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Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder

Brief description of the patient

Brief explanation of the presenting symptoms

Typical symptoms include reliving the traumatic incident, maintaining a high degree of anxiety or alertness, and a general numbing of response. The patient says she is reliving the event. “Concerning him. That evening. Everything that occurred. I see every detail, and it simply replays in my head over and again. I can’t get away from it. I awake wailing, even though I’m awake, the memory of it is still there, his breathing on my neck and his hands on my flesh. I’m having trouble breathing. I can’t… I just want it to go away, to cease…” It is typical to have intrusive recollections or nightmares about the occurrence (Townsend & Morgan, 2018). Some people may be unable to recall specific details of the experience.

According to Townsend and Morgan (2018), depression symptoms are typical with this illness and may be significant enough to earn a depressive disorder diagnosis in addition to PTSD. When the patient says, “Take a look at me. I need counseling. I’m unable to leave the house. I’m terrified of walking out the front door. I needed my father, mother, sister, and boyfriend to help me get into the car and drive me here. I know I’m cranky at home, I weep a lot, and I can’t function. And then there’s our love life, of course.” She displays possible signs of depression. Substance misuse, rage, violent conduct, and interpersonal issues are all rather prevalent symptoms of PTSD.

The whole symptom profile ought to be consistent for more than one month and impede significantly with social, occupational, and other aspects of functioning(Townsend & Morgan, 2018). “I used to work at a clothes store. I worked at a tiny store selling clothes. Not in a long time… I’d want to. It’s not like I’ve given up or am lazy. I simply cannot do it! I want to rebuild my life. Everything seems to have been stolen to me.” The condition can strike at any age. Symptoms may appear during the first three months of the incident or months or years afterward.

Medical History And Allergies

The video does not mention any allergies related to the environment, food, or drugs. The nurse needs to ask about any known food and drug allergies before commencing treatment.

Psychiatric Diagnosis

According to DSM-V, post-traumatic stress disorder falls under trauma and stressor-related disorders. My psychiatric diagnosis is Post-Traumatic Stress Disorder (PTSD). The diagnostic criteria as per the American Psychiatric Association (2013), is:

  1. Direct exposure to real or imminent death, severe accident, or sexual assault as a result of the traumatic incident. Experiencing frequent or extensive exposure to traumatic event details (s)
  2. The manifestation of the accompanying intrusive symptoms related to the traumatic event(s), commencing after the traumatic event(s) happened:
  3. Recurrent, uncontrollable, and upsetting recollections of the traumatic occurrence (s).
  4. Recurrent disturbing nightmares in which the dream’s composition effect is linked to the traumatic occurrence (s).
  5. Dissociative reactions, flashbacks in which the patient thinks or acts as if the traumatic event(s) are reoccurring.
  6. Prolonged avoidance of cues connected with the incident(s), commencing shortly after the traumatic event(s), as shown by one or both of the following:
  7. Avoiding or trying to avoid upsetting memories, thoughts, or sensations linked with or related to the traumatic event (s).
  8. Avoidance of or attempts to avoid external reminders that evoke upsetting memories, thoughts, or feelings regarding or closely related to the traumatic incident (s).
  9. Negative cognitions and mood changes related to the traumatic event(s), commencing or worsening after the traumatic event(s), as demonstrated by two (or more) of the following: 1. Persistence of an exaggeration of negative thoughts or expectations about oneself, others, or the world
  10. Persistent, erroneous beliefs regarding the cause or effects of the traumatic event(s), leading the individual to blame themself or others.
  11. Prolonged negative emotional state
  12. Significantly reduced interest or engagement in major activities.
  13. Feelings of separation or isolation from others.
  14. Inability to feel good emotions consistently
  15. Significant changes in arousal and reactivity related to the traumatic event(s), commencing or worsening after the traumatic event(s), as demonstrated by two (or more) of the following:
  16. Irritable behavior and furious outbursts (usually without provocation) exhibited as verbal or physical aggressiveness toward people or objects.
  17. Sleep deprivation
  18. Disturbance duration (Criteria  B, C, D, and E) is more than one month.

Differential Diagnosis

Disorders of adjustment The stressful event in adjustment disorders might be of any kind, as opposed to the one specified by PTSD Criterion A (American Psychiatric Association, 2013). An adjustment disorder is diagnosed when exposure to a stressor that fits PTSD Criterion A does not match all other PTSD criteria.  When the PTSD symptom pattern emerges in reaction to a stressor that does not match PTSD Criterion A, an adjustment disorder is also identified.

Acute stress disorder (ASD). Acute stress disorder differs from PTSD in that the symptom pattern in acute stress disorder is limited to 3 days to 1 month after exposure to the stressful incident.

Obsessive-compulsive disorder (OCD). There are recurring intrusive thoughts in OCD. The unwanted thoughts are not tied to a traumatic situation, compulsions are typically present, and other PTSD or acute stress disorder symptoms are usually missing. A major depressive episode. Major depression may or may not be preceded by a traumatic incident and should be recognized in the absence of other PTSD symptoms (American Psychiatric Association, 2013). Major depressive disorder, in particular, lacks any PTSD Criterion B or C symptoms. It also excludes a handful of PTSD Criterion D and E symptoms.

Suicide Risk Assessment

The five-step suicidal evaluation procedure, according to Townsend and Morgan (2018), consists of identifying risk and protective variables, conducting a suicidality inquiry, determining risk level and selecting an applicable response, and documenting the process, including a follow-up plan.

  1. Nurses must recognize risk factors for suicide. Take note of the ones that can be altered to reduce risk. The psychiatric nurse should identify the risk variables that could lead to the client committing suicide. The patient has a traumatic event, which increases the chance of suicide.
  2. Identify the protective elements. The nurse should make a note of the things that can be modified. These are critical factors in avoiding suicidal thoughts. The psychiatric nurse should analyze what provides comfort, decreases stress, emotional control, medication management to cope, and the current coping abilities of the patient (Townsend & Morgan, 2018).
  3. Carrying out a suicide investigation is the 3rd step. The nurse should evaluate the patient’s suicidal ideation, strategies, actions, and motivation. The psychiatric nurse must identify the factors that may lead to the patient’s suicidal behavior. Understanding her reasons for attempting suicide and her purposes may be beneficial. Furthermore, if the patient has previously expressed suicidal thoughts, she is more likely to carry out the plan.
  4. Determine the level of risk and the relevant course of action. Choose a suitable intervention to address and reduce risk. The patient had no plans to commit suicide. If she is contemplating suicide, the risk factors must be identified and addressed.
  5. Make documentation. Make a note of the risk assessment, justification, intervention, and follow-up.

Psychiatric Scales

The Posttraumatic Stress Disorder Checklist (PCL-5) is a self-report instrument with 20 items that correlate to the DSM-5’s 20 symptomatology of PTSD. It provides a comprehensive evaluation of the severity of PTSD both during the time of diagnosis and throughout treatment. Individual item scores on a four-point scale can be computed to provide relevant data about the intensity of the four DSM-5 symptom clusters (Ibrahim et al., 2018).

If a rating of 2 (moderate) is regarded as a positive endorsement of a given criterion, the PCL-5, in conjunction with a diagnostic interview, can be used to make a provisional DSM-5 diagnosis. Ibrahim et al. (2018) show that the PCL-5 tested with veterans, and a score of 31 to 33 was determined to be a valid cutoff for a positive screen.

  1. Medications being ordered

Paroxetine and sertraline, both selective serotonin reuptake inhibitors, are indicated for the treatment of PTSD in adults. These medications will be administered only if the patient refuses trauma-focused psychological treatment and has had little or no improvement after a course of trauma-focused psychological treatment. The first dose of paroxetine or sertraline is 20 mg/day, taken orally in the morning. It is increased if there is insufficient clinical improvement after many weeks.

The whole therapeutic impact may not be seen for five weeks or longer. A daily dose of 20 to 60 milligrams is recommended. The combined daily maximum dose of paroxetine and sertraline should not exceed 80 mg (Townsend & Morgan, 2018). All antidepressants, according to Townsend and Morgan (2018), come with a warning label. According to Townsend and Morgan (2018), the FDA includes a black-box warning concerning an increased risk of suicidality in children and adolescents with all antidepressants.

Non-pharmacological Treatments

A comprehensive trauma treatment program includes various activities such as educating patients, peer interaction, and trauma-focused psychotherapy. According to Townsend Morgan (2018), both psychoeducation and peer therapy assist patients in comprehending their feelings and emotions in the aftermath of traumatic situations. Clients are advised on how to minimize subsequent exposure to the incident, how to lessen stress reactions, and where to go for ongoing help. Clients are less prone to blame themselves and are more likely to comply with therapy if they realize that their reactions to stressful experiences are predictable.

Cognitive-Behavioral Therapy (CBT). In general, the goal of cognitive therapy is to assist clients in identifying incorrect patterns of thinking that raise the risk of depression and challenge such ideas with more accurate cognitions. This similar strategy is used in trauma treatment to target abnormalities in clients’ threat evaluation processes and to desensitize them to trauma-related stimuli (American Psychiatric Association,2013). CBT is a very successful method, including modifications such as exposure treatment and stress-inoculation training.

Medical Tests

 To ensure that the thyroid is working correctly, a complete blood count (CBC) and thyroid function test can be performed (Townsend & Morgan, 2018). Thyroid illness can affect one’s mood, creating anxiety or depression. If a patient has an underactive thyroid (hypothyroidism), they may have the following symptoms: Mild to severe exhaustion and sadness.

Questions To Further Solidify Diagnosis

Additional questions to ask include whether the patient has experienced social, psychiatric, or psychological regression, such as language loss. Auditory pseudo-hallucinations, such as hearing one’s thinking spoken, as well as paranoid ideation, can occur(American Psychiatric Association, 2013). Following severe traumatic events, the patient may also experience difficulties regulating emotions or maintaining stable interpersonal relationships, as well as dissociative symptoms, and the nurse should inquire about this as well.

Further Directives For The Patient

American Psychiatric Association (2013) shows that chronic maladaptive response to a traumatic, overwhelming experience is known as post-trauma syndrome. The nurse should review coping methods utilized in reaction to trauma, as well as those employed in stressful situations, as well as alternate options. The nurse should also include accessible support systems, such as religious and cultural influences, to assist the patient in dealing with the trauma. It is also critical to develop and practice more adaptive coping methods for potential future post-trauma responses, such as substance usage or psychosomatic responses.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596

Ibrahim, H., Ertl, V., Catani, C., Ismail, A. A., & Neuner, F. (2018). The validity of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) as a screening instrument for Kurdish and Arab displaced populations living in the Kurdistan region of Iraq. BMC Psychiatry, 18(1), 259. https://doi.org/10.1186/s12888-018-1839-z

Townsend, M., & Morgan, K. (2018). Pocket guide to psychiatric nursing, 10e. F.A. Davis.

Post-Traumatic Stress Disorder Instructions

 Week 9: Psychotherapy With Trauma and Stressor-Related Disorders
Disorders resulting from trauma are significantly different from other psychiatric-mental health issues. Unlike disorders such as schizophrenia or major depressive disorder, trauma-related disorders do not occur randomly in the population. Instead, trauma is something that occurs as a result of the lived experience of a traumatic event. According to the National Institute of Mental Health (2017), more than half of the population will experience a traumatic event during their lifetime. Although most people will recover from the trauma on their own, some require therapeutic interventions. While there are medications that can help individuals with trauma and posttraumatic stress disorder (PTSD), the foundation of treatment continues to be psychotherapy. 

This week, you explore psychotherapy for trauma by assessing a case presentation for clients presenting with posttraumatic stress disorder. You also examine therapies for treating these clients and consider potential outcomes.

Reference: National Institute of Mental Health. (2017). Post-traumatic stress disorder (PTSD). https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml

Learning Objectives
Students will:

Explain the neurobiological basis for PTSD
Apply assessment and diagnostic reasoning skills to clients presenting with posttraumatic stress disorder
Recommend therapeutic approaches for treating clients presenting with posttraumatic stress disorder
Analyze the importance of using evidence-based psychotherapy treatments for clients with posttraumatic stress disorder
Learning Resources
Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 

For reference as needed
American Psychiatric Association. (2017). Clinical practice guideline of PTSD. https://www.apa.org/ptsd-guideline

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA\'s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

Credit: Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept  of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Tye, S., Van Voorhees, E., Hu, C., & Lineberry, T. (2015). Preclinical perspectives on posttraumatic stress disorder criteria in DSM-5. Harvard Review of Psychiatry, 23(1), 51–58. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542003/

Credit: Preclinical Perspectives on Posttraumatic Stress Disorder Criteria in DSM-5 by Susannah Tye, PhD, Elizabeth Van Voorhees, PhD, Chunling Hu, MD, PhD, and Timothy Lineberry, MD, in HARVARD REVIEW OF PSYCHIATRY, Vol. 23/Issue 1. Copyright 2015 by ROUTLEDGE. Reprinted by permission of ROUTLEDGE via the Copyright Clearance Center.

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

Chapter 3, “Assessment and Diagnosis” (Previously read in Week 2)
Chapter 7, “Eye Movement Desensitization and Reprocessing Therapy”
Chapter 11, “Trauma Resiliency Model Therapy”
Chapter 15, “Trauma-Informed Medication Management”
Chapter 17, “Stabilization for Trauma and Dissociation”
Chapter 18, “Dialectical Behavior Therapy for Complex Trauma”
Required Media (click to expand/reduce)

Grande, T. (2019, August 21). Presentation example: Posttraumatic stress disorder (PTSD) [Video]. YouTube. https://www.youtube.com/watch?v=RkSv_zPH-M4

Gift from Within. (Producer). (2008). PTSD and veterans: A conversation with Dr. Frank Ochberg [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/ptsd-and-veterans-a-conversation-with-dr-frank-ochberg

Assignment: Posttraumatic Stress Disorder

Photo Credit: Getty Images/iStockphoto

It is estimated that more almost 7% of the U.S. population will experience posttraumatic stress disorder (PTSD) in their lifetime (National Institute of Mental Health, 2017). This debilitating disorder often interferes with an individual’s ability to function in daily life. Common symptoms of anxiousness and depression frequently lead to behavioral issues, adolescent substance abuse issues, and even physical ailments. For this Assignment, you examine a PTSD video case study and consider how you might assess and treat clients presenting with PTSD.

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide about diagnosing and treating PTSD.
View the media Presentation Example: Posttraumatic Stress Disorder (PTSD) and assess the client in the case study. 
For guidance on assessing the client, refer to Chapter 3 of the Wheeler text.
Note: To complete this Assignment, you must assess the client, but you are not required to submit a formal comprehensive client assessment.

The Assignment
Succinctly, in 1–2 pages, address the following:

Briefly explain the neurobiological basis for PTSD illness.
Discuss the DSM-5 diagnostic criteria for PTSD and relate these criteria to the symptomology presented in the case study. Does the video case presentation provide sufficient information to derive a PTSD diagnosis? Justify your reasoning. Do you agree with the other diagnoses in the case presentation? Why or why not?
Discuss one other psychotherapy treatment option for the client in this case study. Explain whether your treatment option is considered a “gold standard treatment” from a clinical practice guideline perspective, and why using gold standard, evidence-based treatments from clinical practice guidelines is important for psychiatric-mental health nurse practitioners.
Support your Assignment with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

By Day 7
Submit your Assignment. Also attach and submit PDFs of the sources you used.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK9Assgn+last name+first initial.(extension)” as the name.
Click the Week 9 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 9 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:

Week 9 Assignment Rubric

Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:

Submit your Week 9 Assignment draft and review the originality report.

Submit your Assignment by Day 7
To Participate in this Assignment:

Week 9 Assignment

What’s Coming Up in Week 10?