview progresses, Stan starts to exhibit significant anxiety and the CNS starts to consider if Stan needs hospitalization. She asks Stan if he has any thoughts of wanting to harm himself or others. Stan says, "I made it back from combat without dying. Why would I then go ahead and kill myself? I would never do that; then surviving war would be meaningless. I swear I would never do anything to myself." Stan asks the CNS if she is thinking about hospitalizing him and says, "I really don't want to be hospitalized. I'm overwhelmed, but I'm OK to be at home. People don't get hospitalized for PTSD, right?" What is the best response for the CNS?
Correct Response: "Inpatient treatment is not always necessary for the symptoms of PTSD but when a client gets so overwhelmed by symptoms that they become a risk for harm to themselves or others, then we have to consider a brief inpatient stay." Explanation: PTSD can be effectively treated in an outpatient setting. Inpatient treatment for individuals with symptoms of PTSD is not indicated unless they become a risk for harming themselves or others. In that case, a person may be hospitalized briefly until they are assessed to be safe from self-harm or harm to others. It is not true that long-term inpatient hospitalization is the best treatment for PTSD and dismissing Stan's feelings is nontherapeutic. Insurance should not determine anyone's course of treatment. It is not possible for Stan to commit to never wanting to harm himself or others, since the future is unknowable. Therefore, the nurse should not request that promise from Stan, and she should not, in turn, promise that they will never hospitalize him.
While doing his initial interview, Stan expresses sadness and frustration that he has not been able to overcome his symptoms on his own. He tells the CNS that other people he fought alongside are back home having no problems at home or at work. He asks why he has been unable to reintegrate into life at home like they did. What is the best response to Stan's question?
Correct Response: One theory about why PTSD develops in some and not others is related to what the traumatic event was, variables within the individual, and what the recovery environment is like. Explanation: There are no specific characteristics about an individual and/or a traumatic event that can accurately predict who will and who will not develop PTSD. However, a mix of characteristics that are relevant to the experience and an individual's response to the experience may facilitate the development and recovery of PTSD. The severity of the trauma, the anticipatory preparation for the event, the exposure to death, and the location of the event are characteristics of the traumatic experience that may play a role in the development of symptoms of PTSD. Other characteristics that are relevant to the development of symptoms of PTSD include the individual's coping resources, presence of existing psychopathology, temperament, and prior experience with stress and trauma. Variables that play a role in the quality of a person's social network, and society's attitude toward the traumatic event. The DSM-5 diagnosis applies to adults, adolescents, and children older than 6 years old.
Upon completing Stan's initial assessment and beginning documentation, the CNS considers Stan's nursing diagnoses. What is Stan's priority nursing diagnosis?
Correct Response: Posttrauma syndrome related to a distressing event considered to be outside the range of usual human experience. Explanation: Posttrauma syndrome related to a distressing event considered to be outside the range of usual human experience is the priority nursing diagnosis for Stan. His experiences in was are outside of the range of usual human experiences, and his symptoms are interfering with his daily functioning. While Stan is experiencing impairments in psychomotor functioning, it is due to the traumatic event, and his risk for trauma is a lower priority. While grief over the loss of people he fought alongside is likely a factor in Stan's PTSD symptoms, his primary problems are caused by the posttrauma syndrome rather than his grieving. It is possible that Stan is experiencing spiritual distress, but this has not come up in his interviews thus far, and is therefore not a priority nursing diagnosis.
The CNS and the staff psychiatrist confer and consider the diagnosis of acute stress disorder (ASD) for Stan, which is characterized by symptoms similar to PTSD including recurrent distressing dreams, avoiding conversations about past events, problems with concentration, and exaggerated startle response. Why would the psychiatrist decide a diagnosis of ASD does not apply to Stan?
Correct Response: The duration of ASD symptoms lasts from 3 days to 1 month following trauma exposure while symptoms of PTSD last more than 1 month. Explanation: The diagnostic criteria for ASD are similar to those for PTSD. The primary difference between ASD and PTSD is the amount of time the individual has experienced the symptoms. ASD lasts for 3 days to 1 month following trauma, while PTSD persists longer than 1 month. ASD can be a precursor to PTSD. ASD can occur from directly experiencing traumatic events in a war. The symptoms of ASD can be as severe as those of PTSD and can impact social and occupational functioning. Drug and alcohol use can exacerbate both the symptoms of ASD and PTSD, but it is not the cause of either disorder.
The prescribing doctor had decided to put Stan on an SSRI antidepressant medication. Which medications below might be prescribed for Stan?
Correct Response: ✓ Citalopram (Celexa) ✓ Escitalopram (Lexapro) ✓ Paroxetine (Paxil) Explanation: Citalopram, Escitalopram, and Paroxetine are SSRIs. Tranylcypromine is a monoamine oxidase inhibitor (MAOI), and Aripiprazole is an antipsychotic medication.
Stan goes to his first appointment and meets with the clinical nurse specialist (CNS) who takes a full history. Stan tells her about his military career, wounds, and recent behaviors. The CNS listens to Stan and begins to consider the possibility of a diagnosis of posttraumatic stress disorder (PTSD). What behaviors might indicate a diagnosis of PTSD? Choose all that apply.
Correct Response: ✓ Problems with concentration. ✓ Recurrent distressing dreams about the traumatic event. ✓ Exaggerated startle response. Explanation: According to the DSM-5, symptoms of PTSD include problems with concentration, recurrent distressing dreams about the traumatic event, and an exaggerated startle response. Stan exhibits these symptoms, noting trouble concentrating getting in the way of getting a job, experiencing nightmares regularly, and feeling the need to attack in response to any loud noise. Hallucinations and nausea are not symptoms of PTSD.
Which categories of medications will most likely be prescribed to Stan?
Correct Response: ✓ Selective serotonin reuptake inhibitors (SSRIs) ✓ Serotonin norepinephrine reuptake inhibitors (SNRIs). Explanation: Therapy in conjunction with SSRI or SNRI antidepressant medications have been shown to be more effective than either alone. Benzodiazepines to decrease anxiety are less effective for the full range of symptoms that Stan is experiencing, and can be addictive. Stan is not experiencing psychosis, so antipsychotics would not be appropriate. Additionally, mood stabilizers are appropriate for mood disorders, not PTSD.
When comparing the differences between a self-help group and group therapy, categorize which statements are true and which are false. For each statement below, choose "True" or "False".
True: ✓ Self-help groups are traditionally not led by mental health professionals ✓ Group therapy is led by a mental health professional. ✓ Self-help groups are usually free. False: ✓ A self-help group encourages anyone with any diagnosis to attend. ✓ Self-help groups are helpful in relieving isolation but little else. Explanation: Self-help groups are not led by mental health professionals. The leaders of self-help groups are traditionally individuals who lead based on their own histories and success in coping with their issues. Group therapy is traditionally led by a mental health professional who had been trained in the dynamics of group process, and may not have similar experiences as the members of the group. Individuals in self-help groups share a common problem or issue, and individuals with significantly different diagnoses would not be encouraged to attend the group because they would gain little from attending. For Stan, it would be suggested that he attend a self-help group of other veterans who have suffered from symptoms of PTSD. Self-help groups are usually free. Traditionally, self-help groups do not charge a fee as group therapy would. There may be a voluntary payment, or suggested payment, but no client is "billed" for a self-help group. Self-help groups are helpful in relieving isolation, but little else is false. Self-help groups can promote coping skills, understanding, and emotional support.
