Chapter 19

Trauma- and Stressor-Related Disorders

PTSD, Acute Stress Disorder, &
Adjustment Disorder

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 Historical and Epidemiological Data
• Posttrauma response was historically known as shell shock,
battle fatigue, accident neurosis, or posttraumatic neurosis.
• Renewed interest about the disorder began in the 1970s, in
response to problems encountered by Vietnam veterans.
• Diagnosis of posttraumatic stress disorder (PTSD) first
appeared in the 3rd edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-3, 1980).

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 Historical and Epidemiological Data (cont’d)

• More than half of all individuals will experience a

traumatic event in their lifetime, but less than 10
percent will develop PTSD.
• The traumatic event is described as one that is
“outside the range of usual human experience.”
• PTSD is more common in women than in men.

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 Historical and Epidemiological Data (cont’d)

• Individuals who have difficulties with stress

reactions to more “normal” events may be
diagnosed with Adjustment Disorder.
• Adjustment disorders are quite common and
can occur at any age.

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Application of the Nursing Process: Trauma-Related Disorders

• Posttraumatic Stress Disorder

–A reaction to an extreme trauma, which is likely to
cause pervasive distress to almost anyone, such as
natural or man-made disasters, combat,
serious accidents, witnessing the violent
death of others, being the victim of torture,
terrorism, rape, or other crimes

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 Posttraumatic Stress Disorder (cont’d)
• Characteristic symptoms include
– Re-experiencing the traumatic event
– A sustained high level of anxiety or arousal
– A general numbing of responsiveness
– Intrusive recollections or nightmares
– Amnesia to certain aspects of the trauma
– Depression; survivor’s guilt
– Substance abuse
– Anger and aggression
– Relationship problems
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 Posttraumatic Stress Disorder (cont’d)
• Symptoms may begin within the first 3
months after the trauma, or there may be a
delay of several months or even years

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 Acute Stress Disorder (ASD)
• Similar to PTSD in terms of precipitating
traumatic events and symptomatology
• Symptoms are time limited: up to 1 month
following the trauma
• If the symptoms last longer than 1 month, the
diagnosis would be PTSD

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 Trauma-Related Disorders
• Predisposing factors
– Psychosocial theory
• Seeks to explain why some individuals exposed to
massive trauma develop PTSD while others do not
• Variables include characteristics that relate to
– The traumatic experience
– The individual
– The recovery environment

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 Trauma-Related Disorders (cont’d)
• Predisposing factors (cont’d)
– Learning theory
• Negative reinforcement leads to the reduction in an
aversive experience, thereby reinforcing and
resulting in repetition of the behavior
• Avoidance behaviors
• Psychic numbing

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 Trauma-Related Disorders (cont’d)
• Predisposing factors (cont’d)
– Cognitive theory
• A person is vulnerable to posttraumatic stress
disorder when fundamental beliefs are invalidated by
experiencing trauma that cannot be comprehended
and when a sense of helplessness and hopelessness
prevail

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 Trauma-Related Disorders (cont’d)
• Predisposing factors (cont’d)
– Biological aspects
• It is suggested that the symptoms related to the
trauma are maintained by the production of
endogenous opioid peptides that are produced in the
face of arousal, and which result in increased feelings
of comfort and control.
• When the stressor terminates, the individual may
experience opioid withdrawal, the symptoms of
which bear strong resemblance to those of PTSD.
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 Trauma-Related Disorders (cont’d)
• Predisposing factors (cont’d)
– Biological aspects (cont’d)
• Disregulation of the opioid, glutamatergic,
noradrenergic, serotonergic, and neuroendocrine
pathways may also be involved in the pathophysiology
of PTSD.

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 Nursing Diagnosis/Outcome Identification

• Nursing diagnoses for trauma-related disorders

may include
– Posttrauma syndrome
– Complicated grieving

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 Outcome Criteria
• The client
– Can acknowledge the trauma and the impact on his or her
life
– Can demonstrate adaptive coping strategies
– Has made realistic goals for the future
– Has worked through feelings of survivor’s guilt
– Attends support group of individuals recovering from similar
traumatic experiences
– Verbalizes desire to put trauma in the past and progress with
his or her life.
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 Planning/Implementation
• Nursing care of the client with a trauma-
related disorder is aimed at
– Reassurance of safety
– Decrease in maladaptive symptoms
– Demonstration of more adaptive coping strategies
– Adaptive progression through the grieving process

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 Evaluation
• Evaluation of care for the client with a trauma-
related disorder is based on successful
achievement of the previously established
outcome criteria
– Can the client discuss the traumatic event without
experiencing panic anxiety?
– Has the client learned new, adaptive coping
strategies for assistance with recovery?

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Application of the Nursing Process: Stressor-Related
Disorders
Adjustment Disorders
– Characterized by a maladaptive reaction to an
identifiable stressor or stressors that results in the
development of clinically significant emotional or
behavioral symptoms
– Symptoms occur within 3 months of the stressor
and last no longer than 6 months
• Exception: The “Related to Bereavement” subtype

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 Adjustment Disorders (cont’d)
• Types of Adjustment Disorders
– With Depressed Mood
– With Anxiety
– With Mixed Anxiety and Depressed Mood
– With Disturbance of Conduct
– With Mixed Disturbance of Emotions and Conduct
– Related to Bereavement
– Unspecified
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Adjustment Disorders (cont’d)
• Predisposing factors
– Biological theories
• Genetics
• Vulnerability related to neurocognitive or intellectual
developmental disorders

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 Adjustment Disorders (cont’d)
• Predisposing factors (cont’d)
– Psychosocial theories
• Childhood trauma, dependency, arrested development
• Constitutional factor (birth characteristics)
• Developmental stage and timing of the stressor
• Available support systems
• Dysfunctional grieving process

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 Adjustment Disorders (cont’d)
• Predisposing factors (cont’d)
– Transactional model of stress/adaptation
– Interaction between individual and environment
– Type of stressor
– Situational factors
– Intrapersonal factors

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 Adjustment Disorders (cont’d)
• Nursing diagnosis
– Complicated grieving
– Risk-prone health behavior
– Anxiety

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 Adjustment Disorders (cont’d)
• Outcome criteria
– The client
• Verbalizes acceptable grieving behaviors
• Demonstrates a reinvestment in the environment
• Accomplishes ADLs independently
• Demonstrates ability to function adequately
• Accepts change in health status
• Sets realistic goals for the future
• Demonstrates ability to cope effectively with change in
lifestyle
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 Adjustment Disorders (cont’d)
• Planning/Implementation
– Nursing intervention for the client with an
adjustment disorder is aimed at
– Adaptive progression through the grief process
– Helping the client achieve acceptance of a change in
health status
– Assisting with strategies to maintain anxiety at a
manageable level

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 Adjustment Disorders (cont’d)
• Evaluation
– Evaluation is based on accomplishment of
previously established outcome criteria
• Does client demonstrate progression in the grief
process?
• Does client discuss the change in health status and
modification of lifestyle it will affect?
• Does client set realistic goals for the future?

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 Treatment Modalities
• Trauma-related disorders
– Cognitive therapy
– Prolonged exposure therapy
– Group/family therapy
– Eye movement desensitization and reprocessing
– Psychopharmacology

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 Treatment Modalities (cont’d)
• Adjustment disorders
– Individual psychotherapy
– Family therapy
– Behavior therapy
– Self-help groups
– Crisis intervention
– Psychopharmacology

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 Nursing Process
1. Two months ago, Ms. T was sexually
assaulted while jogging in an isolated park. She is
hospitalized for suicidal ideation at this time. She awakens in
the middle of the night screaming about having nightmares of
the incident. Which of the following is the most appropriate
initial nursing intervention?
a) Call the doctor to report the incident
b) Stay with Ms. T until the anxiety has subsided
c) Administer prn alprazolam
d) Allow her some privacy to work through the emotions

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 Nursing Process (cont’d)
Correct answer: B
It is important to not leave a client who is
experiencing flashbacks or nightmares alone. Clients
often feel they are “going crazy” when this happens,
and the presence of a trusted individual calms fears
and reassures the client of her safety.

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 Treatment Modalities
2. Which of the following medications is
considered to be a first-line medication of
choice in the treatment of PTSD?
a) Alprazolam
b) Propranolol
c) Carbamazepine
d) Paroxetine
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 Treatment Modalities (cont’d)
Correct answer: D
The SSRIs are now considered first-line treatment of
choice for PTSD because of their efficacy,
tolerability, and safety ratings. Paroxetine and
sertraline have been approved by the FDA for this
purpose.

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