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Acute Stess Disorders and Post-traumatic Stress Disorders

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  • 1. Presented by: Eric F. Pazziuagan, RN, MAN
  • 2. Disorders that can develop after exposure to a clearly identifiable traumatic event that threatens the self, others, resources, and/or sense of control or hope. The event overwhelms the individual’s coping strategies.
  • 3.  Community violence, war, terrorist attack, being a hostage or POW, torture, disasters, bombings, f atalities in fires or accidents, catastrophic illness, gross injury to self or others, childhood sexual abuse, chronic abuse as a child or adult, rape, assault, and sudden or major personal losses.
  • 4. 7.8 to 8% of American adults Women are twice likely to have PTSD
  • 5.  Individual’s pre-existing characteristics and conditions  Usual coping style and defense mechanisms  Personal and social resources  Previous exposure to trauma  Meaning of the event to the individual
  • 6.  ASD: dissociative symptoms during or immediately after the distressing event: amnesia, depersonalization, derealization , decreased awareness of surroundings, numbing, detachment, or lack of emotional response,  PTSD: not made because of initial reactions at the time of the trauma but is based on characteristic symptoms that occur 1 month after the trauma.
  • 7.  PTSD may be unrecognized for years (even 10-20 years).  Persistent attempt to avoid situations, activities, and sometimes even people who might evoke memories of the trauma.  Denial, repression, and suppression are common in both disorders.  Constricted or blunted affect, or a limitation in the range of feelings might occur.  Might feel detached or estranged from family and friends.  Inability to trust might lead to withdrawal.  Interest to activities is often lost.  Perceptions of the future might change.
  • 8.  Might be in the form of intrusive, unwanted memories, upsetting dreams or nightmares, illusions, or suddenly the feeling as if the event were recurring (flashbacks).  PTSD: hallucination related to the event.  Might have obvious connections to the trauma or might not resemble the original situation at all.  Latter case, patients might try to avoid all activities and people in an effort to prevent reexperiencing the flashback.
  • 9.  Increased arousal, anxiety, restlessness, irritab ility, disturbances in sleep, and impairment in memory or concentration.  PTSD: occasional outbursts of anger or rage and survivor guilt- guilt about surviving or the actions to survive.
  • 10.  Psychological and physiologic symptoms that develop during exposure to situations resembling the original trauma (e.g., anxiety, panic attacks, GI disorders, headache)  Problems with grief, depression, suicidal ideations and attempts, impulsive selfdestructive behaviors, anxiety-related disorders, and substance abuse.  Might appear avoidant, schizoid, schizophrenic, paranoi d or even manic (which complicate treatment).
  • 11.  Preexisting psychiatric disorders, including personality disorders can increase the risk.  History of previous traumas leads to an increased risk for PTSD after later traumas.  Events in later life might trigger previously unrecognized PTSD.  Some difficulties: arrests, unemployment, homelessness, abusi veness, divorce and paranoia toward authority figures or others whom the patient sees as directly or indirectly responsible for not helping with the original traumatic situation.
  • 12.  Common: mistrust, isolation, abandonment fears, workaholism, focusing on the need of others, feelings of inadequacy, anger toward God, unresolved grief, and fear of losing control of emotions.  Family members, friends, and co-workers might develop problems as well, as “secondary victims.”
  • 13. Effective approach: prevent or minimize symptoms.  Application of critical incidence stress management (CISM) principles to disaster situations:         Precrisis preparation Large-scale demobilization procedures Individual acute crisis counseling Brief small group discussions (defusings) Longer small group discussions (critical incident stress debriefings or CISDs) Family crisis intervention techniques Follow-up procedures and/or referral for psychological assessment or treatment
  • 14. Goals of treatment:  Progressive, intensive review of the traumatic experiences (exposure therapy)  Integration of the feelings and memories, often from the least to the most painful.  Moving from a victim status to a survivor status, from “I can’t go on because of this” to “I have learned from it and can go on with life.”  Potential for growth and development of improved coping skills, appreciation of value of life, and enhanced relationships. 
  • 15.  First priority: development of trust; might be difficult.  Other priorities: safety and security (risk of suicide and aggression).  Patients need to hear that they are not crazy but are having typical reactions to a serious trauma (teach about dynamics of ASD and PTSD).  Be prepared to hear horror stories about hideous injuries, unpredicted behaviors, and gross destruction.
  • 16.  Gently clarify connections between original trauma and current feelings and problems.  Patients need to evaluate their past behaviors according to the original context of the situation, not by current values and standards.  Specific techniques: exposure therapy (imaginal or in vivo), systematic desensitization, CBT, eye movement desensitization and reprocessing.  Safe verbalization of feelings, particularly anger, that have been ignored or repressed.  Writing a journal, expressive therapt (art,music or poetry).
  • 17.  Empathy and reassurance that they will be safe and need to be taught relaxation techniques, so they are not overwhelmed of the anxiety.  Take time to focus on emergent problems and potential solutions.  Encourage adaptive coping skills and use of relaxation strategies.  Discourage dysfunctional activities.  Develop interpersonal skills and reestablish relationships that provide and support and assistance.  Couple or family education and counselling.
  • 18.  Benzodiazepines (e.g., clonazepam) to reduce levels of conditioned fear and anxiety symptoms; might help with sleep disturbances and nightmares; risk of dependence.  Clonidine and propranolol: diminish peripheral autonomic response associated with fear, anxiety, and nightmares.  Valproic acid or carbamazepine: mood swings, explosive outbursts and intense feelings of being out of control; dcreases hyperarousal, startle response, and nightmares.
  • 19.  SSRI (paroxetine, escitalopram, and sentraline): reverse continued emergency responses and decreased repetitive behaviors, disturbing images, and somatic states.  TCAs: depression, anhedonia, sleep disturbances.  Antipsychotics: if with psychotic thinking; hyperarousal and sleep disturbances; respiradone or quetiapine to c=decrease flashbacks and nightmares.
  • 20.  Social activities can help rebuild social skills that have been damaged by suspiciousness and withdrawal.  Recreational and exercise programs can help reduce tension and promote relaxation.  Groups: self-esteem, decision making, assertiveness, anger management, stress management, relaxation techniques.  Group meetings for victims.
  • 21.  Be nonjudgmental and honest; offer empathy and support; acknowledge any unfairness or injustices related to the trauma.  Assure patients that their feelings and behaviors are typical reactions to serious trauma.  Help patients recognize the connections between the trauma experience and their current feelings, behaviors, and problems.  Help patients evaluate past behaviors in the context of the trauma, not in the context of current values and standards.
  • 22.  Encourage safe verbalization of feelings, especially anger.  Encourage adaptive coping strategies, exercise, relaxation techniques, and sleeppromoting strategies.  Facilitate progressive review (imaginal or in vivo) of the trauma and consequences.  Encourage patients to establish or reestablish relationships.