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Ch. 13: Trauma and Stressor-Related Disorders

Key Terms:
Acute stress disorder: diagnosis is appropriate when symptoms appear within the first month after the
trauma and do not persist longer than four weeks
Adaptive disclosure: combat specific therapy for veterans with posttraumatic stress disorder; eight
sessions designed to help identify unhelpful beliefs about the trauma and find ways to move forward
adjustment disorder: a group of symptoms, such as stress, feeling sad, or hopeless, and physical
symptoms that occur following the stressful life event; the reaction is stronger than would be expected
for the event that occurred
depersonalization: feelings of being disconnected from himself or herself; the client feels detached
from his or her behavior
derealization: client senses that events are not real, when, in fact, they are
disinhibited social engagement disorder: occurs before the age of five years in response to the trauma
of child abuse or neglect; the child with DSED exhibits unselective 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
dissociation: 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
dissociative disorders: these disorders have the essential feature of a disruption in the unusually
integrated functions of consciousness, memory, identity, or environmental perception; they include
amnesia, fugue, and dissociative identity disorder
exposure therapy: behavioral technique that involves having the client deliberately confront the
situations and stimuli that he or she is trying to avoid
grounding techniques: helpful to use with a client who is dissociating or experiencing a flashback;
grounding techniques remind the client that he or she is in the present, as an adult, and is safe
hyperarousal: symptoms that arise from high levels of anxiety, including insomnia, irritability, anger
outbursts, watchfulness, suspiciousness, and just distrustfulness. Often seen with PTSD.
posttraumatic stress disorder (PTSD): a disturbing pattern of behavior demonstrated by someone who
has experienced a traumatic event; for example, a natural disaster, combat, or an assault; begins three
or more months following the trauma
reactive attachment disorder (RAD): occurs before the age of five years in response to the trauma of
child abuse or neglect; the child with rad exhibits minimal social and emotional responses to others,
lack a positive affect, and maybe sad, irritable, or afraid for no apparent reason.
repressed memories: memories better buried deeply in the subconscious mind or repressed because
theyre too painful for the victim to knowledge; often relate to childhood abuse
Survivor: View of the client as a survivor of trauma or abuse rather than as a victim; helps to refocus
clients view of himself or herself as being strong enough to survive the ordeal, which is a more
empowering image than seeing oneself as a victim

Learning Objectives:

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Ch. 13: Trauma and Stressor-Related Disorders
1. Discuss the characteristics, risk factors, and dynamics of immediate and longer term individual
responses to trauma and stressors.
a. PTSD
i. Characteristics:
1. re-experiencing the trauma through dreams or recurrent and intrusive thoughts;
a. Flashbacks, memories, dreams, or reactions to external cues about the
event and therefore avoid stimuli associated with the trauma
2. showing emotional numbing such as feeling detached from others;
a. feels a numbing of general responsiveness and shows persistent signs of
increased arousal such as insomnia, hyperarousal, or hypervigilance,
irritability, or angry outbursts
b. they report losing a sense of connection and control over their life leaving
to avoidance behavior, or trying to avoid any places or people or
situations that may trigger memories of the trauma
3. and being on guard, irritable or experiencing hyperarousal.
a. they seek comfort, safety, security, and can actually become increasingly
isolated over time which can heighten the negative feelings he or she was
trying to avoid
ii. Risk Factors
1. Exposure to actual or threatened death, serious injury, or sexual violence and
one for more ways
a. Directly experiencing the traumatic event
b. Witnessing, in person, the event(s) as it (they) occurred to others
c. Learning that the traumatic events occurred to a close family member or
a close friend
d. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (ex. First responders collecting human remains; police
officers repeatedly exposed to details of child abuse
2. presence of one or more intrusion symptoms associated with the traumatic
events, beginning after the traumatic events occurred
a. Recurrent, involuntary, and intrusive distressing memories of the
traumatic events
b. Recurrent distressing dreams in which the content and/or aspect of the
dream are related to the traumatic events
c. dissociative reactions suggest flashbacks in which the individual feels or
acts as though the traumatic events were recurring

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Ch. 13: Trauma and Stressor-Related Disorders
d. intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event
e. marked physiological reactions to internal or external cues that symbolize
or resemble an aspect of the traumatic events
3. persistent avoidance of stimuli associated with the traumatic events, beginning
after the traumatic event occurred, as evidenced by one or both of the following
a. Avoidance of war efforts to avoid distressing memories, thoughts, or
feelings about or closely associated with the traumatic events
b. Avoidance of or effort to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts or feelings about or closely associated with the
traumatic events.
4. Negative alteration in cognitions and mood associated with the traumatic
events, beginning or worsening after the traumatic events occurred, as
evidenced by two or more of the following:
a. Inability to remember an important aspect of the traumatic event
b. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world
c. persistent, distorted cognitions about the cause or consequences of the
traumatic events that led the individual to blame himself or others
d. persistent negative emotional state
e. Markedly diminished interest or participation in significant activities
f. Feelings of detachment or estrangement from others
g. persistent inability to experience positive emotions
5. Marked alterations in arousal and reactivity associated with the traumatic
events, beginning or worsening after the traumatic event occurred, as evidenced
by two or more of the following:
a. Irritable behavior and angry outbursts typically expressed as verbal or
physical aggression toward people or objects
b. reckless or self-destructive behavior
c. hypervigilance
d. exaggerated startle response
e. problems with concentration
f. sleep disturbance
6. Duration of the disturbance is more than one month
7. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
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Ch. 13: Trauma and Stressor-Related Disorders
8. the disturbance is not attributable to the physiological effects of a substance or
another medical condition
b. Adjustment disorder: in reaction to a stressful event that causes problems for the individuals;
the person has more than he expected difficulty coping with or as simulating the events into
their life
i. Financial, relationships, and work related stressors are the most common events
ii. symptoms developed within a month and lasting no more than six months
iii. outpatient counseling or therapy is the most common and successful treatment
c. Acute stress disorder: occurs after a traumatic event
i. Re-experiencing, avoidance and hyperarousal that occur from three days to four weeks
following a trauma
ii. can be a precursor to PTSD
iii. Cognitive behavioral therapy and involving exposure and anxiety management can help
prevent the progression to PTSD
d. Reactive attachment disorder (RAD): occurs before the age of five years in response to the
trauma child abuse or neglect
i. Child shows disturbance, inappropriate social related in most situations
ii. the child with RAD exhibits minimal social and emotional responses to others, lacks a
positive affect, and may be sad, irritable, or afraid for no apparent reason
e. Disinhibited social engagement disorder (DSED): also occurs before the age of five years in
response to child abuse or neglect
i. The child exhibits unselective socialization, allowing or tolerating social interaction with
caregivers and strangers alike
ii. They lack the hesitation in approaching or talking to strangers evident in most children
and their age
iii. Grossly deficient parenting in institutionalization are the two most common situations
leading to this disorder
2. Examine the occurrence of various longer-term responses to trauma and stress.
a. PTSD (see next objective)
b. Dissociative disorders
i. Dissociative amnesia: With dissociative amnesia, the client cannot remember important
personal information.
ii. Dissociative identity disorder (see next objective)
iii. Depersonalization/derealization disorder: With depersonalization disorder, the client
has persistent or recurring feeling of being detached from his or her mental processes or
body (depersonalization) or sensation of being in a dream-like state where the
environment seems foggy or unreal (derealization). The client is not psychotic or out of
touch with reality.
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Ch. 13: Trauma and Stressor-Related Disorders
c. Adjustment disorder:
i.
d. Reactive Attachment Disorder:
i. Child shows disturbance, inappropriate social related in most situations
ii. the child with RAD exhibits minimal social and emotional responses to others, lacks a
positive affect, and may be sad, irritable, or afraid for no apparent reason
3. Describe responses to trauma and stressors, specifically posttraumatic stress disorder and
dissociative identity disorder.
a. PTSD
i. PTSD is a disorder associated with the event exposure, rather than personal
characteristics, especially with the adult population. The effects of the trauma at the
time are more powerful predictors of PTSD for most people.
ii. 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.
iii. Adolescents with PTSD are More likely to develop PTSD than children or adults
iv. age, gender, type of trauma, and repeated trauma are related to increased PTSD rates.
v. Adolescents with PTSD are increased risk for suicide, substance abuse, poor social
support, academic problems, and poor physical health.
vi. 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.
vii. Dreams, or recurrent and intrusive thoughts
viii. Showing emotional numbing such as feeling detached from others
ix. Being on guard, irritable, or experiencing hyperarousal
x. They seek comfort, safety, and security, but can actually become increasingly isolated
over time, which can heighten negative feelings they were trying to avoid.
b. Dissociative Identity Disorder (formerly multiple personality disorder)
i. Inability to recall important personal information
4. Apply the nursing process to the care of clients with trauma or stressor-related diagnoses.
a. Assessment
i. MSE
b. Data Analysis
i. Commonly used nursing diagnoses in the acute care setting
1. Risk for self-mutilation
2. Risk for suicide
3. Ineffective coping
4. Posttrauma response
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Ch. 13: Trauma and Stressor-Related Disorders
5. Chronic low self-esteem
6. Powerlessness
ii. Longer-term diagnoses
1. Disturbed sleep pattern
2. Sexual dysfunction
3. Rape-trauma syndrome
4. Spiritual distress
5. Social isolation
c. Outcome identification
d. Intervention
i. Promote Clients Safety
ii. Help the client cope with stress and emotions
1. Grounding techniques: remind the client they are in the present, is an adult, and
is safe. Validating what the client is feeling during these experiences is
important.
iii. Helping to Promote the clients self-esteem
iv. Establishing social support
e. Evaluation
i. Long-term treatment outcomes for clients who have survived trauma or abuse may take
years to achieve. The effects of trauma and abuse can be far-reaching and can last a
lifetime.
5. Provide education to clients, families, and communities to promote prevention and early
intervention for trauma and stressor-related responses.
a. Ask for support from others
b. Avoid social isolation
c. Join a support group
d. Share emotions and experiences with others
e. Follow a daily routine
f. Set small, specific, achievable goals
g. Accept feelings as they occur
h. Get adequate sleep
i. Eat a balanced, healthy diet
j. Avoid alcohol and other drugs
k. Practice stress-reduction techniques
6. Evaluate your own experiences, feelings, attitudes, and beliefs about responses to trauma and
stress.
a. If the nurse is overwhelmed by the violence or death in a situation, the clients feelings of being
victimized or traumatized beyond repair are confirmed. Conveying empathy and validating
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Ch. 13: Trauma and Stressor-Related Disorders
clients feelings and experiences in a calm, yet caring professional manner is more helpful than
sharing the clients horror.
b. Remaining nonjudgmental of the client is important, but doesnt happen automatically. The
nurse may need to deal with personal feelings by talking to a peer or counselor.

UNIT 4: NURSING PRACTICE FOR PSYCHIATRIC DISORDERS