post traumatic stress disorder

Post traumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma.”

1. Post traumatic stress disorder. Presentee-Navdeep Kaur

2. INTRODUCTION Post traumatic stress disorder (PTSD)  is a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma.” This event may involve the threat of death to oneself or to someone else, or someone else's physical, sexual, or psychological integrity, overwhelming the individual's psychological defenses.

3. CONT. Post Traumatic Stress Disorder (PTSD), once called shell shock or battle fatigue syndrome , is a serious condition that can develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened.

4. DEFINITION Post Traumatic Stress Disorder is described as the development of characteristic symptoms following exposure to an extreme traumatic stress or involving a personal threat to physical integrity of others”. For e.g. being kidnapped or taken hostage, being tortured, experiencing disasters etc

5. CONT.. Post-traumatic stress disorder (PTSD) is a debilitating condition that affects people who have been exposed to a major traumatic event. PTSD is characterized by upsetting memories or thoughts of the ordeal, "blunting" of emotions, increased arousal, and sometimes severe personality changes.

6. INCIDENCE AND PREVALENCE The life time incidence of PTSD is 9-15% The life time prevalence of PTSD is about - 8% -10-12% among women - 5-6% among men PTSD can appear at any age Most prevalent in young adults Lifetime prevalence significantly high in women

7. CAUSES OF PTSD Psychological Trauma PTSD is believed to be caused by either physical trauma or psychological trauma or more frequently a combination of both. Possible sources of trauma include: Experiencing or witnessing childhood or adult physical, emotional or sexual abuse

8. CONT. Physical assault Adult experiences of sexual assault, Accidents  Drug addiction Illnesses Medical complications

9. Cont.. Employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). Violent assault Kidnapping Sexual assault Torture

10. Cont. Experiencing a disaster Violent automobile accidents Getting a diagnosis of a life-threatening illness Prisoner of war or concentration camp victim

11. Cont.. Children may develop PTSD symptoms by experiencing sexually traumatic events like age-inappropriate sexual experiences. A preliminary study found that mutations in a stress-related gene interact with child abuse to increase the risk of PTSD in adults

12. Neuro-Endocrinology PTSD symptoms may result when a traumatic event causes an overactive adrenaline response, which creates deep neurological patterns in the brain. PTSD displays biochemical changes in the brain and body that differ from other psychiatric disorders such as major depression.

13. People with PTSD also show: A low secretion of cortisol  and high secretion of catecholamine in urine, with a nor epinephrine/ cortisol ratio consequently higher than comparable non-diagnosed individuals.

14. Brain catecholamine levels are low, and  corticotrophin-releasing factor  (CRF) concentrations are high. Together, these findings suggest abnormality in the  hypothalamic-pituitary-adrenal (HPA) axis.

15. s Low cortisol levels may predispose individuals to PTSD. Because cortisol is normally important in restoring  homeostasis  after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.

16. Neuro - Anatomy Genetics There is evidence that susceptibility to PTSD is hereditary.

17. RISK FACTORS Although most people (50-90%) encounter trauma over a lifetime, only about 8% develop full PTSD. Early childhood developmental experience Childhood trauma Trauma severity Chronic adversity Familial stressors increase risk for PTSD Being punished severely during childhood. Childhood asocial behavior and depression

18. Cont. Female gender Middle-aged (40 to 60 years old) Little or no experience coping with traumatic events Ethnic minority Lower socioeconomic status Children in the home Women with spouses exhibiting PTSD symptoms Pre-existing psychiatric conditions Primary exposure to the event including injury, life-threatening situation, and loss Living in a traumatized community

19. SIGN AND SYMPTOMS OF PTSD

20. RE-EXPERIENCING Flashbacks —re-living the trauma over and over, including physical symptoms like a  racing heart  or  sweating Bad dreams Frightening thoughts Hallucinations Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings.

21. AVOIDANCE Staying away from places, events, or objects that are reminders of the experience Feeling strong guilt, depression, or worry Losing interest in activities that were enjoyable in the past Having trouble remembering the dangerous events.

22. Cont. Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car. .

23. HYPERAROUSAL Being easily startled Feeling tense or "on edge" Having difficulty sleeping, and/or having angry outbursts. Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating

24. Cont.. The person may also suffer physical symptoms, such as: - Increased blood pressure and heart rate - Rapid breathing - Muscle tension - Nausea - Diarrhea

25. EMOTIONAL NUMBING AND DYSPHORIA Numbing symptoms (such as loss of interest and feeling emotionally numb) Dysphoric symptoms: these include symptoms of emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating.

26. COMMON SYMPTOMS Hyper alertness Fear and anxiety Nightmares and flashbacks Avoidance of recall situations Anger and irritability Guilt Depression Increased substance abuse Negative world view Decreased sexual activity

27. PROTECTIVE FACTORS High school degree or college education Older age at entry to war Higher socioeconomic status A more positive paternal relationship as pre-military protective factors

28. DIAGNOSTIC CRITERIA The diagnostic criteria for PTSD, per the Diagnostic and Statistical Manual of Mental Disorders  IV  (DSM IV-TR), may be summarized as: Exposure to a traumatic event Persistent re-experience (e.g. flashbacks, nightmares) Persistent avoidance of stimuli associated with the trauma (e.g. avoidance of experiences that the fear will trigger flashbacks and re-experiencing of symptoms , fear of losing control)

29. Cont. d) Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hyper vigilance). e) Duration of symptoms for more than 1 month. f) Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)

30. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) outlined three forms of the disorder: Acute : onset within six months of the event and lasting less than six months Chronic : symptoms lasting six months or more Delayed : onset at least six months after the event

31. DIAGNOSTIC CRITERIA DSM-5 A. Exposure to actual one threatened death, or serious injury in one or the following way- Directly experiencing the traumatic event. Witnessing, in person, as event occurs to others. Learning the traumatic event occurred to close family member or friend. Experiencing repeated or extreme exposure to aversive details of the traumatic event. B. Presence of intrusion symptom associated with traumatic event, beginning after the treatment occurred-: Recurrent distressing memory of traumatic event.

32. Recurrent distressing dream. Dissociative reactions(flashbacks) Prolonged psychological distress at exposure to internal or external cues. Marked physiological reactions. C. Persistent avoidance of stimuli: - Avoidance or efforts to avoid distressing memories, thoughts or feelings. - Avoidance or efforts to avoid external reminders(place, conversation)

33. D. Negative alterations in mood associated with the traumatic event: Inability to remember important aspect of traumatic event Persistent negative beliefs or expectations. Persistent distorted cognitions about the cause or consequences of the traumatic event. Persistent negative emotional state. Diminished interest in significant activities. Persistent inability to experience positive emotions.

34. E. Marked alteration in arousal and reactivity associated with traumatic event. Irritable behavior and angry ouburst . Self destructive behavior.

35. DIFFERENTIAL DIAGNOSIS Difficult to distinguish from related disorders exhibiting phenomenological similarities. Borderline personality disorder, dissociative disorder, generalized anxiety disorder etc. Careful review of time course relating symptoms to traumatic event. Patients with dissociative behavior do not have avoidance behavior.

36. TREATMENT

37. TREATMENT The treatment for PTSD includes: Pharmacotherapy Psychotherapy

38. PHARMACOTHERAPY

39. PSYCHOTHERAPY Cognitive-behavior therapy Group therapy Exposure therapy Eye movement and desensitization reprocessing (EMDR) Group therapy Family therapy

40. Cognitive therapy The behavioral techniques in cognitive therapy are - scheduling activities self- reliance training role playing diversion techniques Therapists encourage patients to relax and remove them from the source of stress. Encourage patients to review and abreact emotional feelings. Encourage patients to plan for the future recover

41. EXPOSURETHERAPY The patient re-experiences the traumatic event through imaging techniques . Ceases anxiety associated with traumatic memory and corrects belief that memory must be avoided Encourage self control by exposure exercises Teach methods of stress management including relaxation techniques

42. Eye movement desensitization reprocessing( emdr ) Most preferable method Patient focuses on lateral moment of clinician’s finger. Maintain mental image of the traumatic event. Patient work through the traumatic event while in state of deep relaxation

43. Group therapy Consist of 5-6 people with therapist. Identify and recognizes that others have similar problems. Gain support and empathy from fellow group members. Sharing of traumatic experiences. Support from other group members

44. Family therapy Aimed at increasing family’s coping. Individual stability and change. Good network of support. Recover faster.

45. ACTIVITIES Relaxed activities should be given: Breathing exercise Meditation Yoga Prayer Listening music Drawing Finger painting

46. PROGNOSIS Good prognosis: Rapid engagement of treatment Early and ongoing social support Avoidance of re- traumatization Absence of other psychiatric disorders Absence of substance abuse

47. COMPLICATONS Alcohol abuse Drug abuse Depression Anxiety Fear of things that are not usually frightening to others (phobia) Involvement in antisocial activities (prostitution) in case of women experiencing sexual assault

48. NURSING MANAGEMENT Nursing management includes: Nursing assessment Nursing diagnosis Nursing interventions Client education

49. NURSING ASSESMENT Post traumatic stress disorder will be identified on the basis of following features: Exposure of traumatic event Re-experience of traumatic event Persistent avoidance of stimuli associated with persistent symptoms of increased arousal. Duration of disturbances Disturbances causing significant distress or impairment.

50. NURSING DIAGNOSIS Dysfunctional grieving related to loss of self following the traumatic event as evidenced by avoidance and depression. Inability to express feelings related to fear of intensity as evidenced by helplessness and hopelessness. 3. Feeling of fear, anxiety and unsafe related to generalized traumatic experience as evidenced by nightmares and flashbacks

51. CONT.. 4. Decreased ability to deal with stress related to unresolved grief following the trauma as evidenced by emotional numbing. 5. Risk of violence related to hostile and aggressive behavior as evidenced by hyperarousal . 6. Disturbance in interpersonal relationship related to lack of trust and difficulty in expressing feelings as evidenced by less social interaction.

52. references Townsand MC. Psychiatric mental health nursing. 8 th ed Jaypee ; New Delhi;p.559-578. Sreevani R. Mental health nursing. 3 rd ed Jaypee ;New Delhi; p. Ahuja Neeraj . A Short Textbook of Psychiatry. 7 th ed Jaypee ; New Delhi; p.112 Online References post traumatic stress disorder - https://www.google.co.in - https://en.wikipedia.org/wiki/Posttraumatic_ stress_disorder