I. What is PTSD?

Post traumatic stress disorder (PTSD) is a disturbing pattern of behavior

demonstrated by someone who has experienced, witnessed, or been confronted with a
traumatic event such as a natural disaster, combat, or an assault. A person with PTSD
was exposed to an event that posed actual or threatened death or serious injury and
responded with intense fear, helplessness, or terror.

Below is “Life Events Checklist” that is used to screen individuals with a history
of exposure to some type of trauma.
Life Events Checklist:
Clinical Course

The four subcategories of symptoms in PTSD include reexperiencing the trauma

through dreams or recurrent and intrusive thoughts, avoidance, negative cognition or
thoughts, being on guard, or hyperarousal. The person persistently re-experiences the
trauma through memories, dreams, flashbacks, or reactions to external cues about the
event and therefore avoids stimuli associated with the trauma. The victim feels a
numbing of general responsiveness and shows persistent signs of increased arousal
such as insomnia, hyperarousal or hypervigilance, irritability, or angry outbursts. He or
she reports losing a sense of connection and control over his or her life. This can lead to
avoidance behavior or trying to avoid any places or people or situations that may trigger
memories of the trauma. The person seeks comfort, safety, and security, but can
actually become increasingly isolated over time, which can heighten the negative
feelings he or she was trying to avoid. Box 13.2 is the PTSD Checklist that details many
of the symptoms people experience.

In PTSD, the symptoms occur 3 months or more after the trauma, which
distinguishes PTSD from acute stress disorder, which may have similar types of
symptoms but lasts 3 days up to 1 month. The onset can be delayed for months or even
years. Typically, PTSD is chronic in nature, though symptoms can fluctuate in intensity
and severity, becoming worse during stressful periods. Often, other life events can
exacerbate PTSD symptoms. In addition, many clients with PTSD develop other
psychiatric disorders, such as depression, anxiety disorders, or alcohol and drug abuse.
PTSD can occur at any age, including during childhood. Estimates are that up to
60% of people at risk, such as combat veterans and victims of violence and natural
disasters, develop PTSD. Complete recovery occurs within 3 months for about 50% of
people. The severity and duration of the trauma and the proximity of the person to the
event are the most important factors affecting the likelihood of developing PTSD. One-
fourth of all victims of physical assault develop PTSD. Victims of rape have one of the
highest rates of PTSD at approximately 70%.

Etiology
PTSD and acute stress disorder had long been classified as anxiety disorders,
though they differ from other diagnoses in that category; they are now classified in their
own category. There has to be a causative trauma or event that occurs prior to the
development of PTSD, which is not the case with anxiety disorders, discussed further in
PTSD is a disorder associated with event exposure, rather than personal
characteristics, especially with the adult population. In other words, the effects of the
trauma at the time, such as being directly involved, experiencing physical injury, or loss
of loved ones in the event, are more powerful predictors of PTSD for most people.
This is particularly true of single-event trauma, or triggering event, such as
natural disasters. However, lack of social support, peri-trauma dissociation, and
previous psychiatric history or personality factors can further increase the risk of PTSD
when they are present pretrauma (Lies, Lau, Jones, Jensen, &
Tan, 2017).
In addition, people who participate in posttrauma counseling right after the event
decrease their risk of PTSD. Studies of adolescents with PTSD indicate they are more
likely to develop PTSD than children or adults. Age, gender, type of trauma, and
repeated trauma are related to increased PTSD rates. Adolescents with PTSD are at
increased risk for suicide, substance abuse, poor social support, academic problems,
and poor physical health. Trauma-focused CBT is beneficial and can be delivered in
school or community-based settings. It also has positive long-term effects both with
PTSD and other comorbid conditions (Gutemann, Schwartzkopff, & Stell, 2017). PTSD
may disrupt biologic maturation processes contributing to long-term emotional and
behavioral problems experienced by adolescents with this disorder that would require
ongoing or episodic therapy to deal with relevant issues.

II. How will you know a client has PTSD?

The following criteria apply to adults, adolescents, and children older than 6 years. For
children 6 years and younger, see the following corresponding criteria.

A. Exposure to actual or threatened death, serious injury, or sexual violence in

one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing in person the event(s) as it (they) occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or a close
friend. In cases of actual or threatened death of a family member or friend, the event(s)
must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television,
movies, or pictures unless this exposure is work-related.

B. Presence of one (or more) of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the

traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or effect of
the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels
or acts as though the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s),

beginning after the traumatic event(s) occurred, as evidenced by one or
both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or

feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or
the world (e.g., “I am bad,” “No one can be
trusted,” “The world is completely dangerous,” “My whole nervous system is
permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of
the traumatic event(s) that lead the individual to blame him or
herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in significant
activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation)

typically expressed as verbal or physical aggression toward people
or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless
sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance

(e.g., medication, alcohol) or another medical condition.

Children are more likely to develop PTSD when there is a history of parental
major depression and childhood abuse. Psychopathology in the parents results in a
stress-laden environment for the child and is much more likely to end in a PTSD
diagnosis. These risks are diminished when post event counseling occurs soon after the
trauma. Parental participation in treatment significantly enhances the benefits of CBT for
traumatized children. It also improved depressive symptoms commonly.

III. Explain the psychotherapy treatment of PTSD which includes

Cognitive Therapy, Exposure Therapy, and EMDR.
Treatment

Counseling or therapy, individually or in groups, for people with acute stress

disorder may prevent progression to PTSD. Therapy on an outpatient basis is the
indicated treatment for PTSD. There are some medications that may also contribute to
successful resolution, especially when targeting specific issues, such as insomnia. A
combination of both therapies produces the best results (Greenbaum, Neylan, & Rosen,
2017). Inpatient treatment is not indicated for clients with PTSD; however, in times of
severe crisis, short inpatient stays may be necessary. This usually occurs when the
client is suicidal or is being overwhelmed by reexperiencing events, such as flashbacks.
S
 CBT and specialized therapy programs incorporating elements of CBT are
the most common and successful types of formal treatment. The choice of therapy
can depend on the type of trauma, as well as the choice to seek formal individual or
group counseling. Self-help groups offer support and a safe place to share feelings.

Exposure therapy is a treatment approach designed to combat the avoidance

behavior that occurs with PTSD, help the client face troubling thoughts and feelings,
and regain a measure of control over his or her thoughts and feelings. The client
confronts the feared emotions, situations, and thoughts associated with the trauma
rather than attempting to avoid them.

Various relaxation techniques are employed to help the client tolerate and
manage the anxiety response. The exposure therapy may confront the event in reality,
for example, returning to the place where one was assaulted, or may use imagined
confrontation, that is, mentally placing oneself in the traumatic situation. Prolonged
exposure therapy has been particularly effective for both active military personnel and
veterans (Horesh, Qia, Freedman, & Shalev, 2017).

Adaptive disclosure is a specialized CBT approach developed by the military to

offer an intense, specific, short-term therapy for active-duty military personnel with
PTSD. It incorporates exposure therapy as well as the empty chair technique, in which
the participant says whatever he or she needs to say to anyone, alive or dead. This is
similar to techniques used in Gestalt therapy. Despite the short six-session format, this
approach seems well tolerated and effective in reducing PTSD symptoms and
promoting posttrauma growth (Yeterian, Berke, & Litz, 2017).

Cognitive processing therapy has been used successfully with rape survivors
with PTSD as well as combat veterans. The therapy course involves structured sessions
that focus on examining beliefs that are erroneous or interfere with daily life, such as
guilt and self-blame; for example, “It was my fault, I should have fought harder” or “I
should have died with my fellow Marines;” reading aloud a written account of the worst
traumatic experience; recognizing generalized thinking, that is, “No one can be trusted;”
and regaining more balanced and realistic ways of appraising the world and
themselves (Stayton, Dickstein, & Chard, 2018).

Community-Based Care
Most care provided to people in the aftermath of traumatic experiences is done on an
outpatient basis. Individual therapy, group therapy, and self-help groups are among the
most common treatment modalities. In addition, both clients and families can implement
many self-care interventions to promote physical and emotional well-being. These
suggestions are discussed in “Client
and Family Education.”

CLIENT AND FAMILY EDUCATION

• Ask for support from others.
• Avoid social isolation.
• Join a support group.
• Share emotions and experiences with others.
• Follow a daily routine.
• Set small, specific, achievable goals.
• Accept feelings as they occur.
• Get adequate sleep.
• Eat a balanced, healthy diet.
• Avoid alcohol and other drugs.
• Practice stress reduction techniques.

Mental Health Promotion

It is not possible to avoid many of the traumatic events in life that can potentially
cause mental health problems. Natural disasters such as earthquakes and hurricanes
are beyond human control. It is also not possible to avoid all the man-made traumatic
events that occur; people have been victims of trauma while shopping, watching a
movie, or during any other ordinary daily activity. One of the most effective ways of
avoiding pathologic responses to trauma is effectively dealing with the trauma soon
after it occurs.
In addition to first aid responders for disastrous events, counselors are often
present to help people process the emotional and behavioral responses that
occur.
Some people more easily express feelings and talk about stressful, upsetting, or
overwhelming events. They may do so with family, friends, or professionals. Others are
more reluctant to open up and disclose their personal feelings. They are more likely to
ignore feelings, deny the event’s importance, or insist “I’m fine; I’m over it.” By doing
that, they increase the risk of future problems such as PTSD.

It is essential to have an accurate diagnosis of PTSD. Stress immediately after

an event is acute stress disorder, while PTSD is delayed in onset. Some individuals will
report “having PTSD” but are self-diagnosed. They may have autism spectrum disorder,
a grief reaction, or any variety of problems. Effective treatment is possible only with
accurate, professional diagnosis.

Short Hospital Treatment for Survivors of Trauma and

Abuse

Clients with PTSD and dissociative disorders are found in all areas of health
care, from clinics to primary care offices. The nurse is most likely to encounter these
clients in acute care settings only when there are concerns for personal safety or the
safety of others or when acute symptoms have become intense or overwhelming and
require stabilization. Treatment in acute care is usually short-term, with the client
returning to community-based treatment as quickly as possible.
IV What medications are used for PTSD?
Medications may be used for clients with PTSD to deal with symptoms such as
insomnia, anxiety, or hyperarousal. Studies show that selective serotonin reuptake
inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor antidepressants
are most effective, followed by second- generation antipsychotic, such as risperidone.
Evidence is lacking for the efficacy of benzodiazepines, though they are widely
used in clinical practice (Friedman & Bernardy, 2017). A combination of medications and
CBT is considered to be more effective than either one alone.