INTRODUCTION
The diagnosis of posttraumatic stress disorder (PTSD) first appeared in 1980 in the third edition of diagnostic and statistical manual of mental disorders (DSM-III). It underwent some revision in 1987 in the revised third edition (DSM-III-R). The fourth edition (DSM-IV) defineor they it in six parts: (1) the person must have experienced, witnessed, or been confronted with an event in volving death, serious injury, or a threat to the physical integrity of the self or others. (2) the traumatic event must be persistenly reexperienced in the form of distressing imegs, thoughts, perception, dreams, or reliving; intense psychological or physiological reactivity may also be present on being reminded of the event. (3) persistent avoidence of stimuli associated with the trauma and numbing of responsiveness must be present since the trauma. (4) persistent symptoms of increased arousal should be present since the trauma. (5) duration should be at least four weeks. (6) the distrubance sholud cause clinically significant distress in social, accupational or other important areas or functioning.
EPIDEMIOLOGY
A number of studies have examined the prevalence of PTSD; they can be grouped into studies of community populations and studies of high risk groups exposed to a trauma. The epidemiological studies take into account nontreatment-seeking populations, since treatment seekers are probably atypical for the disorder. For example, one researcher noted that only 1 out of 20 comumunity-based cases had received psychiatric treatment.
The most widely used instrument, the diagnostic interview svhedule (DIS), may have underestimated the prevalence of PTSD, although a recent modification probably yields a sensitive and accurate estimate. Studies using the old version of the DIS suggest a lifetime prenalence in the 1 to 3 percent range; an additional 6 to 14 percent of the population have experienced subclinical forms of the disorder and a life time 39 percent prevalence of exposure to a traumatic event.
Among population who were chosen on the basis of expesure to a stressor, lifetime prevalence rates for PTSD range from 3,6 to 75 percent with various instrument. The national vietnam veterans readjustment study, in many ways a model epidemiological study found lifetime rates for PTSD to be 30 percent for male vietnam theater veterans and 26 percent for female vietnam theater veterans. An additional 22 percent of veterant had experienced partial or subclinical forms of PTSD.
Early reports showed high rates of psychiatric morbidity after exposure to extreme trauma. Unfortunately, those studies cold not apply contemporary diagnostic criteria for PTSD, so it is unclear just what the prevalence of the disorder would have been. However, reports were almost certainly describing states akin to PTSD. Included in the reports were an 85 percent prevalence of concentration camp syndrome in survivors of nazi death camps and a 100 percent prevalence of some from of psychopathology. Fifty-seven percent (26 out 46 survivors) had psychiatric complication after the 1941 coconut grove nightclub fire. Those early studies were important in highlighting the heavy toll taken after exposure to disaster.
Clearly, PTSD is common, as are traumatic stressors, using the DSM-IV definition; those events as a group are not outside normal human experience.
ETIOLOGY
PTSD is one of only a few disorder in DSM-IV that is defined by its cause. Without a stressor, the disorder cannot exist, but the trauma is not sufficient; many traumatized paople do not have the disorder. The relative importence and teh predisposing elements of the trauma are not clearly understood; the same is true for other causative factors. An interactive relation may exist between one event and one victim. At all events, no model of the cause of PTSD would be complete unless it took into account pretrauma (that is, personal vulnerability), trauma (stressor characteristics), and posttrauma variabels.
STRESSORS A consistent relation emerges between the magnitude of the stress exposure and the risk of PTSD. The relationholds true across several kinds of trauma, including combat, homicidal crime, and sexual trauma. No evidence suggests that a certain threshold of severity must be met, not does good evidence suggest that low magnitude stress (for example, divorce, loss of income, chronic illnes inthe family) gives rise to PTSD to any appreciable axtent.
Besides the events involving actual or threatened death or injury or a threar to the physical of the self or others, cognitive appraisal factors ae probably important. For example, one study noted that a rape victim’s perception of being in a safe place at the time of the assault predicted high levels of symptomps. The experience of being intensely afrai, helpless, or horrified is alikely risk factor. Extreme shame or guilt may also be a risk factors, as in participants in a brutal atricity.
ASSESMENT
Because client with anxiety disorder are consumed by the need to keep anxiety at manageable levels, they have little time or energy to devote to personal growth or to developing mutually satisfying relationship with others. In fact, these people usually develope inflexible and maladaptive patterns of relating to people. Two of the more common patterns are:
1. exhibiting excessive dependence on others and
2. using tactics to distance one’s self from others.
Assessment should consist of the collection of physical, psychological, and social data. Anxiety is a mental and physical condition. With major symptoms resulting from stimulation of the autonomic nervous system. Therefore, before an anxiety disorder can be diagnosed, the clinican must rule out organic causes of anxiety (Dubin and Weiss 1991):
· Abouse of alcohol or drugs
· Symptoms that began in respons to an illness
· Side effect from prescribed medications
Specifict symptoms should be noted, along with statements made by the client about his or her subjective distress. The nurse must use clinical judgement to determine the level of anxiety the client is experiencing. External and internal stressors should be identified, if possible, and and the degree to which the clients life is disurpted should be evaluated. Because client with anxiety disorder usually remain in contact with reality, they are often able to collaborate, to some extent, with the nurse during the assessment. Suggestion for the kind of questions the nurse can ask in order togather and assess physical, psychological. The data collected about behaviors exhibited by individuals with anxiety disorder are usually markedly different from data collected about individuals with psychoses.
People who are experiencing anxiety disorder often resort to the use of ego defens mechanisms being employed and the pupose they serve should be determined. Although it is difficult to pose specific questions to assess the use of deffense mechanisms, their use may become apparent to the nurse durring the course of interviews and observations.
Although violence is exhibited by only a small number of clients, the nurse must be aware that very high levels of anxiety may evoke the “fight-or flight” response the nurse must, therefore, assess the risk for aggression as well as for suicide. High levels of anxiety can be a debilitating illness, even resulting in a complete inability to function (Gold 1992). Suicide is often a possibility, and some belive that individuals with panic disorder may have as high a risk for suicide (or higher) as those with major depressions (weissman et al 1989).
NURSING DIAGNOSIS
Several nursing diagnoses should be considered for clients experiencing anxiety and ego-dystonic behaviors associated with anxiety reduction. Several etological statements may be used for a nursing diagnosis of anxiety, including anxiety related to
- Exposure to phobic object
- Threat to self-concept
- Actual or perceived loss of significant other
- Actual or perceived change in socioeconomic status
NURSING ASSESSMENT: ANXIETY DISORDERS
| ASSESSMENT | | DATA-GATHERING STRATEGIES |
| | Physical parameters | |
| Presence of anxiety Potential to flee or fight Impact of anxiety on physical functioning | | “tell me what you are experiencing” Observe appearance, behavior, posture, gait, and expression. Moniture pulse, respiration, sleep patterns, elimination, appetite, and energy level. |
| | Psychological parameters | |
| Understanding of illness Mood Self-esteem Normal coping ability Defense mechanisms used Thought content or process Potential for suicide | | “what problem bring you here?” “did this problem occur suddenly or over a period of time?” “described how you are feeling” observe affect. “how do you feel about your self?” “what do you like and dislike about your self?” “when you experience stress, what do you do to decrease it?” Observe and listen during interview. Note distractibility and vigilance. Note circumstantiality (many digressions before eventually concluding a thought) and blocking (sudden stopping of speech due to anxiety) “are you preoccupied with any idea?” “does one thought repeatedly force itself into awareness?” “do you have any especially strong fears?” If a client indicates feeling hopeless, helpless, or worthless, investigate whether he or she has considered suicied. |
| | Social parameters | |
| Characteristic patterns of relationships Identification of stressors or threats to self-concept, role, values, social status, or supprt system Ability to function Degree of strain in relationships Secondary gains Diversional activity | | “describe your relationship with family/friends/peers” What do you think night be causing this problem?” “what changes occured in your life this past year?” “how is this problem interfering with your life?” Investigate effects on work, school,churh, hobbies, social activities, and sexual functioning. “desribe any strain on relationship with others this problem has caused.” “how has this problem changed your relationship with?” Note benefits to client as result of symptoms. “what do you like to do for fun or recreation?” |
- Changed in status and prestige
- Lack of recognition from others
- Interference with ability to perform compulsions
Ineffective individual coping is anursing diagnosis that may also have several different etiologies, such as
- Execissve negative beliefs about self
- Inadequate psychological resources
- Unsatisfactory support system
- Hypervigilance related to sever anxiety
- Sever or panic level anxiety
- Ineffective use of defense mechanisms
- Compulsions related to need for excessive cleanliness
- Resistiveness associated with compulsivity
The diagnosis of alteration in thought proceses as a result of sever or panic levels of anxiety must also beconsidered multiple etiologies exist, and some are listed blow.
- Inability to understand directions
- Pathological use of defense mechanisms
- Excessive use of reason and logic related to overcaitiousness and fear of making a mistake
- Preoccupation with obsessive thought
- Disorganized thinking related to intense fear of a specific object, person or situation
In disturbance in self-estem, low self-esteem is nearly always present and may be related to inability to control ego-dystonic symptoms or to other reason powerlessness related to inability to control symptoms may also be an appropriate diagnosis. A diagnosis of altered role performance is possible when assessment reneals inability assume responsibilites associated with usually roles. Risk for alterations in health maintenance may also be related to phobias if ritualistic behaviour or excessive caution prevents the individual from seeking health care.
PLANNING
Planning occurs on two levels:
- The content level-planning goals and
- The process level-dealing with nurses reactions and feelings.
NURSING DIAGNOSES: ANXIETY DISORDERS
| NURSING DIAGNOSIS | POSSIBLE GOAL AND OUTCOME CRITERIA |
| Anxiety related to unexpected panic attack or related to re-experiencing traumatic events Ineffective individual coping related to excessive anxiety (related to distorted cognitive perception of problem) Disturbance in self-esteem related to shame or guilt Disturbance in self-esteem related to change in role performance Altered thought processess related to severe anxiety Diversional activity deficit related to preoccupation with symptoms Social isolation related to avoidance behavior, or related to shame associated with symptoms Knowledge deficit related to disfunctional appraisal of situation Sleep-pattern disturbance related to physiologic symptoms of anxiety Self-care deficit related to ritualistic behavior Altered nutrition (less than body requirements) related to inability to stop performance of rituals Impaired skin integrity related to ritulas of excessive washing or excessive picking at the skin. | Client will demonstrate psychological and physiological comfort by (date). As evidenced by
Client will employ aternative coping resources by (date). As evidenced by
Client will demonstrate improved self-esteem by (date). As evidenced by
Client will employ ability to perform in usual roles at premorbid level by (date). As evidenced by
Client will demonstrate abillity to concentrate by(date) Client will report absence of obsessive thoughts by (date) Client will report experiencing and will exhibit, mild to moderate anxiety in presence of phobic object by (date) Client will use leisure time constructively by (date). As evidenced by
Client will increas interaction with others by (date). As evidenced by
Client will state relationship between anxiety and the developing of his or her symptoms by (date) Client will express satisfaction with rest-sleep pattern by (date). As evidenced by
Client will appear rested by (date). As evidenced by
Client will independently perform bathing. Hygiene, grooming, and dressing tasks by (date). As evidenced by clean, appropriate appearance. Client will maintain ideal body weight ± 10 pounds.as evidenced by weekly weight graph. Client’s skin will be intact. As evidenced by
|
DIAGNOSIS AND CLINICAL FEATURES
In the immediate aftermath of trauma, a polymorphic symptomp picture may emerge; the full complex of PTSD may not appear until several weeks later. A marked level of dissociation may be seen within the first few days of exposure to an extreme trauma, giving rise to the clinical diagnosis of acute stress disorder, which was introduced in DSM-IV for the first time. In other instance no clear-cut symptoms may emerge untill some later time, when PTSD appears as a dealayed response. Yet other manifestations may develop in which only some elements of PTSD appear, such as intrusive and arousal symptomps.
The stressor must meet two criteria:
- Be life-threatening or associated with serious injury or threat in physical integrity; and
- Evboke instense fear, helplessness, or horror in the victim.
Symptomp are grouped into three categories:
- Intrusive, painfull, persistent, and recurrent reexperiencing of the trauma (the B criteria);
- Persistent avoidance of stimuli associated with the trauma and numbing of general responsivenness ( the C criteria); and
- Persistent increased arousal that was not present before the trauma (the D criteria). Besides being conversant with the symptoms themselves, an assessor of PTSD must pay attention to the qualifying adjectives: “persistent” “recurent,” and “diistressing.” The assessor must also decide whether or not numbed responsiveness and hyperarousal occurred subsequent to the trauma. In cases of chronic PTSD and in cases of early traumatization, arriving at such judgements is not easy; indeed the validity of such a construct can be questioned when traumatic events like incest and childhood abuse were the causes of PTSD. Unless proper attention is given to those point, PTSD may be overdiagnosed.
DIFFERENTIAL DIAGNOSIS
GENERALIZED ANXIETY DISORDER The hyperarousal symptoms described in the D criteria set are similar to those present in generalized anxiety disordrer, but that disorder lacks a traumatic origin and the intrusive symptoms found in criteria B. Nonetheless, if any anxious patient present with ready startle, remains on guard, and does not responds to the usual measures for generalizaed anxiety disorder, the clinician should consider a diagnosis of PTSD.
DEPRESSION Depressive features of reduced interest, estrangement, numbing, poor concertation, and insomnia occur in PTSD. Intrusive trauma-bound symptoms are not a feature of depression. However, after exposure to trauma, posttraumatic reactions are seen, and the clinician needs to address the traumatic component. Polysomnigraphs and neuroendocrine studies may help in the differential diagnosis of PTSD and major depressive disorder.
PPANIC DISORDER Panic attacks resemble the autonomic hyperactivity in PTSD (criteria D). To distinguish the two, the interviewer should establish whether the panic attacks are related to the trauma or to remainders of it.
OBSESSIVE-COMPULSIVE DISORDER PTSD and obsessive-compulsive disorder both share the occurrence of repetitive, distressing recollections, images, or thoughts. To distinguish between the two this orders, the clinician must ontain a careful history, asking about the occurrence oof the trauma and establishing whether the intrusive phenomena are thematically linked to the event.
DISSOCIATIVE DISORDERS Plashbacks, numbing, and amnesia may suggest dissoceative disorder. When those symptoms are prominent or presenting features, the clinician must elicit a clear history of the additional intrusive, avoidant, and hyperarousal features that occur in PTSD but not in dissociative disorder.
BORDERLINE PERSONALITY DISORDER The diagnosis of borderline personality disorder is often made when PTSD is a more appropriate diagnosis or, at least, anecessary concomitan diagnosis. A clinican who makes the diagnosis of borderline personality disorder must inquire further into possible early trauma and ensuing symptoms.
MEDICAL DISORDERS After a patient sustains a head injury, the clinican must evalute the degree of any brain damage and its possible contribution to some of the symptoms (for example, impaired memory and concentration, hyperarousal, dissociative symptoms). Close collaboration with a neurologist is advisable.
The clinican should also clarify the role of alcohol or psychoactive substance intoxication and with drawal, since those disorder can aggravate PTSD symptomps.
FACTITIOUS DISORDER PTSD must sometime be distinguished from factitious disorders. Helpful clues are corroborative evidence that a trauma did occur and that the patient is ussualy distressed about the trauma and often reluctant at first to discuss its details. Factitious symptoms often vary in response to the immediate environment.
MALINGERING The clinician should evaluate the parameters of factitious disorder. Moreover, the motivational factors for malingering are usulay quite clear.
COURSE AND PROGNOSIS
In the immediate aftermath of a trauma, a high percentage of persons have acute stress disorder or a similiar set of symptoms. Those reactions are normally short-lived, but, by one month after the traumatic event, 70 to 90 percent of the victims may show the full symptom picture of PTSD. Such findings have been reported, for example, in rape victims.
About 30 percent of patients recover completely, 40 percent continue to have mild symptoms, 20 percent continue to have moderate symptoms, and 10 percent remain unchanged or become worse. Relative proportions of the intursive, avoidant, and hyperarousal symptoms vary over time. The intrusive features may be prominent initially, with the avoidant features becoming prominent later. During worl war II the observation was made that marked startle and hypervigilance when persisting beyond the acute reaction, despite treatment was a sign of relatively poor prognosis.
Unfortunately, the passage of time does not always bring with it automatic improvement, and symptoms often worsen with age. Particular symptoms that increase with the time include startle, nightmares, irritability, and depression.
DELAYED-ONSET POSTTRAUMATIC STRESS DISORDER
Although delayed-onset PTSD is rare, its existence is clearly established in a variety of victims groups. it is particularly well described among veterans of combat and victims of early sexual trauma. for reasons not fully understood, the disorder may arise de novo as long as 30 to 40 years after the trauma. in such cases an inciting trigger may activate unresolved aspects (unintegrated memories) of the original trauma. in other cases coping mechanisms, such as working and physical activity, may have succesfully allowed denial; when those mechanisms are no longer available, because of retirement of physical illness, the memories appear. in addition, PTSD usually coexists with other psychiatric disorder; activation of the comorbid state can activate PTSD.
| Nursing intervention | Rationale |
| Involve the client in decisions about the client’s care and treatment.
| This involvement helps foster feelings of empowerment, control, and confidence in the client rather than feelings of being a helpless victim of external effects. |
| Engage the client in group therapy session with other Client with posttraumatic stress disorder when the client is ready for the group process | The group process provides additional support and understanding though involvements with other who may have similiar problems. Also, seeing the success of other gives hope to the client. |
| Promote the client’s awareness of his or her own avoidance of experiences similiar to the traumatic event | Awareness gives the client the oppurtunity to integrate the past traumatic event into present and future life experiences without fear or apprehension. |
| Provide realistic feedback and praise whenever the client attempts to use learned strategis to manage anxiety and reduce posttraumatic stress response.
| Positive reinforcement promotes self-esteem and gives the client the confidence to continue working on the treatment plan. |
| Assist the client and family to develop realistic life goals (school, work, community, and leisure activities) | The client and family will be better prepared for a hopeful future that will absorb and alleviate the posttraumatic streess response. |
EVALUATION
Ø Evaluation of outcome criteria is a critical method that determiners:
· Client (individual, family, community) progress and response to treatment
· Effective use of the nursing process
· Accoutability for the nurse’s standards of care
Ø Evaluation is dynamic and may be used at any stage of the nursing process.
REFERENCE
- Kaplan, Sadock, B. 1995. Comprehersive Text Book of Psychiatry (6th edition), vol 1. Maryland: william anf wikirs
- Haladay W, fartinash. 2007. Psychiatriy nursing care plans (5th ed). Philadelphia: mosby Elsevier
- M. varcarolis, Elizabeth. 1994. Foundation of psychiatic: Mental health nursing. Philadelphia: W.B saunders compary.
- http://www.athealth.com/Practitioner/ceduc/parentingstyles.html(parrenting)
- http://pendidikankita.com/?content=article_detail&idb=38
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