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Confronting posttraumatic stress disorder

FAGAN, NANCY RN; FREME, KATHLEEN RN, BSN

ARTICLES

Find out how to help a disturbed patient cope during real or perceived threats.

Many people who've survived an intense emotional trauma remain haunted by unwanted memories. Here's how to recognize a posttraumatic stress reaction and intervene therapeutically.

Nancy Fagan and Kathleen Freme are staff nurses at Baystate Medical Center in Springfield, Mass.

HAVE YOU EVER cared for a patient whose fearful response to a procedure or care situation seemed extreme? Maybe he wasn't reacting to the procedure itself, but rather to the memory of an earlier trauma.

Posttraumatic stress disorder (PTSD) is a term commonly associated with soldiers plagued by horrific memories of battle. But combat experiences aren't the only cause of PTSD. Other traumatic events, including rape, childhood abuse, or involvement in a car accident, natural disaster, or terrorist attack also can trigger the disorder. Long after the event, an experience that evokes memories of the event—even something as subtle as a certain sound or smell—can trigger intense emotions linked to the original trauma, causing abnormal behavior.

At least 3.6% of Americans ages 15 to 54 have PTSD. When you understand what signs and symptoms to look for and why they occur, you're more likely to recognize a PTSD response and help the victim get appropriate treatment.

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Reliving the trauma

Experiencing or witnessing a frightening event that arouses intense feelings of fear, helplessness, or horror sets the stage for PTSD. The trauma has such a strong impact on the victim that he can't shake the experience and continues to relive painful emotions associated with it. Sudden flashbacks may intrude on his thoughts. Other signs and symptoms include an exaggerated startle reflex, sleep disturbances and nightmares, irritability, angry outbursts, difficulty concentrating, hallucinations, sexual dysfunction, and an inability to speak about the tragedy. A child suffering from PTSD may express fear and helplessness with disorganized or agitated behavior.

Someone with PTSD may experience unwanted memories when exposed to certain stimuli. Hypersensitive to real or perceived stressors or the suggestion of certain situations, he may relive the trauma as his mind flashes back to the original horror. He may turn to substance abuse to deaden troubling symptoms or develop a concurrent psychiatric problem, such as an eating disorder, obsessive-compulsive disorder, or multiple personality disorder. (See “Anxiety Disorders: Helping Your Patient Conquer Her Fears” in the December issue of Nursing2003 for more information on various anxiety disorders.)

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Flight, fight, or freeze

By mimicking the response to an imminent threat, a PTSD episode activates the flight, fight, or freeze response in which complex psychobiologic reactions involve the release of endogenous catecholamines, triggering neurochemical changes. The pituitary gland becomes hyperresponsive, causing increased heart rate, muscle tension, elevated blood glucose level, and hyperventilation.

Although flight, fight, and freeze are appropriate survival mechanisms during a real threat, they're debilitating if activated when the threat has passed. When triggered inappropriately in PTSD, they can have crippling social and psychological consequences, such as chronic anxiety, anger, violent behavior, and withdrawal. Anxiety and avoidance typify flight, and increased anger and aggression represent fight. Numbing, disassociation, and alteration in self-perception characterize freeze. In some people, these abnormal long-term reactions can cause chronically elevated blood cortisol levels.

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Identifying PTSD and helping the patient

Not everyone who survives a traumatic experience develops PTSD. But by knowing the risk factors, you can identify patients at risk and intervene or refer them appropriately.

Perceiving a threat on one's life is a key theme. Other predictors include a history of childhood sexual abuse, depression or another psychiatric disorder, and substance abuse. Combat veterans, victims of sexual assault or childhood abuse, survivors of life-threatening accidents, relatives of homicide victims, and survivors of domestic violence are especially vulnerable to PTSD.

If you suspect that a patient in your care may have PTSD and this diagnosis isn't part of his medical history, tell his primary health care provider your concerns. She'll assess the patient for PTSD and, if indicated, refer him to a mental health professional for diagnosis and treatment. (See Diagnosing and Treating PTSD for commonly prescribed treatments.)

Besides requesting a specialist's help, you can use the following techniques to prevent problems from escalating:

  • Provide a calm, safe, comfortable environment.
  • Meet your patient's basic needs by addressing hunger, fatigue, cold, and loneliness.
  • Establish trust by assuming a positive, consistent, honest, and nonjudgmental attitude.
  • Communicate clearly and concisely.
  • Redirect any perceptions your patient may have that he's responsible for this disorder.
  • Help him understand that his symptoms are a common reaction to stressors.
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Awareness is key

No matter where you work, you may encounter a patient with PTSD. By recognizing clues in his history and behavior, you can intervene appropriately and refer him for the help he needs.

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Diagnosing and treating PTSD

In most cases, a mental health professional diagnoses and treats posttraumatic stress disorder (PTSD). Careful clinical interviews and valid tools to assess the patient's psychological status are the best diagnostic gauges. (Assessment instruments are available at the National Center for PTSD Web site listed at the end of this article.)

Because the signs and symptoms of PTSD vary, management and treatment are controversial and changing. Most strategies involve a combination of patient education, drug therapy, and psychotherapy. Selective serotonin reuptake inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft) can help ease symptoms such as nightmares, emotional numbness, and intrusive thoughts in 3 to 4 weeks. The drugs can help the patient open up and safely experience rather than hide his emotions. Individual psychotherapy and group and family therapy are also treatment options.

Some cases of PTSD resolve with time; others persist for years. Studies show that letting someone exposed to a catastrophic event talk about his experience reduces his likelihood of developing PTSD. In fact, with the help of family, friends, or clergy, he may never need professional help for this problem.

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SELECTED WEB SITES

American Psychological Association: Warning Signs of Trauma Related Stress http://www.apa.org/practice/ptsd.html

National Center for PTSD, Department of Veterans Affairs http://www.ncptsd.org/index.html

PTSD Alliance http://www.ptsdalliance.org/home2.html

Last accessed on January 7, 2004.

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SELECTED REFERENCES

Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington, D.C., American Psychiatric Association, 2000.
    Holbrook, T.: “Perceived Threat to Life Predicts Posttraumatic Stress Disorder after a Major Trauma: Risk Factors and Functional Outcome,” Journal of Trauma. 51(2):287–293, August 2001.
    Lange, J., et al.: “Primary Care Treatment of Post-Traumatic Stress Disorder,” American Family Physician. 62(5):1035–1040, September 2000.
    © 2004 Lippincott Williams & Wilkins, Inc.