Management of patient with PTSD & Adjustment disorders

1. ACUTE STRESS REACTION
DISORDERS
PREPARED BY
MRS. DIVYA PANCHOLI
ASSISTANT PROFESSOR, SSRCN, VAPI
MRS. DIVYA PANCHOLI 1

2. ACUTE STRESS REACTION DISORDERS
• It is characterized by symptoms
like anxiety, despair and anger or
over activity.
• These symptoms are clearly
related to the stressor.
• If removal from the stressful
environment is possible, the
symptoms resolve rapidly.
MRS. DIVYA PANCHOLI 2

3. DEFINITION OF POSTTRAUMATIC STRESS
DISORDER
When an individual
who has been
exposed to a
traumatic event
develops anxiety
symptoms,
reexperiencing of
the event, and
avoidance of stimuli
related to the event
lasting more than
four weeks.
(According to DSM-IV)
MRS. DIVYA PANCHOLI 3

4. (PTSD)
• PTSD is of a reaction to extreme
stressors such as floods, earthquakes,
war, rape or serious physical assault.
MRS. DIVYA PANCHOLI 4

5. Etiology
• Psychosocial Theory
• One psychosocial model that has become widely
accepted seeks to explain why certain persons
exposed to massive trauma develop PTSD and
others do not.
• Variables include characteristics that relate to
(1) The traumatic experience,
(2) The individual, and
(3) The recovery environment.
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6. 1. THE TRAUMATIC EXPERIENCE.
• Specific characteristics relating to the trauma have been
identified as
● Severity and duration of the stressor
● Exposure to death
2. THE INDIVIDUAL.
• Variables that are considered important in determining an
individual’s response to trauma include:
● Effectiveness of coping resources
● Degree of ego strength
3. THE RECOVERY ENVIRONMENT.
• It has been suggested that the quality of the environment
● Availability of social supports
● The cohesiveness and protectiveness of family and friends
● The attitudes of society regarding the experience
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7. SIGNS AND SYMPTOMS OF PTSD
Symptoms may develop after a
period of latency, within 6
months after the stress or may
be delayed
• Intense feeling of fear and dread
following traumatic event
• Mental reruns of the event
(Flashbacks)
• Emotional numbness following
the event
• Avoidance of people, places or
things associated with events
• Insomnia, recurring distressing
dreams
• Increased vigilance or
watchfulness
• Startles easily
• Depression
• Irritability and aggressiveness
• Impaired social or work
functioning difficulty in
interpersonal relationships
MRS. DIVYA PANCHOLI 7

8. Treatment For Posttraumatic Stress
Disorder
• Antidepressants
• The SSRIs are now considered first-line
treatment of choice for PTSD
• Anxiolytics
• Alprazolam has been prescribed for PTSD
clients for its antidepressant and antipanic
effects.
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9. NURSING INTERVENTIONS
• Establish trusting relationship
• Encourage the patient to express her grief,
complete the mourning process
• Use crisis intervention techniques as needed
• Assist in regaining control over angry outbursts by
identifying how anger escalates
• Encourage move from physical to verbal
expressions of anger
• Teach the patient about medications and adverse
effects and advise her not to discontinue
medication without physician consultation
MRS. DIVYA PANCHOLI 9

10. Nursing Diagnosis
• Post trauma syndrome related to
distressing event evidenced by
flashbacks.
• Complicated grieving related to loss of
self as perceived before the trauma or
other actual or perceived losses
incurred during or after the event
evidenced by irritability
MRS. DIVYA PANCHOLI 10

11. ADJUSTMENT
DISORDERS
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12. TERMINOLOGY
• Adjustment: The process of modifying one’s
behavior in changed circumstances or an altered
environment in order to fulfill psychological,
physiological and social needs.
• Adjustment disorder: It is characterized by a
maladaptive reaction to an identifiable
psychosocial stressor or stressors that results in the
development of clinically significant emotional or
behavioral symptoms.
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13. EPIDEMIOLOGIACAL FACTORS
• Adjustment disorders are one of the most common
psychiatric diagnoses for disorders of patients
hospitalized for medical and surgical problems.
• In one study, 5 percent of people admitted to a hospital
over a 3-year period were classified as having an
adjustment disorders.
• Adjustment disorders are more common in women than
in men by about 2 to 1.
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14. PREDISPOSING FACTORS
Biological theory:
• Chronic disorders, such as cognitive disorders
or mental retardation, are thought to impair the
ability of an individual to adapt to stress,
causing increased vulnerability to adjustment
disorder.
• genetic factors also may influence risks for
maladaptive response to stress.
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15. CONTI…
• Psychosocial theories:
• early childhood trauma, increased dependency, and related
ego development.
• predisposition to adjustment disorder to factors such as
developmental stage, timing of the stressor, and available
support systems. When a stressor occurs, and the individual
does not have the developmental maturity, available support
systems, or adequate coping strategies to adapt, normal
functioning is disrupted, resulting in psychological or somatic
symptoms.
• The disorder also may be related to a dysfunctional grieving
process. The individual may remain in the denial or anger
stage, with adequate defence mechanisms to complete the
grieving process.
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16. ADJUSTMENT PROBLEMS BASED ON
FIXATIONS AT PSYCHOSEXUAL STAGES
I. Oral stage
(birth to 2 years)
Sarcasm, argumentativeness, greediness,
acquisitiveness, over dependency
II. Anal stage (2-4 years)
Emotional outbursts such as rages and
temper tantrums; compulsive orderliness
and over controlled behaviour
III. Phallic stage (4-6
years)
Problems with gender identification
IV. Genital stage
(puberty to adulthood)
Narcissism or extreme self-love
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17. ERIKSON'S PSYCHOSOCIAL STAGES
Developmental
Phase
Psychosocial Stage Related Adjustment Problems
I. Infancy Trust vs. mistrust Mistrust of others
II. Early childhood
(ages 1-3)
Autonomy vs. shame
and doubt
Doubt in oneself and mistrust in
environment
III. Play age
(ages 3-5)
Initiative vs. guilt
Overdeveloped conscience which
prevents independent action;
excessive guilt
IV. School age
(ages 5-10)
Industry vs. inferiority
Doubt in one's ability to perform
adequately for society; feelings of
inferiority and inadequacy
V. Adolescence
Identity vs. identity
diffusion
Doubt about one's sexual, ethnic,
or occupational identityMRS. DIVYA PANCHOLI 17

18. TYPES OF ADJUSTMENT
DISORDER
• The following categories, identified by the DSM-IV-TR, are distinguished
by the predominant features of the maladaptive response.
Adjustment disorder with anxiety
Adjustment disorders with depressed
mood
Adjustment disorder with disturbance
of conduct
Adjustment disorder with mixed
disturbance of emotions and conduct
Adjustment disorder, unspecified
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19. ADJUSTMENT DISORDER WITH
ANXIETY
• This category denotes a
maladaptive response to a
psychosocial stressor in which
the predominant manifestation
is anxiety.
• The symptoms may reveal
nervousness, worry, and
jitteriness.
• The clinician must differentiate
this diagnosis from those of
anxiety disorders.
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20. ADJUSTMENT DISORDERS WITH
DEPRESSED MOOD
• This category is the most
commonly diagnosed adjustment
disorder. The clinical
presentation is one of
predominant mood disturbance,
although less pronounced than
that of major depression.
• The symptoms, such as
depressed mood, tearfulness,
and feelings hopelessness,
exceed what is an expected or
normative response to an
identified psychosocial stressor.
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21. ADJUSTMENT DISORDER WITH
DISTURBANCE OF CONDUCT
• This category is characterized by
conduct in which there is
violation of the rights of others
or of major age-appropriate
societal norms and rules.
• Examples include truancy,
vandalism, reckless driving,
fighting, and defaulting on legal
responsibilities. Differential
diagnosis must be made from
conduct disorder or antisocial
personality disorder.
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22. ADJUSTMENT DISORDER WITH
MIXED DISTURBANCE OF
EMOTIONS AND CONDUCT
• The predominant features
of this category include
emotional disturbance (e.g.
anxiety or depression) as
well as disturbances of
conduct in which there is
violation of the rights of
others or of major age-
appropriate societal norms
and rules (e.g., truancy,
vandalism, fighting).
MRS. DIVYA PANCHOLI 22

23. ADJUSTMENT DISORDER, UNSPECIFIED
•This subtype is used when the
maladaptive reaction is not consistent
with any of the other categories.
•Manifestations may include physical
complaints, social withdrawal, or work
or academic, inhibition, without
significant depressed or anxious mood.
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24. CLINICAL FEATURES
EMOTIONAL SIGNS
• Sadness
• Hopelessness
• Lack of enjoyment
• Crying spells
• Nervousness
• Anxiety
• Worry
• Desperation
• Trouble sleeping
• Difficulty
concentrating
• Feeling overwhelmed
and thoughts of suicide
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25. BEHAVIOURAL SIGNS
• Fighting
• Reckless driving
• Ignoring important tasks such as bills or homework
• Seeking approval from others by any way possible
(cheating/lying/escaping reality)
• Avoiding family or friends
• Performing poorly in school
• Skipping school
• Vandalizing property.
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26. NURSING DIAGNOSIS
• Complicated grieving related to real or perceived loss of
any concept of value to the individual evidenced by
interference with life functioning, developmental
regression, or somatic complaints.
• Risk-prone health behavior related to change in health
status requiring modification in lifestyle (e.g. chronic
illness, physical disability) evidenced by inability to
problem-solve or set realistic goals for the future.
• Anxiety related to situational and/or maturational crisis
evidenced by restlessness, increased helplessness and
diminished productivity.
MRS. DIVYA PANCHOLI 26

27. TREATMENT
Major goals of therapy for the individuals with
adjustment disorders:
• To relieve symptoms associated with a stressor.
• To enhance coping with stressors that cannot be
reduced or removed.
• To establish support systems that maximizes
adaptation.
MRS. DIVYA PANCHOLI 27

28. THERAPIES
INDIVIDUAL
PSYCHOTHERAPY
FAMILY THERAPY
BEHAVIOR
THERAPY
SELF-HELP
GROUPS
CRISIS
INTERVENTION
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29. INDIVIDUAL PSYCHOTHERAPY
• Most common treatment for adjustment disorder
• It allows the client to examine the stressor that is
causing the problem, possibly assign personal meaning
to the stressor, and confront unresolved issues that may
be exacerbating this crisis.
• Techniques are used to clarify links between the current
stressor and past experiences, and to assist with the
development of more adaptive coping strategies.
• Psychiatrists treating adjustment disorders must be
particularly aware of problems of secondary gain.
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30. FAMILY THERAPY
• The focus of treatment is shifted from the
individual to the system of relationships in
which the individual is involved.
• The maladaptive response of the identified
client is viewed as symptomatic of a
dysfunctional family system.
• Emphasis is placed on communication, family
rules, and interaction patterns among the
family members.
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31. BEHAVIOR THERAPY
• The goal of behavior therapy is to
replace ineffective response patterns
with more adaptive ones.
• The situations that promote ineffective
responses are identified and carefully
designed reinforcement schedules, along
with role modeling and coaching, are
used to alter the maladaptive response
patterns.
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32. SELF-HELP GROUPS
• Group experiences with or without a professional
facilitator provides an arena in which members may
consider and compare their responses to those of
individuals with similar life experiences.
• Members benefit from learning that they are not
alone in their painful experiences. Hope is derived
from knowing that others have survived and even
grown form similar experiences.
• Members of the group exchange advice, share coping
strategies, and provide support and encouragement
for each other.
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33. CRISIS INTERVENTION
• In crisis intervention, the therapist, or other
intervener, becomes a part of the individual’s life
situation. Because of increased anxiety, the individual
with adjustment disorder is unable to problem solve,
so he or she requires guidance and support from
another to help mobilize the resources needed to
resolve the crisis.
• The ultimate goal of crisis intervention in the
treatment of adjustment disorder is to resolve the
immediate crisis, restore adaptive functioning, and
promote personal growth.
MRS. DIVYA PANCHOLI 33

34. PSYCHOPHARMACOLOGY
• Patients with severe anxiety bordering
on panic can benefit from anxiolytics
such as diazepam (Valium), and those in
withdrawn or inhibited states may be
helped by a short course of psycho
stimulant medication.
• Antipsychotic drugs may be used if there
are signs of decompensation or
impending psychosis.
• Selective serotonin reuptake inhibitors
have been found useful in treating
symptoms of traumatic grief.
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35. You can refer following link also
• https://www.youtube.com/watch?v=hzSx4rMyVjI
• https://www.youtube.com/watch?v=b_n9qegR7C4
• https://www.youtube.com/watch?v=aAvZPaDlwR0
• https://www.youtube.com/watch?v=YMC2jt_QVEE
• https://www.youtube.com/watch?v=rHg_SlEqJGc
• https://www.youtube.com/watch?v=Jqj5zDbkPxY
• https://www.youtube.com/watch?v=FeLLt39DI8A
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36. MOVIES RELATED TO ACUTE STRESS
DISORDER & ADJUSTMENT DISORDER
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37. MRS. DIVYA PANCHOLI 37

38. MRS. DIVYA PANCHOLI 38