Post Traumatic stress disorder

1. PTSD (post
traumatic
stress
disorder)By: Rasida K.
Amilasan, RN, BSN

2. P
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3. POST TRAUMATIC STRESS DISORDER
(PTSD)
Grieving-like behaviors that result from a
major and severe trauma like rape, assault,
accidents, fire, wartime combat, acts of
violence, or natural disaster;
Usually occurs AFTER a major traumatic
events (usually after ONE month)
Acute Stress Disorder – anxiety during or
immediate after a traumatic event (within 4
weeks or 1 month); may resolve after 4
weeks.
3

4.  May show physical manifestations:
a. Flashbacks
b. Insomnia and nightmares
c. Eating problems
d. Depression and isolation
e. Hypervigilance and guilt about surviving
the event;
4

5.  Types of PTSD:
a. Acute – less than 3 months after the
event;
b. Chronic – 3 months or more after the
event;
c. Delayed – at least 6 months after the
event;
5

6. Signs and Symptoms:
 Anger
 Poor impulse control
 Chronic anxiety and tension
 Avoidance of people, places, and
things associated with the traumatic
events
 Emotional detachment or numbness
 Social withdrawal
 Decreased self - esteem

7. Diagnosing PTSD ( key
assessment)
 inability to recall specific aspects of
the traumatizing event
 Recurring dreams, flashbacks, or
thoughts of the traumatic event
 Feeling or acting as one did when event
originally occurred
 Intense distress when faced with cues
reminiscent event

8.  Treatments:
a. Psychotherapy
b. Pharmacotherapy
1. Antidepressants – SSRI (1st line drugs to treat
depression).
2. Benzodiazepines
3. Beta – adrenergic blockers
4. TCA’s
5. MAOI
8

9.  Nursing Interventions:
P – provide safe environment for
the client.
T – try to recall the traumatic
event.
S – suicide precaution.
D – don’t leave client alone.
9

10. Nursing interventions (cont.):
 Deal constructively with patient’s displays of
anger
 Encourage patient to assess angry outbursts
by identifying how anger escalates
 Assist in regaining control over angry
impulses, help to identify situations in which
patient lost control, to talk about past and
precipitating events

11.  Use displacement as means of dealing
with urges( from self or others),
provide safe, staff – monitored room
 Encourage move from physical to verbal
expressions of anger

12. Dissociative disorders
By: Rasida K. Amilasan, R

13. DISSOCIATIVE DISORDERS
Rare; Disturbances in the normal waking state;
Is characterized by splitting off or removal
from conscious awareness of some information,
feeling, or mental function;
Affect fundamental aspects of consciousness,
memory, identity, self – perception, and
perception of the environment;
Also associated with traumatic events and
severe anxiety;
13

14. Types:
 Depersonalization
 Dissociative amnesia
 Dissociative fugue
 Dissociative identity
disorder

15. Diagnosing dissociative
disorder:
 Dissociative disorders interview
schedule
 SCID – D
 Diagnostic drawing series

16. Depersonalization
disorder

17. • An altered self-perception in which one’s own
reality is temporarily lost or changed;
• Feeling of self- detachment; Persistent or
recurrent feeling of being detached from the
person’s own mental processes or body;
• Patient may perceive change in consciousness as
barrier between herself and outside world;
Depersonalization disorder

18. • The client may experience feelings of
detachment but intact reality testing;
• Patient may feel that external world is unreal
or distorted;
• Sudden onset, usually occurring in adolescent
or in early adulthood;
• Symptom of depersonalization is brief and
has no lasting effects
• Typically progresses; in many patients
becomes chronic with exacerbations and
remissions
• Resolution usually occurs gradually

19. Causes:
• Exact cause is unknown
• Severe stress
• History of physical, mental, or
substance abuse
• History of OCD
sensory deprivation
• Neurophysiologic factors

20. Signs and symptoms:
• Feeling detached from entire being and
body or loss of touch with reality
• Loss of self – control
• Difficulty speaking
• Obsessive rumination
• Disturbed sense of time

21. Diagnostics:
• Rule out physical disorders
• Psychological tests and
special interviews
• Confirmed if DSM – IV – TR
criteria met

22. Treatment:
• Many recover without treatment
• Treated when condition is persistent,
recurrent, or distressing
• Psychotherapy
• Cognitive – behavior therapy
• Hypnosis
• Drugs:
• SSRIs, TCAs
• Identifying and addressing all stressors
linked to onset

23. Nursing interventions:
• Establish therapeutic, nonjudgmental
relationship with patient
• Encourage patient to recognize that
depersonalization is a defense mechanism
• Recognize and deal with anxiety – producing
experiences
• Assist patient in establishing relationships

24. Dissociative Amnesia

25.  inability to recall important personal
information that can’t be explained by
ordinary forgetfulness and because it is
anxiety provoking;
 memory impairment may be partial or
complete;
 amnesia may be anterograde (recent
information) or retrograde (past information);
 Forgetting basic autobiographical information
 Most patients aware that they have “lost”
some time
25
Dissociative Amnesia

26. Types:
 Localized
 Selective
 Generalized
 Continuous
 Systematized

27. Causes:
 Stress caused by traumatic
experience
 Predisposition
 History of physical, emotional, or
sexual abuse

28. Signs and symptoms:
 Patient may seem perplexed and
disoriented or wander aimlessly
 Can’t remember event that precipitated
episode
 Doesn’t recognize inability to recall
information
 When episode ends, unaware of memory
disturbances

29. Diagnostics:
 Physical examination to rule out organic
cause of symptoms
 Psychiatric examination, including
psychological tests
 Must meet DSM – IV – TR criteria

30. Treatment:
 Helping patient recognize traumatic event
trigger
 Teaching of reality – based coping strategies
by psychotherapist
 When recovery is urgent, questioning patient
under hypnosis or in drug – induced, semi
hypnotic state
 Drugs:
 Benzodiazepines
 SSRIs

31. Nursing interventions:
 Establish therapeutic, nonjudgmental
relationship
 Encourage patient to verbalize feelings of
distress
 Help patient recognize that memory loss is a
defense mechanism
 Help patient deal with anxiety – producing
experiences
 Teach and assist patient in using reality based
coping strategies
 Teach family members techniques for dealing
with patient’s memory loss

32. Dissociative Fugue

33.  Sudden travel away from home and assumes
a new personality with inability to recall the
past;
 This may occur suddenly for several hours
or days;
 Follows severe psychosocial stress (marital
quarrels, personal rejections, or natural
disaster)
 It allows escape or flight from an
intolerable situations.
 “When the fugue state stops or lost ….. the
client returns home …… UNABLE to recall
the fugue state.”
33
Dissociative (Psychogenic) Fugue

34. Upon return to pre – fugue state, patient may
have no memory of events that occurred
during fugue
Inability to recall past
Confusion about personal identity
Occasional formation of new identity during
episode
Degree of impairment varies with duration of
fugue and nature of personality state evoked
usually resolves rapidly
34

35. Causes:
 Precise cause unknown
 Follows extremely stressful event
 Heavy alcohol use (possible predisposing
factor)

36. Signs and symptoms:
 Often asymptomatic during fugue
 Confusion about identity or puzzled about
past
 Confrontational when new identity (or absence
of identity) is challenged
 Depression
 Discomfort
 Shame
 Intense internal conflict
 Suicidal or aggressive impulses
 Confusion, distress, even terror due to failure
to remember events during the fugue

37. Diagnostics:
 Psychiatric examination (during suspected
fugue)
 Psychological history to check for
episodes of violent behavior
 May not be able to diagnose until fugue
ends
 Physical examination to rule out medical
conditions
 Confirmed if DSM – IV – TR criteria met

38. Treatment:
 Psychotherapy
 Anxiolytics
 SSRI
 Establish trusting relationship
 Hypnosis
 Cognitive therapy
 Group therapy
 Family therapy
 Creative therapies such as music or
art therapy

39. Nursing interventions:
 Encourage patient to identify emotions
that occur under stress
 Monitor patient for signs and symptoms
of overt aggression toward self or others
 Teach patient effective coping skills
 Encourage patient to use available social
support systems

40. Dissociative Identity
Disorder (DID)

41. 41
• or multiple personality;
• existence of two or more fully developed
distinct and unique personalities within the
person;
• the personalities may take full control of
the person one at a time;
• the personalities may or may not be aware
of each other;
• the person is unable to recall important
information;
Dissociative Identity Disorder

42. 42
• char by sudden transition from one
personality to the other RELATED TO
STRESS;
• “dissociation is used as a method of
distancing and defending self from anxiety
and traumatic events;”
• Clients with depersonalization disorder (like
DID) are not admitted unless they are
suicidal;
CAUSE:
• Strong connection between DID and history
of severe childhood abuse

43. Signs and symptoms:
 Lack of recall beyond ordinary forgetfulness
 Pronounced changes in facial presentation,
voice behavior
 Hallucinations particularly auditory and visual
 Suicidal tendencies or other self – harming
behaviors

44. Diagnostics:
 Correct diagnosis only after months or
even years in mental health system
 Medical history revealing unsuccessful
psychiatric treatment, periods of
amnesia, and disturbances in time
perception
 DSM – IV – TR criteria

45. Treatment:
 GOAL: “Integrate the personalities or
memories so that they can coexist with the
original personality and prevent personality
from splitting again.”
 Long term process
 After stabilization, decreasing degree of
dissociation, enhancing cooperation and
consciousness among subpersonalitie, and
ultimately merging them into one personality

46. 46
• Family and couples therapy
• Psychotherapy
• Hypnosis
• Drugs :
Benzodiazepines
SSRIs
TCAs
Treatment cont.:

47. The don’ts of DID therapy
 Don’t encourage patient to create new
personalities
 Don’t suggest that patient adopt names for
subpersonlities
 Don’t encourage subpersonalities to function
more autonomously
 Don’t encourage patient to ignore certain
subpersonalities
 Don’t exclude unlikable subpersonalities from
therpy