CHAPTER 16 1. Describe clinical manifestations of each disorder covered under the general umbrella of trauma-related and dissociative disorders. 2. Describe the symptoms, epidemiology, comorbidity, and etiology of trauma-related disorders in children. 3. Discuss at least five of the neurobiological changes that occur with trauma. 4. Apply the nursing process to the care of children who are experiencing trauma-related disorders. 5. Differentiate between the symptoms of posttraumatic stress, acute stress, and adjustment disorders in adults. 6. Describe the symptoms, epidemiology, comorbidity, and etiology of trauma-related disorders in adults. 7. Discuss how to deal with common reactions the nurse may experience while working with a patient who has suffered trauma. 8. Apply the nursing process to trauma-related disorders in adults. 9. Develop a teaching plan for a patient who suffers from posttraumatic stress disorder. 10. Identify dissociative disorders, including depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder 11. Create a nursing care plan incorporating evidence-based interventions for symptoms of dissociation, including flashbacks, amnesia, and impaired self-care. 12. Role-play intervening with a patient who is experiencing a flashback. Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis Traumatic life events are associated with a wide range of psychiatric and other medical disorders. Traumatic events are not always as extraordinary as war and may be as common as interpersonal trauma, sexual abuse, physical abuse, severe neglect, emotional abuse, repeated abandonment, or sudden and traumatic loss in childhood, adolescence, or adulthood (Huckshorn, 2012). Many psychiatric disorders have trauma as a precipitant. According to the American Psychiatric Association (APA) (2013), disorders included under the trauma umbrella include posttraumatic stress disorder (PTSD), reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. This chapter begins with trauma-related disorders in children and then discusses adult trauma-related disorders. Tragically, children are exposed to many traumatic events without the strength or coping skills to adequately defend themselves. Abuse, interpersonal violence, automobile accidents, natural disasters, war, medical procedures, and illnesses are all traumatizing incidents. Children who have been abused and neglected by their caretakers and other adults are at great risk for developing emotional, intellectual, and social handicaps as a result of their traumatic experiences (U.S. Department of Health and Human Services, 2008). According to the National Child Abuse and Neglect Data System (2010), nearly 700,000 children were victims of abuse and neglect in 2010. Neglect is the most prevalent form of child abuse in the United States. Of those children who died from abuse and neglect, about 68% were due to neglect, 45% from physical abuse and neglect, and 26% as a result of multiple types of abuse. In addition, more than 1% of cases involved sexual abuse. These statistics reflect known cases of abuse; there is little doubt that far more children suffer abuse and neglect than are reported to child protective services agencies. Witnessing violence is traumatizing and a well-documented risk factor for many mental health problems, including depression, anxiety, PTSD, aggressive and delinquent behavior, drug use, academic failure, and low self-esteem (Farrell et al., 2007). Children who have been abused are at risk for abusing others as well as developing dysfunctional patterns in close interpersonal relationships. Other traumatic events for children include invasive medical procedures and critical life-threatening illnesses. It is thought that the younger the child, the more seriously ill, and the more invasive the procedure, the more likely the child will develop PTSD. Research has found that those children who have survived cancer have four times the risk of developing PTSD than their siblings (Stuber et al., 2010). Studies estimate that about the same percentage of boys as girls experience at least one traumatic event: 15% to 43% (U.S. Department of Veterans Affairs, 2010b). Of these children and adolescents who experience trauma, 3% to 15% of girls and 1% to 6% of boys have diagnosable PTSD. Nearly 100% of children who witness their parent’s murder or sexual assault will develop PTSD. Other alarming statistical relationships with PTSD are for children who are sexually abused (90%), exposed to a shooting at school (77%), and who see community violence in urban settings (35%). Comorbidities increase the child’s vulnerability to developing or exacerbating (making worse) PTSD symptoms. Children and adolescents who have suffered toxic stress and trauma often meet the criteria for more than one diagnostic category. Even if a child does not have sufficient symptoms for a diagnosis of PTSD, he or she can still suffer from overwhelming nightmares or difficulties with trust, phobias, somatic problems, impulse control, and identity issues. Learning and attention problems, behavioral problems, sleep disorders, depression, suicide attempts, dissociation, and substance-abuse problems are all significant comorbidities (National Institute on Drug Abuse, 2011; Friedman et al., 2011a, 2011b). These comorbidities cause these injured children to be subjected to an endless cycle of medications, punishments, and inadequate responses that revictimize and stigmatize the child. Genetic variability is thought to play a role in stress reactivity, and epigenetic factors modulate the expression of genotype. Research on animals and humans has found that prenatal exposure to maternal stress can influence later responses to stress in the offspring (Darnaudery & Maccari, 2008). Also, early adversity has been found to alter the DNA in the brain through a process called methylation (Weaver et al., 2010). Methyl groups are attached to genes that govern the production of stress hormone receptors in the brain. This in turn prevents the brain from regulating its response to stress. Parental nurturing may mediate this response, but in the absence of nurturing, these children have difficulties with attention and following directions, are more likely to engage in high-risk behavior as teenagers, and show increased aggression, impulsivity, weakened cognition, and an inability to discriminate between real and imagined threats as adults. Trauma, however, causes a dysregulation that disrupts the integration of these neural networks. The more intense the arousal, the less likely it is that the experience will be processed (Bergmann, 2012). It is thought that the more helpless and less in control of the situation the person feels, the more vulnerable to pathophysiological changes he or she is. Polyvagal theory posits that the autonomic nervous system is not limited to a fight-or-flight response to threat and actually consists of three different responses (Porges, 2011). The sympathetic and parasympathetic systems are governed by the tenth cranial nerve, or vagus nerve, that sends and receives information between the body and the brain through two major vagus nerves, ventral and dorsal, with two branches, myelinated and unmyelinated. Responses are as follows: 1. Myelinated ventral vagal responses are activated during social or intellectual engagement when the individual is “on,” in a state of pleasant, not overwhelming, arousal. This state serves as a gentle brake by inhibiting sympathetic responses of the autonomic system. 2. Unmyelinated ventral vagus responses are activated when we perceive a threat. The attending sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for fight-or-flight responses. After many hours, days, or months the body cannot sustain this state. 3. The third response is the dorsal vagal response that occurs to dampen down the sympathetic nervous system. This is a parasympathetic response, with the heart rate and respiration slowing down and a decrease in blood pressure. Animals in the wild illustrate the ultimate dorsal vagal shutdown by playing dead when extremely threatened. A psychological theory that has important implications for trauma-related disorders is that of attachment theory. This theory describes the importance and dynamics of the early relationship between the infant and the caretaker based on the early work of Bowlby (1988). Attachment patterns or schemas are formed early in life through interaction and experiences with caregivers, and this relationship is embedded in implicit emotional and somatic memories. Research has demonstrated that these templates or patterns of attachment persist into adulthood. These schemas were studied and classified for young children and include secure, avoidant, ambivalent, and disorganized attachment styles (Ainsworth, 1967). Poverty, parental substance abuse, and exposure to violence have received increasing attention and place minority children at greater risk for trauma and stress. Pervasive and persistent economic, racial, and ethnic disparities are called the “millennial morbidities” (Shonkoff & Garner, 2012). A review of 58 studies found that racial and ethnic disparities in children’s health are worsening (Flores, 2010). Differences in cultural expectations, presence of stresses, and lack of support by the dominant culture may have profound effects and increase the risk of mental, emotional, and academic problems. Family stability may provide cushioning effects in the face of poverty and adversity. Working with children and adolescents from diverse backgrounds requires an increased awareness of one’s own biases and of the patient’s needs. The term resilience refers to positive adaptation, or the ability to maintain or regain mental health despite adversity. Studies have shown that factors that enhance resilience include the presence of supportive relationships and attachments as well as the avoidance of frequent and prolonged stress (Herrman et al., 2011). Children brought up in a chaotic or non-nurturing environment suffer neurological consequences that are long-lasting and difficult to remediate (Shonkoff & Garner, 2012). Toxic stress and adverse childhood experiences have been found to result in lifelong consequences for both psychological and physical health (Shonkoff, 2010). Trauma in early childhood also plays a role in the intergenerational transmission of disparities in health outcomes. The nurse’s role is to identify and foster qualities to keep at-risk children from developing emotional problems. Attachment at its most basic level ensures survival of the species. Lack of attachment is counter to such a basic drive. Tizard (1977) conducted one of the best-known early studies related to attachment disorder. Children in this study were abandoned by their parents and lived in an institutional setting. They were provided with play areas, books, and basic needs. What they were not provided with was an adequate ratio of caregivers to children, and caregivers were instructed not to form attachments with the children. After 4 years, eight of the 26 children managed to somehow form attachment with caregivers, eight of the children became emotionally unresponsive, and 10 of the children became indiscriminately social and attention-seeking. The latter two groups coincide with the attachment disorders discussed in this section. The type of data collected to assess the child depends on the setting, the severity of the presenting problem, and the availability of resources; however, assessment is an ongoing process throughout treatment. Methods of collecting data include interviewing, screening, testing (neurological, psychological, intelligence), observing, and interacting with the child or adolescent. Histories are taken from multiple sources, including parents, other caregivers, the child or adolescent, and other adults, such as teachers, when possible. A genogram can document family composition, history, and relationships (refer to Chapter 34). How do family members interact and is the family reinforcing unhealthy behaviors? Specific assessment tools may include instruments such as the Child Dissociative Checklist (Putnam, Helmers, & Trickett, 1993), Trauma Symptoms Checklist for Children (Briere, 1996), and the Child Sexual Behavior Inventory (Friedrich et al., 2001). For those children who are thought to suffer from an attachment disorder, the Disturbances of Attachment interview may be administered (Smyke & Zeanah, 1999). Although a licensed mental health practitioner, such as the advanced practice psychiatric nurse or psychologist, usually gives these assessment tools, parents and teachers can complete structured questionnaires and behavior checklists. Developmental testing should also be conducted for young children since significant developmental delays may be present. The developmental assessment provides information about the child or adolescent’s maturational level. Is the child behaving and functioning at his or her chronological age, or are there areas where the child lags behind the norms and peers? These data are then reviewed in relation to the child’s chronological age to identify developmental strengths or deficits. The Denver II Developmental Screening Test for infants and children up to 6 years of age is a popular assessment tool (Frankenburg et al., 1992). For adolescents, tools may be tailored to specific areas of assessment, such as neuropsychological, physical, hormonal, and biochemical. Some computer-based screening tools for children and adolescents are used in primary care settings to gather sensitive information; these tools will provide privacy while the child is waiting to be seen (Johnson & Newland, 2012). After a comprehensive trauma assessment, two priority nursing diagnoses are applicable (Herdman, 2012). The first is risk for impaired parent/child attachment. This is defined as the risk for disruption of the interactive process between parent/significant other and child that fosters the development of a protective and nurturing reciprocal relationship. Risk factors include: • Anxiety associated with the parent role • Ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization • Inability of parents to meet personal needs • Parental conflict due to altered behavior A child with a trauma-related disorder is at risk for developmental and regulatory disorders. A number of outcomes have been identified related to the nursing diagnoses listed above (Moorhead et al., 2013). An overall attachment outcome would be for the parent and infant/child to demonstrate an enduring affectionate bond. In regard to development, general outcomes would pertain to meeting age-appropriate milestones. The staged model of treatment for trauma includes the following: Stage 1: Providing safety and stabilization through creating a safe, predictable environment; stopping self-destructive behaviors; providing education about trauma and its effects. Stage 2: Reducing arousal and regulating emotion through symptom reduction and memory work through reducing arousal; finding comfort from others; tolerating affect; integrating disavowed emotions and accepting ambivalence; overcoming avoidance; improving attention and decreasing dissociation; working with memories; and transforming memories. Stage 3: Developmental skills catch up through enhancing problem-solving skills; nurturing self-awareness; social skills training; and developing a value system. Interventions in this phase should focus on teaching coping skills to deal with trauma, supporting efforts to achieve socially appropriate goals, and facilitating development of and integration into healthy social support systems. Treatment strategies for the traumatized child are designed to modulate arousal so that the child is helped to stay within a window of tolerance. The window of tolerance is a term that means a balance between sympathetic and parasympathetic arousal (Porges, 2011). Traumatized children have difficulty shifting their emotional and physiological state to accommodate different environments and social contexts. They alternate between hyperarousal (anxiety, fear, hyperactivity, aggression) and hypoarousal (withdrawal, isolation, numbness). Increasing the child’s ability to self-regulate through specific strategies designed to mediate these arousal states while providing a nurturing safe environment supports a sense of well-being, competency and mastery. Since the child with trauma has suffered significant disconnection and fragmentation of relationships with self and others, the most important healing ingredient is that of relationship and connection to others. Connection, caring, and management of the patient’s anxiety are essential to provide the foundation so that integration is possible. Box 16-1 identifies interventions appropriate for a child who has suffered a specific trauma. International guidelines recommend the use of cognitive-behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) as first-line treatments for the treatment of traumatized children (National Institute for Health and Clinical Excellence, 2005). CBT uses a range of strategies such as psychoeducation, behavior modification, cognitive therapy, exposure therapy, and stress management to help the child manage behavior and change maladaptive beliefs and thoughts. EMDR is an innovative evidence-based therapy used to treat children and adults (Fleming, 2012). EMDR processes traumatic memories though a specific eight-phase protocol that allows the person to think about the traumatic event while attending to other stimulation, such as eye movements, audio tones, or tapping. Some believe that it works by causing neurological and physiological changes that help to process and integrate traumatic memories. Specific protocols have been developed for the treatment of children, and even if the child does not remember what happened, EMDR can be helpful. As a licensed mental health provider, advanced practice psychiatric nurses can become certified to use EMDR through additional training. 1. The child’s safety has been maintained. 2. Anxiety has been reduced, and stress is handled adaptively. 3. Emotions and behavior are appropriate for the situation. 4. The child achieves normal developmental milestones for his or her chronological age. 5. The child is able to seek out adults for nurturance and help when needed. Epidemiological studies confirm that most, 55% to 90%, people have experienced at least one traumatic event in their lifetimes, with an average of five traumatic events reported per person (Centers for Disease Control and Prevention, 2010). An individual’s response and the long-term sequelae of a disturbing event is highly individualistic and depends on a multitude of factors, such as the person’s age, developmental stage, coping skills, support system, cognitive deficits, preexisting neural physiology, and the nature of the trauma. Following a traumatic event, nearly 8% of people will develop PTSD (Kessler et al., 1995), with some populations particularly vulnerable. The lifetime prevalence for PTSD is 3.5% of the adult population in the United States with more than a third of these cases classified as severe (National Institute of Mental Health, 2011). The average age of onset is 23 years old, with women more than twice as likely as men (10% vs. 4%) to develop PTSD. This is thought to be due to the greater incidence of sexual assault on women and also the higher likelihood for women to have a past mental health problem such as anxiety and depression, which may make them more vulnerable to response to a traumatic event (National Center for PTSD, 2011). The more adverse childhood experiences (ACE) experienced, the more both medical and mental illness occurs later as adults. Also, while short-term dissociation may actually be adaptive during a distressing event, the tendency toward persistent dissociation may be another significant risk factor (Bryant et al., 2011). Consequences of ACE include obesity, sexually transmitted diseases, alcoholism, severe and persistent mental illness, psychosis, substance abuse, eating disorders, sleep disorders, dissociative disorders, anxiety, and depression (Felitti et al., 1998). Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders (Friedman et al., 2011a, 2011b). Often substances are used to try to manage the feelings and symptoms. Individuals with PTSD are sad, anhedonic, aggressive, angry, guilty, dissociative, and abuse substances. Difficulty with interpersonal, social, or occupational relationships nearly always accompanies PTSD, and trust is a common issue of concern. Common presenting symptoms include chronic pain, migraines, vague somatic complaints, intoxications, anxiety or depression, irritability, avoidance, anger or nonadherence, self-risk behavior, threatening or aggressive behavior, dissociative symptoms, or a change in functioning. Spousal abuse may be associated with hypervigilance and irritability, and chemical abuse may begin as an attempt to self-medicate to relieve anxiety.
Trauma, stressor-related, and dissociative disorders
Trauma-related disorders in children
Epidemiology
Comorbidity
Etiology
Biological factors
Genetic
Neurobiological
Psychological factors
Attachment theory
Environmental factors
Application of the nursing process
Assessment
Developmental assessment
Diagnosis
Outcomes identification
Implementation
Interventions
Advanced practice interventions
Evaluation
Trauma-related disorders in adults
Posttraumatic stress disorder
Epidemiology
Comorbidity
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