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Chapter 28
Trauma- and Stressor-Related Disorders
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Historical and Epidemiological Data
• Posttrauma response was historically known as shell
shock, battle fatigue, accident neurosis, or
posttraumatic neurosis.
• Renewed interest in the disorder began in the 1970s
in response to problems encountered by Vietnam
veterans.
• Diagnosis of Posttraumatic Stress Disorder (PTSD)
first appeared in the third edition of the Diagnostic
and Statistical Manual of Mental Disorders: DSM-III,
1980).
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Historical and Epidemiological Data
(cont.)
• More than half of all individuals will
experience a traumatic event in their
lifetimes, but less than 10 percent will
develop PTSD.
• The traumatic event is described as one
that is outside the range of usual human
experience.
• PTSD is more common in women than in
men.
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Historical and Epidemiological Data
(cont.)
• Individuals who have difficulties with
stress reactions to more normal events
may be diagnosed with Adjustment
Disorder.
• Adjustment disorders are quite common,
and can occur at any age.
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Application of the Nursing Process:
Trauma-Related Disorders
• Posttraumatic Stress Disorder
– A reaction to an extreme trauma, which is likely
to cause pervasive distress to almost anyone,
such as natural or manmade disasters, combat,
serious accidents, witnessing the
violent death of others, being
the victim of torture, terrorism,
rape, or other crimes.
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Posttraumatic Stress Disorder (cont.)
• Characteristic symptoms include:
– Reexperiencing the traumatic event
– A sustained high level of anxiety or arousal
– A general numbing of responsiveness
– Intrusive recollections or nightmares
– Amnesia to certain aspects of the trauma
– Depression, survivors guilt
– Substance abuse
– Anger and aggression
– Relationship problems
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Posttraumatic Stress Disorder (cont.)
• Symptoms may begin within the first 3
months after the trauma, or there may be a
delay of several months or even years.
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Acute Stress Disorder (ASD)
• Similar to PTSD in terms of precipitating
traumatic events and symptomatology
• Symptoms are time limited—up to 1 month
following the trauma
• If the symptoms last longer than 1 month, the
diagnosis would be PTSD.
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Trauma-Related Disorders (cont.)
• Predisposing Factors
– Psychosocial theory
• Seeks to explain why some individuals exposed to
massive trauma develop PTSD while others do not
• Variables include characteristics that relate to:
– The traumatic experience
– The individual
– The recovery environment
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Predisposing Factors (cont.)
• Learning Theory
– Negative reinforcement leads to the reduction in
an aversive experience thereby reinforcing and
resulting in repetition of the behavior.
– Avoidance behaviors
– Psychic numbing
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Predisposing Factors (cont.)
• Cognitive Theory
– A person is vulnerable to PTSD when
fundamental beliefs are invalidated by
experiencing trauma that cannot be
comprehended and when a sense of
helplessness and hopelessness prevail.
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Predisposing Factors (cont.)
• Biological Aspects
– It is suggested that the symptoms related to the
trauma are maintained by the production of
endogenous opioid peptides that are produced
in the face of arousal and which result in
increased feelings of comfort and control.
– When the stressor terminates, the individual
may experience opioid withdrawal, the
symptoms of which bear strong resemblance to
those of PTSD.
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Predisposing Factors (cont.)
• Biological Aspects (cont.)
– Dysregulation of the opioid, glutamatergic,
noradrenergic, serotonergic, and neuroendocrine
pathways may also be involved in the
pathophysiology of PTSD.
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Nursing Diagnosis/Outcome
Identification
• Nursing diagnoses for Trauma-Related
Disorders may include:
– Posttrauma syndrome
– Complicated grieving
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Outcome Criteria
• The Client:
– Can acknowledge the trauma and the impact on his
or her life
– Can demonstrate adaptive coping strategies
– Has made realistic goals for the future
– Has worked through feelings of survivor’s guilt
– Attends support group of individuals recovering
from similar traumatic experiences
– Verbalizes desire to put trauma in the past and
progress with his or her life
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Planning/Implementation
• Nursing care of the client with a traumarelated disorder is aimed at:
– Reassurance of safety
– Decrease in maladaptive symptoms
– Demonstration of more adaptive coping strategies
– Adaptive progression through the grieving
process
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Evaluation
• Evaluation of care for the client with a traumarelated disorder is based on successful
achievement of the previously established
outcome criteria.
– Can the client discuss the traumatic event without
experiencing panic anxiety?
– Has the client learned new, adaptive coping
strategies for assistance with recovery?
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Application of the Nursing Process:
Stressor-Related Disorders
• Adjustment Disorders
– Characterized by a maladaptive reaction to an
identifiable stressor or stressors that results in the
development of clinically significant emotional or
behavioral symptoms
– Symptoms occur within 3 months of the stressor
and last no longer than 6 months.
• Exception: The “Related to Bereavement” subtype
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Adjustment Disorders (cont.)
• Types of Adjustment Disorders
– With Depressed Mood
– With Anxiety
– With Mixed Anxiety and Depressed Mood
– With Disturbance of Conduct
– With Mixed Disturbance of Emotions and Conduct
– Related to Bereavement
– Unspecified
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Adjustment Disorders (cont.)
• Predisposing Factors
– Biological theories
• Genetics
• Vulnerability related to neurocognitive or intellectual
developmental disorders
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Adjustment Disorders (cont.)
• Predisposing Factors (cont.)
– Psychosocial theories
•
•
•
•
•
Childhood trauma, dependency, arrested development
Constitutional factor (birth characteristics)
Developmental stage and timing of the stressor
Available support systems
Dysfunctional grieving process
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Adjustment Disorders (cont.)
• Predisposing Factors (cont.)
– Transactional model of stress/adaptation
•
•
•
•
Interaction between individual and environment
Type of stressor
Situational factors
Intrapersonal factors
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Adjustment Disorders (cont.)
• Nursing Diagnosis
– Complicated grieving
– Risk-prone health behavior
– Anxiety
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Adjustment Disorders (cont.)
• Outcome Criteria
– The Client:
•
•
•
•
•
•
•
Verbalizes acceptable grieving behaviors
Demonstrates a reinvestment in the environment
Accomplishes ADLs independently
Demonstrates ability to function adequately
Accepts change in health status
Sets realistic goals for the future
Demonstrates ability to cope effectively with change in
lifestyle
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Adjustment Disorders (cont.)
• Planning/Implementation
– Nursing intervention for the client with an
adjustment disorder is aimed at:
• Adaptive progression through the grief process
• Helping the client achieve acceptance of a change in
health status
• Assisting with strategies to maintain anxiety at a
manageable level
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Adjustment Disorders (cont.)
• Evaluation
– Evaluation is based on accomplishment of
previously established outcome criteria.
• Does client demonstrate progression in the grief
process?
• Does client discuss the change in health status and
modification of lifestyle it will affect?
• Does client set realistic goals for the future?
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Treatment Modalities
• Trauma-Related Disorders
– Cognitive therapy
– Prolonged exposure therapy
– Group/family therapy
– Eye movement desensitization and reprocessing
– Psychopharmacology
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Treatment Modalities (cont.)
• Adjustment Disorders
– Individual psychotherapy
– Family therapy
– Behavior therapy
– Self-help groups
– Crisis intervention
– Psychopharmacology
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Nursing Process
1. Two months ago, Ms. T was sexually assaulted while
jogging in an isolated park. She is hospitalized for
suicidal ideation at this time. She awakens in the
middle of the night screaming about having
nightmares of the incident. Which of the following is
the most appropriate initial nursing intervention?
A.
B.
C.
D.
Call the doctor to report the incident.
Stay with Ms. T until the anxiety has subsided.
Administer prn alprazolam.
Allow her some privacy to work through the
emotions.
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Nursing Process (cont.)
• Correct answer: B
– It is important to not leave a client who is
experiencing flashbacks or nightmares alone.
Clients often feel they are “going crazy” when this
happens, and the presence of a trusted individual
calms fears and reassures the client of her safety.
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Treatment Modalities
1. Which of the following medications is
considered to be a first-line medication of
choice in the treatment of PTSD?
A.
B.
C.
D.
Alprazolam
Propranolol
Carbamazepine
Paroxetine
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Treatment Modalities (cont.)
• Correct answer: D
– The SSRIs are now considered first-line treatment
of choice for PTSD because of their efficacy,
tolerability, and safety ratings. Paroxetine and
sertraline have been approved by the FDA for this
purpose.
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