Post Traumatic Stress Disorder

Aria Hospital School of Nursing

Abstract
Post traumatic stress disorder is a severe anxiety disorder that affects “5 million people each year,” (Valente, 2010). PTSD effects more women than, with approximately 58% of at risk individuals including combat veterans. If left untreated, PTSD leaves those affected with quality of life issues, social interactions, daily functioning, and psychological issues. Over the years, there has been an increase in the awareness of post traumatic stress, and the impact of its diagnosis, (Bastien, 2010). Treatment relies on a multidimensional approach, including supportive patient education, cognitive therapy, and psychopharmacology. This paper will review PTSD, including clinical manifestations, diagnosis, medical and nursing management and community resources available to those affected by this disease.

Description of Disease
“Posttraumatic stress disorder (PTSD) is an anxiety disorder with a sustained and dysfunctional emotional reaction to a traumatic event, threat of injury or death, and pain,” (Valente, 2010). A traumatic event can be military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault. Most people who are exposed to a traumatic event will have stress reactions for the immediate days or weeks following the incident, however with some time will be able to deal with the event and return to normal. However, some people will have stress reactions that do not go away on their own and may even worsen with time. These individuals are at risk for developing PTSD.
Post traumatic stress disorder became a formal diagnosis in the 1980s, however was recognized as early as the American Civil War when combat veterans were referred to as suffering from “soldier’s heart.” After serving in wars, many returned home deeply traumatized, which led to systemic descriptions of the symptoms under names such as “shellshock” and “combat fatigue.”
Clinical Manifestations
Although symptoms may occur immediately following the experience, to be formally diagnosed, “the precipitating traumatic event must have occurred at least 3 months prior to assessment,” (Gill, Saligan, Henderson, & Szanton, 2009). The individual must also have three different types of symptoms, re-experiencing symptoms, avoidance and numbing symptoms, and hyper arousal symptoms.
Re-experiencing symptoms involve reliving the traumatic event. The patient may have recurring memories of the event, nightmares of the event, intense fear, anxiety or physical discomfort when they are reminded of the event or flashbacks of the event. Avoidance and numbing symptoms are efforts individuals make to avoid the event or situations that may trigger memories of the event. They may avoid people, places or things that remind them of the event. They may find it difficult to be in touch with their feelings or express emotions towards other people. They may become less interested in activities they once enjoyed, and may even think they will have a shortened life span and will not reach personal goals such as a career or a family. Hyper arousal symptoms can cause difficulty sleeping, difficulty with concentration and outbursts of anger. They may feel that they are more attentive and always read to react, or that they get startled easily.
Diagnosis
Diagnosing patients with PTSD is often difficult and can be unrecognizable at times. PTSD is unique among psychiatric disorders because it is not only identified by symptoms, but also by the traumatic event that occurred prior to the symptoms. “Patients who have experienced a traumatic event may be guarded, defensive, and unwilling to talk about it,” (Gill, Saligan, Henderson, & Szanton, 2009), which can make it difficult to make an accurate diagnosis.
Mental health professionals have come up with specific requirements that must be met to get a diagnosis of PTSD. “The APA endorses case evaluation on a multiaxial system, to facilitate comprehensive and systematic evaluation with attention to the various mental disorder and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem,” (Townsend, 2006). Individuals are assessed based on a five axis different dimensions, including clinical syndromes, personality and mental retardation, general medical conditions, psychosocial and environmental problems and global assessment and functioning.
A Primary Care PTSD Screen (PC-PTSD) is a 4-item screen that was designed for use in primary care and other medical settings and is currently used to screen for PTSD in veterans at the VA. This screening tool is a four item screen that includes an introductory sentence to cue respondents to traumatic events. It is suggested that if a patient answers “yes” to any 3 of the 4 items, it is a positive screen and to here is a need for follow up. “A positive result automatically triggers a consult by a provider who has been trained to conduct a protocol-directed examination,” (Wieland, Hursey, & Delgado, 2010).
Medical Management
“Effective treatment strategies involve a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and psychosocial and medication treatments,” (Valente, 2010). Psychotherapy can be useful in treating many psychological disorders including PTSD. Patients tend to have a decrease in anxiety when able to openly discuss their mental health concerns. Psychotherapists’ help patients learn about their condition, as well as how to cope with it. Cognitive therapy is used to determine how the individual responds to certain situations. “Cognitive therapy is very structured and orderly, which is important for the anxious client who is often confused and lacks self-assurance,” (Townsend, 2006). Behavior therapy has two common forms, systematic desensitization and implosion therapy. Systematic desensitization consists of gradually exposing the patient to fearful situations, after they have mastered the art of relaxation. Implosion therapy is similar to systematic desensitization; however relaxation is not a part of this therapy.
In addition to psychological therapy, pharmacological therapy may also be needed. Serotonin reuptake inhibitors (SSRIs) are the first line medications used in PTSD. “The FDA has only approved the SSRIs paroxetine (Paxil) and sertraline (Zoloft) for use in treating PTSD,” (Gill, Saligan, Henderson, & Szanton, 2009). Tricyclic antidepressants and MAO inhibitors have also been found to be effective in treating PTSD. In addition to antidepressants, patients may be prescribed mood stabilizers, anti-anxiety medications, adrenergics, and atypical psychotics. These additional medications must be selected based on the patient’s presenting symptoms.
Nursing Management
It is important to recognize the increasing awareness of PTSD in men and women returning from our ongoing ware as well as our veterans. Providing nursing care to the patients who suffer from PTSD can be difficult, especially if the person shows an extremely apprehensive response to treatment. Patients suffering from PTSD need to be treated with the fullest care and respect, as their extreme responses may not be directly related to the treatment, but to the memories associated to the trauma they experienced.
Patients suffering with PTSD are likely to experience ineffective coping, ineffective role performance, and dysfunctional grieving. Throughout the interview process and treatment phase, it is important for the nurse to implement certain interventions to establish a therapeutic relationship and reach specified outcomes. Townsend mentions several nursing interventions that should be included in the plan of care. Assigning the patient to the same staff member as often as possible, using a nonthreatening, matter-of-fact, but friendly approach, and being consistent as well as spending time with the patient facilitate a trusting relationship. It is important to stay with the patient during periods of flashbacks while offering reassurance of safety and security assists with calming fears of personal safety the patient may have. Encouraging the patient to talk about the trauma at their own pace, while providing a private environment with family members if they choose facilitates the debriefing process. Discussing coping strategies both previously used, as well as alternative strategies assists in resolving the post-traumatic response. Assisting the patient in understanding the trauma and discussing their feelings can help the patient formulate meaning of the event, allowing the patient to incorporate the event into basic beliefs. This will affect how the patient eventually comes to reassess self and world. Assessing the patient for maladaptive coping strategies such as substance abuse is important because these behaviors will interfere with the recovery process. Identifying available community resources is also an important intervention from a nursing aspect, as support groups have been identified as a major predictor in the successful recovery, (Townsend, 2006).
Community Resources
There are many sources available to individuals affected by PTSD. These resources can be found in local hospitals, inpatient and outpatient clinics, education centers and shelters.
1. Philadelphia VA Medical Center
3900 Woodland Avenue
Philadelphia, PA 19104
215-83-5800
2. Impact Services
1952 East Alleghany Avenue
Philadelphia, PA 19134
215-739-1600
3. Psych Options
1735 Market Street
Philadelphia, PA 19103
4. The Philadelphia Veterans Multi-Service and Education Center
213-217 North 4th Street
Philadelphia, PA 19106
215-923-VETS
5. Assignment Hope
1731 North 25th Street
Philadelphia, PA 19121
267-228-3909

References
Bastien, D. (2010). Phamacological Treatment of Combat Induced PTSD: A Literature Review. British Journal of Nursing , 19 (5).
Gill, J. R., Saligan, L. N., Henderson, W. A., & Szanton, S. A. (2009). PTSD Know the Warning Signs. The Nurse Practitioner , 34 (7), 30-37.
Townsend, M. C. (2006). Psychiatric Mental Health Nursing. Philadelphia: F.A. Davis Company.
Valente, S. M. (2010, November). Evaluating and Managing Adult PTSD in Primary Care. The Nurse Practitioner , 41-47.
Wieland, D., Hursey, M., & Delgado, D. (2010). Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Military Mental Health Issues. Pennsylvania Nurse , 4-11.