Post Traumatic Stress Disorder, Part I – An Overview

September 13, 2001

FROM ANOTHER LIST, BUT THOUGHT SOME OF U MIGHT GET SOME INFO. FROM IT!!!

MOM-BILLIE

Carolyn Chambers , ARNP, EdD

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The goal of this program is to update nurses’ knowledge of the

identification and care of patients with Post Traumatic Stress Disorder.

After you study the information presented here, you will be able to:

a.. Discuss the etiology of Post Traumatic Stress Disorder (PTSD).

b.. Identify five symptoms of PTSD.

c.. List the three stages in the process of healing from a trauma.

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, a soldier involved in the Persian Gulf War, has nightmares

about the firefight that cost him his leg.

, a battered wife, has had difficulty falling asleep and frequent

suicidal ideas, and has lost all interest in work and other parts of her

life for the past three months.

Ira, a victim of the Oklahoma City bombing, swears at the nurses

caring for him, has difficulty trusting authority figures and public

institutions, and sees no future for himself.

Janet, a rape victim, resists recounting the details of her attack and

reports numbing of emotions and persistent symptoms of sleeplessness and

irritability for more than a month.

What do each of these people have in common? They are victims of Post

Traumatic Stress Disorder (PTSD). This condition was once associated mainly

with the survivors of wars, but today it is used to describe a wide range of

trauma survivors – rape, crime, and torture victims; survivors of natural

catastrophes, vehicular accidents, and technological disasters; and abused

women and children. Also at high risk for PTSD are rescue squad workers,

police officers, firefighters, and nursing personnel who witnessed or

experienced a traumatic or life-threatening event that had the potential for

bodily harm.1,2 Even people who have had a miscarriage or experienced job

loss may suffer from PTSD.3

At first glance, combat veterans, hurricane survivors, and nurses seem

a very divergent group. What makes them similar? They all have at least one

common experience: They have all been rendered helpless in a situation of

great danger. While each survivor is unique in history and coping

strategies, they share a similar and fairly predictable set of psychological

and physiological reactions that identifies PTSD.

Common Reactions, Uncommon Causes

Primary symptoms of those who suffer PTSD include insomnia, substance

abuse, nightmares, anxiety, depression, and anger and fear that the horror

will return. War-related flashbacks have been glamorized in movies and

newspapers. Less publicized are the agonizing self-doubts, and fears of

nightmares, flashbacks, and/or impending death. Less well-known are the

reactions of battered wives and abused children: sleeping disturbances,

flashbacks, addiction, chronic anxiety, and low-grade depression.2 Avoidance

strategies; acting out; tuning out; imagining themselves somewhere else; and

temporarily being unable to move, speak, or feel are also possible.

Investigations have shown that given sufficient stress, PTSD can

develop. Other factors, such as an individual’s previous psychological state

or mental stability, are unreliable in predicting its occurrence.4 During

World War II, for example, some soldiers with sterling records of mental

health and family stability developed the disorder, while others who had

preexisting psychological or low socioeconomic status did not. The critical

variable was the degree of stress to which the survivor was exposed.5,6

Likewise, a large-scale study of crime victims found that a victim’s

race, sex, income level, educational status, previous history of psychiatric

illness (including panic disorder, agoraphobia, or depression) did not

predict PTSD. The determining factor was the stressfulness of the crime.

PTSD rates were lower for victims of burglary when they weren’t home, while

threat to life was correlated with much higher incidence.7

PTSD does not develop because of some inherent weakness in the

personality. Trauma changes personality, not the other way around. Although

pretrauma personality does affect the interpretation of and the reactions to

a traumatic occurrence, the intensity and duration of the stressful event

are more significant factors in assessing the problem.

PTSD is not the only reaction to trauma. If the condition is of short

duration – occurring within four weeks of the traumatic event and lasting a

minimum of two days and a maximum of a month – it is called acute post

traumatic stress disorder. Some survivors may react with psychosomatic

problems or panic attacks.

Physiological Changes

When trauma occurs, it affects the whole being – not just the mind or

emotions, but also the body. Central nervous system changes include

catecholamine reactions and depletion of neurotransmitters. Physiologically,

trauma can give rise to a host of “hyperarousal” bodily changes, including

heightened heart rate, blood sugar, and muscle tension. Perspiration

increases, pupils dilate, and rapid, shallow breathing ensues. The

individual may exhibit signs of hyperventilation: irregular heart rate,

choking sensations, shortness of breath, and confusion or inability to

concentrate.8

Many emotionally distressing symptoms of PTSD also have a

physiological basis.9 For example, , the combat veteran mentioned above,

has nightmares of the firefight that cost him his leg nearly every night. He

has tried to rid himself of the nightmares, but has been unsuccessful. If

physiological research is correct, his recurring nightmares are beyond his

control: The situation he lived through was severe enough to profoundly

alter his thinking, his emotions, and even his physical reactions.

It need not take hours, months, or years to create such lifelong

reactions. A single life-or-death incident that lasts only a few seconds can

traumatize an individual. For example, Seles, the number one female

tennis player several years ago, was stabbed in the back at a major European

tennis tournament. Despite her work with a psychologist and the complete

physical healing of her wound, she was too afraid to return to playing

competitive tennis for more than two years. In those few moments when the

individual is experiencing the traumatic event, emotions, identity, and

sense of the world as an orderly, secure place can be severely shaken and

even shattered. Trauma can lead to a profound rupture in the individual’s

sense of self-worth and trust in the world as a safe place.

The Dynamics Of PTSD

The diagnosis of PTSD can only be made if the individual meets all of

six symptomatic criteria stipulated by the American Psychiatric Association.

Generally, a person who suffers from the disorder experiences a cycle of

intrusive recall of the trauma, accompanied by reexperiencing physiological

hyperarousal and psychological symptoms. This is usually followed by a

repression of memories, called numbing, and in some cases, partial or total

amnesia of the event.

Symptoms are sometimes directly related to the type of trauma. For

example, survivors of family abuse – one of the most common causes of PTSD –

often share special profiles that are characterized by four oppositional

stances or “polarities.”10

1. Naivete vs. cynicism or suspiciousness. The survivor may hold a

joyful “all will be well” view of the world or an extremely negative one.

The naive optimism reflects the survivor’s denial of the abuse and the wish

it had not ever happened. Cynicism or suspiciousness reflects the victim’s

recognition of the abuse and generalization of cruelty and manipulativeness

of the abuser to others and to the world in general.

2. Worthlessness vs. specialness. Victims may feel worthless due to

humiliation from their abusers, who sometimes relegate them to subhuman

status. However, survivors may also feel important, as if they had been

chosen for special, if horrible, treatment.

3. Self-punitive vs. self-indulgent behavior. This polarity mimics the

abuser’s pattern of first punishing, then indulging the victim. It may also

reflect survivor self-hatred and feelings that they deserved to be abused.

Alternately, or at the same time, victims may reward themselves because they

feel deprived or self-pitying.

4. Intense dependency vs. excessive caretaking. Abusers often foster

the victim’s dependency through forced isolation and appeals to the victim

for sympathy. Ironically, victims often continue to function as the

emotional, physical, and sometimes the financial or sexual caretakers of

their abusers.

The terms epiphenomena, masked presentation, and secondary

elaborations all refer to the secondary symptoms or psychological syndromes

that evolve to allow survivors to cope with the trauma. The longer

individuals have suffered from trauma without assistance and the more severe

the experience, the more likely that secondary symptoms – alcoholism or drug

abuse, eating or panic disorders, or phobias – occur. This can happen when

survivors are in the numbing stages of PTSD, have difficulty remembering, or

are amnesic.2

Following The Trail Of PTSD

After a traumatic event has been identified, a knowledgeable nurse can

use three categories of questions – presence of intrusive thoughts,

avoidance reactions, and physical symptoms – to assess the extent to which

an adult survivor is suffering from PTSD.10 When a therapeutic relationship

has already been established and the individual is ready to discuss the

event, questions can be phrased in a direct, personal manner. When a person

is in the early stages of PTSD or extremely anxious, and/or a therapeutic

relationship is just being established, questions need to be less obtrusive.

Questions that are less direct and nonspecific allow the survivor more

control over the amount of sharing that will occur. The answers to these

questions can then be compared to the criteria published in the DSM-IV by

the American Psychiatric Association.

l. To assess the presence of intrusive thoughts:

a.. Are you bothered by upsetting thoughts and nightmares of the

trauma (for example, rape, fire, crash, or war)? OR Tell me about your

sleeping patterns.

b.. Do you often feel as though you are actually reliving the

trauma? OR What are your feelings about the trauma?

c.. Does it upset you to be exposed to anything that reminds you of

the traumatic experience? OR What are your feelings when you are reminded of

the trauma?

2. To assess the presence of avoidance reactions:

a.. Do you find yourself trying to avoid thinking about the trauma?

OR What have you been thinking about since the trauma?

b.. Do you stay away from situations that remind you of the trauma?

OR Tell me about your experiences with situations that remind you of the

trauma?

c.. Do you have trouble recalling exactly what happened to you? OR

How has your memory been since the event?

d.. Do you feel detached or cut off from other people? OR How have

things been between you and other people since the event?

e.. Do you feel numb emotionally? OR Tell me about your feelings.

3. To assess the presence of physical symptoms:

a.. Are you having trouble sleeping?

b.. Have you felt irritable or had outbursts of anger?

c.. Have you had trouble concentrating?

d.. Do you feel jumpy or become easily startled?

e.. What kind of physical reactions do you have when you are exposed

to anything that reminds you of the trauma?

f.. Does your heart ever beat too fast without exertion

(palpitations)?

g.. Do you sweat too much without exertion (diaphoresis)?

h.. Do you have headaches, tight shoulders, or other signs of muscle

tension?

The Process Of Healing

Individuals who have experienced trauma progress through three stages

of recovery – victim, survivor, and thriver.9 As with many “stage theories”

the lines of demarcation may not be clear-cut: They may overlap, not occur

in all individuals, or reappear at a later date.

There is a tendency for the least traumatic memories to emerge first

and the most traumatic ones to appear later in the healing process. With

each new revelation, the survivor may regress temporarily to the victim

stage, exhibiting thoughts, feelings, and behaviors characteristic of that

stage. None of the stages may uniformly characterize an individual. For

example, a patient may be in the thriver stage at work, the victim stage

regarding intimate relationships, and in the survivor stage when dealing

with family relationships.

a.. The victim stage consists of three phases: prediscovery of the

trauma, early awareness, and discovery. Symptoms of PTSD may appear in

prediscovery with little understanding of why they are occurring. Patients

can feel inner chaos, which may be reflected in personal relationships. They

often suffer from poor recall, and sometimes total amnesia, of parts or all

of the traumatic event. Individuals may suffer from low self-esteem or feel

physically, emotionally, or financially vulnerable from the effects of a

trauma of which they are fully conscious. They may engage in escapist

activities – substance abuse, or a change of job, residence, or

relationship – in a search for relief. As the awareness phase begins,

victims have a vague sense that they have been affected by trauma. This

awareness leads to heightened anxiety, along with depression, irritability,

and dissatisfaction with themselves and others. As in any crisis, when

survivors finally face their traumatic experiences, reactions vary from

initial disbelief and shock, vacillation between denying and admitting

fragmented facts of the trauma, to a surge in PTSD symptoms, such as

flashbacks and nightmares.

b.. Because the essence of being a victim is being out of control,2

entering the survivor stage means taking control of one’s environment and

inner self. A commitment to therapy or some other effort to be healed must

be made. The trauma is confronted and the intense feelings associated with

it begin to emerge from repression to find constructive expression. With

healing, repressed memories and feelings no longer control the individual’s

inner life, relationships, and external behavior because they have lost

their power.2

c.. In the thriver stage, personal goals replace the trauma as

central organizing principles for life. Survivors pursue new education,

work, and life goals. They improve their relationships. Emotional upheavals

are fewer and less bothersome, and greater periods of peace and serenity

emerge. Symptoms that may persist become fewer and less intense. Survivors

learn to manage their symptoms with less anxiety and panic.

Factors That Enhance Recovery

If the stressor is sufficiently great, almost anyone can develop PTSD,

but the impact of the trauma is not uniform. Some individuals suffer

long-term impairment, while others are able to overcome the event in a short

time. PTSD is complex and subject to the effects of personal and social

factors. Good health and the absence of physical disfigurement due to the

trauma enhances recovery. Those who are able to return to some, or all,

pretrauma roles have a better chance of overcoming PTSD. Finally, the

encouragement of significant others and the support of adequate finances and

healthcare services contribute to a better prognosis.2

Nurses can identify and encourage those who have experienced

significant trauma to seek therapy and build a network of support. Clinical

specialists and nurse practitioners in psychiatric/mental health are good

referral sources for treating these patients. Part II of this series will

explore the role of nurses in the therapeutic process of PTSD.

A Clinical Definition

Individuals must meet all of the following criteria for a

diagnosis of PTSD:

a.. Experienced or witnessed at least one trauma or

life-threatening event that had the potential for bodily harm to which they

responded with fear, helplessness, or horror.

b.. Continued reliving of the trauma in the form of what is

referred to as reexperiencing phenomena – nightmares, flashbacks, and

intrusive thoughts about the traumatic event.

c.. Numbing of emotions and persistent avoidance of situations

reminiscent of the trauma.

d.. Symptoms of physiological hyperarousal, including startle

response, difficulty falling asleep, irritability, and hyperalertness.

e.. Symptoms persist for at least one month following the

event.

f.. Evidence of clinically significant distress or dysfunction

in social, occupational, or other important areas of functioning.

Symptoms of PTSD

Primary:

a.. Flashbacks or unwanted memories of the trauma and related

events

b.. Sleep disturbances of insomnia, fitful sleep, nightmares,

and “night sweats”

c.. Anxiety

d.. Emotional numbing

e.. Tendency to react under stress with survival mechanisms

appropriate to the trauma; for example, incest victims may become

flirtatious or seductive, or war veterans may become threatening and highly

aggressive

f.. Suicidal thoughts and feelings

g.. Loss of interest in work or other activities

h.. Fantasies of retaliation

i.. Cynicism and distrust of authority figures and public

institutions

j.. Feelings of alienation and problems with intimate

relationships or any relationship

k.. Hypersensitivity to injustice

l.. Tendency to have fits of rage, be passive, or alternate

between them

m.. Hyperventilation

n.. Hyperalertness

o.. Social isolation or emotional distance from others

p.. Overprotectiveness and fear of losing others

q.. Avoidance of activities that arouse memories of trauma

r.. Survivor guilt

s.. Fear of the trauma returning

t.. All-or-nothing thinking

u.. Dissociative trance states, denial, and “out-of-body”

experiences

v.. Organ-specific psychosomatic problems

w.. Physical symptoms specific to the trauma, such as pain in

the anal or vaginal area after rape

x.. Crying episodes

y.. Self-blame

z.. Mood swings

aa.. Difficulty concentrating2,10

Secondary Elaborations:

a.. Eating disorders: bulimia nervosa, anorexia nervosa,

compulsive eating

b.. Alcohol or drug abuse

c.. Compulsive gambling or spending

d.. Psychosomatic conditions

e.. Amnesia

f.. Phobias

g.. Homicidal, suicidal, or self-mutilating behavior

h.. Panic disorders

i.. Delinquent or criminal behavior

j.. Depression or depressive symptoms

k.. Fainting spells

l.. Psychotic episodes

m.. Borderline personality

n.. Sleepwalk disorder2

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Carolyn Chambers , ARNP, EdD, works with victims of PTSD, and

offers consultation and workshops for nurses and others interested in this

disorder through her independent private practice at Bay Area Psychological

Services, St. sburg, FL.

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References

1. van der Kolb B. Traumatic Stress: The Effects of Overwhelming

Experience on Mind, Body, and Society. Brooklyn, NY: Guilford Press; 1999.

2. Matsakis A. Post Traumatic Stress Disorder: A Complete Treatment

Guide. Oakland, CA: New Harbinger; l994.

3. M & Sommer J. Handbook of Post-Traumatic Therapy. CT:

Greenwood Press; l994.

4. Adler T. PTSD linked to stress rather than character. APA Monitor.

l990;21:3.

5. Van Atta RE. A study of the validity of the MMPI. Post-Traumatic

Stress Disorder Scale: Implications for forensic clinicians. Forensic

Examiner. 1999;8(7,8):20-23.

6. Everson MP, Kotler S, Balckburn WD. Stress and Immune Dysfunction

in Gulf War Veterans. Annuals NY Academy Sci. 1999;876:413-418.

7. Chambless D, Kilpatrick D, and van der Kolk B. Symposium on

post-traumatic stress disorder. Presentation at the Tenth National

Conference of Anxiety Disorders of America. Bethesda, MD; March, l990.

8. Zuercher-White E. An End to panic. Oakland, CA: New Harbinger;

1998.

9. van der Kolk B. The trauma spectrum: the interaction of biological

and social events in the genesis of the trauma response. J Traumatic Stress.

l988; l:3.

10. Hansen P. Survivors and Partners: Healing the Relationships of

Sexual Survivors. Longmont, CO: Heron Hill; l992.

Bibliography

Ellen LS. Guided imagery interventions for symptom management. Annual

review Nurs Res. 1999;17:57-84.

Lyons J. Strategies for assessing the potential for positive

adjustment following trauma. J Traumatic Stress. 1991;4:l.

September 14, 2001

CAN'T REMEMBER IF I THANKED YOU FOR THIS OR NOT SO THANK YOU MOM. I FEAR

THAT A LOT OF PPL ARE GOING TO HAVE NEED OF THIS BEFORE ALL IS SAID AND

DONE. LUV U JO

http://community.webtv.net/jowaca/JOSFAVORITEPICTURES