Transcript Post-traumatic stress disorder (PTSD) is defined as the development

PTSD Presentation.
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Prepared by:
Mr. Mohamed Abu Shawish.
Mr. Mohanned hammdan.
Supervised by:
Dr. Abed Alkareem Radwan.
Presentation Objectives
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Overview of PTSD.
Prevalence of PTSD
Diagnostic criteria of PTSD.
Client assessment.
Etiological theories.
Factors impacting development of PTSD.
Factors impacting PTSD coping ability.
Management of PTSD
Definition of Trauma
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Psychological trauma is generally seen as the
reaction following exposure to an over- whelming
experience that is out of control and to which
earlier coping strategies are found to be
insufficient. (Herman,Terr1992).
History
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PTSD has only been recognized as a formal
diagnosis since 1980. However, it was called by
different names as early as the Civil War, when
combat veterans were referred to as suffering from
solder's heart. In World War One it was called
combat fatigue. In World War Two it was called gross
stress reaction. In Vietnam it was called post
Vietnam syndrome. It has also been called battle
fatigue and shell shock.
Post-traumatic stress disorder
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PTSD) is defined as the development of characteristic
symptoms following expo-sure to an extreme traumatic
stressor involving direct personal experience of an event
that involves actual or threatened death or serious
injury, or other threat to one's integrity; or witnessing an
event that involves death, injury, or a threat to the
physical integrity of another person; or learning about
unexpected or violent death, serious harm, or threat of
death or injury experienced by a family member or
other close associate.
(APA 2000, p 463)
Prevalence & Causes of PTSD
Approximately 7.8% of population.
 Combat war and sexual assaultt are most common
traumas.
 Females may be at greater risk than males. More
women experience high rates of traumatic events,
particularly those events relating to being victims of
crimes. Sexual assault probably has the most impact
on women, and trauma from combat probably has
the most impact on men.
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Diagnostic criteria of PTSD
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Present of traumatic event. )involved actual or
threatened death or serious injury, or threat to the
physical integrity of self or other(.
Pt response to traumatic event. (involved intense fear,
helplessness, or horror).
three Primary PTSD Cluster Symptoms
 Reexperiencing
 Avoidance & Numbing
 Hyperarousal.
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Impairment in social, occupational, or other
important areas of functioning..
Duration:
At least 30 days.
 Acute = < 3 months
 Chronic = > 3 months.
 with delayed onset” > 6 months after the
event.
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Reexperiencing Symptoms
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Unwanted thoughts or images of the abuse even though
nothing is happening to remind you
Distress or emotional upset when something happens that
reminds you of the trumatice event
Distressing dreams or nightmares about the trumatice event
Suddenly reliving the trumatice event (i.e. flashbacks, acting or
feeling as if the trumatice event is happening again)
Physical reactions when reminded of the trumatice event (i.e.
sweating, rapid breathing, pounding heart, queasy stomach,
muscle tension)
Avoidance & Numbing Symptoms
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Conscious/Deliberate Avoidance
– Efforts to avoid thoughts, feelings, or conversations that remind you of the
trumatice event
Efforts to avoid activities, people, or places that remind you of the
trumatice event
Involuntary Avoidance (Amnesia)
– Inability to recall important parts of the trumatice event
Numbing
– Loss of interest in activities that were once important (i.e. job, school,
hobbies, sports, or social activities)
– Feeling detached or cut off from others
– Feeling emotionally numb (i.e. inability to feel tenderness, loving or joyfull feelings, or inability to cry)
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Hyperarousal Symptoms
Trouble falling or staying asleep
 Feeling irritable or angry
 Difficulty concentrating
 Hyperalert, watchful, or on guard
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Comorbidity
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There is a high level of Comorbidity with PTSD.
MDD(40%-50%).(kessler et al 1995,shalv et al 1998).
GAD – OCD – PD – and substance
misuse.(Green1994).
CLIENT ASSESSMENT
Mental Status: Change in usual behavior
(moody, pessimistic, brooding, irritable);
loss of self-confidence, depressed affect;
feelings seem unreal, business of life no
longer matters
 Muscular tension, tremulousness, motor
restlessness
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Activity/Rest
Sleep disturbances, recurrent intrusive
dreams of the event, nightmares, difficulty
in falling or staying asleep; hypersomnia
(intrusive thoughts, flashbacks, and/or
nightmares are the triad symptomatic of
PTSD)
 Easy fatigability, chronic fatigue
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Ego Integrity
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Various degrees of anxiety with symptoms lasting days, weeks,
or months (2 days to maximum of 4 weeks occurring within 4
weeks of traumatic event [acute stress disorder]; duration of
symptoms less than 3 months [acute PTSD], more than 3
months [chronic PTSD], or onset at least 6 months after
traumatic event [delayed])
Difficulty seeking assistance (e.g., medical, legal) or mobilizing
personal resources (e.g., telling family members/friends of
experience)
Feelings of guilt, helplessness, powerlessness, isolation
Feeling shame for own helplessness; demoralization
Sense of a bleak or foreshortened future (e.g., expects failing
relationships, early death)
Neurosensory
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Cognitive disruptions, difficulty concentrating and/or completing usual life
tasks
Hypervigilence (result of inability to assimilate and integrate experiences)
Excessive fearfulness of objects and/or situations in the environment
triggered by reminders or internal cues that resemble or symbolize the
events; e.g., startle response to loud noises (someone who experienced
combat trauma/bombing), breaking out in a sweat when riding an elevator
(for someone who was raped in an elevator)
Persistent recollection (illusions, dissociative flashbacks, hallucinations) or
talk of the event, despite attempts to forget; impaired/no recall of an
important aspect of the trauma
Poor impulse control with unpredictable explosions of aggressive behavior
or acting-out of feelings such as anger, resentment, malice, and ill will (in
high dudgeon)
Circulation
Increased heart rate, palpitations; increased
blood pressure
 Hot/cold spells, excessive perspiration
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continued
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Pain/Discomfort
Pain/physical discomfort of the injury may be exaggerated
beyond expectation in relation to severity of injury
Respiratory
Increased respiratory rate, dyspnea
Safety
Angry outbursts, violent behavior toward environment/other
individuals
Suicidal ideation, previous attempts
Social Interactions
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Avoidance of people/places/activities that arouse
recollections of the trauma, decreased responsiveness,
psychic numbing, emotional detachment/estrangement
from others; inability to trust
Markedly diminished interest/participation in
significant activities, including work
Restricted range of affect, absence of emotional
responsiveness (e.g., absence of loving feelings)
continued
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Sexuality
Loss of desire; avoidance of/dissatisfaction with
relationships
Inability to achieve sexual satisfaction/orgasm;
impotence
Teaching/Learning
Occurrence of PTSD often preceded or accompanied
by physical illness/harm which lead to low achivement
Use/abuse of alcohol or other drugs
ETIOLOGICAL THEORIES
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Psychodynamics
The client’s ego has experienced a severe trauma, often
perceived as a threat to physical integrity or selfconcept. This results in severe anxiety, which is not
controlled adequately by the ego and is manifested in
symptomatic behavior. Because the ego is vulnerable,
the superego may become punitive and cause the
individual to assume guilt for traumatic occurrence; the
id may assume dominance, resulting in impulsive,
uncontrollable behavior.
Biological
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The amygdala is a key brain structure implicated in PTSD.
Research has shown that exposure to traumatic stimuli can
lead to fear conditioning with resultant activation of the
amygdala and associated structures such as the
hypothalamus, locus ceruleus, periagueductal gray, and
parabrachial nucleus. The activation and the accompanying
autonomic neurotransmitter and endocrine activity produce
many of the symptoms of PTSD.
The orbitofrontal cortex exerts an inhibiting effect on this
activation. The hippocampus also may have a modulating
effect on the amygdala. However, in people who develop
PTSD, orbitofrontal cortex appears less capable of inhibiting
this activation.
Models of Abnormality
Biological model:
Neo-Cortex
Corpus
callosum
Amygdala
Locus
ceruleus
Family Dynamics
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Types of formal education, family life, and lifestyle are
significant forecasters of PTSD. Below average or lack
of success in education, negative parenting behaviors,
and parental poverty have been identified as predictors
for development of PTSD, as well as for per-traumatic
dissociation.
Current research also suggests that the effects of severe
trauma may last for generations, meaning someone
else’s traumatic experience can be internalized by
another, intruding into the second individual’s own
mental life.(for example palestinine refugee(
Factors Impacting the Development of
PTSD
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PRE-EVENT FACTORS
Previous exposure to severe trauma or early childhood victimization
Family Instability
 history of psychiatric disorder, numerous childhood separations,
economic problems, family violence
Early Depression or Anxiety
Early Substance Abuse
Absence of social support during difficult times
Ineffective Coping
Gender: women twice as likely than men to develop PTSD
Age: adults under age of 25 are twice as likely to develop PTSD
Genetics: some families less able to withstand trauma than others
Factors Impacting the Development of
PTSD
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EVENT FACTORS
Geographical closeness to the event
Amount of exposure to the event/trauma
Duration of the trauma
The event’s meaning to the victim
The existence of a continuous threat that the
trauma will continue (i.e. war)
Age: victim being young at the time of event
Factors Impacting the Development of
PTSD
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POST-EVENT FACTORS
Absence of good social support
Not being able to do something about what happened
Indulging in self-pity while neglecting one’s own self-care
Inability to find some meaning in the suffering
Developing Acute Stress Disorder
Experiencing immediate reaction shortly after the
traumatic event:
 physiological arousal, avoidant or numbing symptoms.
Factors Impacting Ability to Cope with
Trauma
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High extroversion (seek out others)
Openness
Conscientious in working toward goals
Agreeableness (ability to get along with others)
Motivation
Optimism
Successful resolution of other crises
Internal Locus of Control
– Belief that control of what happens lies within you, not with sources
outside of you
Self-Efficacy
– Sense of confidence in one’s own coping ability
Coherence
– Recognizing that even significant traumatic events are
understandable, manageable, meaningful
Management of PTSD
• Many of the complications and disability
associated with PTSD may be prevented by
initiating the assessment and treatment
quickly after the traumatic event. Treatment
is best accomplished with a combination of
pharmacologic and non pharmacologic
therapies
Nonpharmacologic Therapies
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Group therapy
Individual and family therapy
Cognitive behavioral therapy
-EMDR
- PET
Play therapy
Art therapy
Anxiety management
Relaxation techniques
Pharmacological Therapies
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Many different drugs have been used to treat symptoms of
PTSD such as benzodiazepines for anxiety, anticonvulsants
for impulsivity, and colnidine for nightmares. The principal
agents of treatment have been various antidepressants and
beta blockers. In severe cases ECT treatment may be used.
Common drugs of choice are the following:
Zoloft
Paxil
Prozac
Nardil
propanolol
NURSING PRIORITIES
1. Provide safety for client/others.
2. Assist client to enhance self-esteem and regain
sense of control over feelings/actions.
3. Encourage development of assertive, not
aggressive, behaviors.
4. Promote understanding that the outcome of the
present situation can be significantly affected by own
actions.
5. Assist client/family to learn healthy ways to deal
with/realistically adapt to changes and events that
have occurred.
Patient-Family Education
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When a family member is diagnosed with PTSD, the
entire family may be effected. Members may
experience shock, fear, anger, and pain because of
their concern for the victim. Living with family
members who have PTSD does not cause PTSD. Yet,
it can cause similar symptoms such as feelings of
alienation from and anger towards the victim. Other
family members may find it hard to communicate with
a person with PTSD. Sleep disturbances and abuse
(physical and substance) may occur among family
members.
Patient-Family Education Cont.
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Family members should engage in
counseling if anger, addiction, or problems in
school or work become issues. Stress and
anger management and couples’ therapy are
possibilities. Families should try to maintain
their outside relationships and should
continue to be involved in pleasurable
activities.
What clients with
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PTSD Need to Know
Important to emphasize that she/he is having these symptoms
because of what happened to her and Not because of
anything about her
PTSD symptoms are normal, common human reactions to
extreme stress after experiencing a highly traumatic event
Trauma associated w/PTSD does not cause or produce
serious mental illness
PTSD is treatable
PTSD is learned. PTSD is acquired according to
psychological learning principles. It is not a disease.
– Since PTSD is learned, it can be unlearned. Although we
cannot change what happened to you, we may be able to
change the way you interpret what happened to you.
Prolong exposure technique
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Edna B. Foa
Edna B. Foa, Ph.D.,
Professor of Clinical Psychology in Psychiatry at the
University of Pennsylvania .
Director of the Center for the Treatment and Study of
Anxiety .
Foa has been an expert in the areas of post-traumatic
stress disorders (PTSD) .
The program she has developed for rape victims is
considered to be one of the most effective therapies for
PTSD.
She has received Scientist Award of s American
Psychological Association.
Traumatic
event
cues
References
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Rob Newell&Kevin Gournay.(2009)Mental
Health Nursing,New York, Toronto.
Kleber. et al(2002)Beyond Trauma. New
York, Plenum Press.
DSM-IV-TR.
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