Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that develops after a tragic experience. A person must repeatedly relive the event in one of five defined ways, avoid stimuli related to the event in three of seven defined ways, and exhibit at least two symptoms of hyperarousal that were not present before the event. There are three interventions commonly used in the treatment of PTSD, critical incident stress debriefing, cognitive behavioral therapy, and eye movement desensitization and reprocessing. The most effective pharmacotherapy intervention is the use of antidepressants with serotoninergic properties. Nurses treating patients with PTSD should be able to provide a calm environment and invoke a trusting relationship with their patient.
Examining Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is a serious anxiety disorder that develops after a traumatic event. Swiss military physicians were among the first to identify and name the collection of symptoms characteristic of PTSD. In 1678 these physicians invented the term “Nostalgia” to define the symptoms plaguing their soldiers. The Swiss were not the only ones noticing this phenomenon, around the same time the German, French, and Spanish had noticed the same symptoms. The German termed it “heimweh” meaning homesickness. The French called it maladie du pays and the Spanish estar roto meaning to be broken (Bently, 2005).
Originally referred to as “shell shock” PTSD was not widely received. During the Civil War the military became overwhelmed with the amount of PTSD suffers. These individuals were often sent home on a train with their names and addresses pinned to their shirts or left to wander about the country side until they died of exposure or starvation. The public soon became overwhelmed with the “disabled soldiers” and as a result the military opened up its first military hospital for the insane in 1863. However this hospital was not maintained after the war. (Bently, 2005) Although PTSD symptoms seem to have been affecting people for thousands of years it was not officially introduced into the DSM until 1980 (Ahmed, 2007). Brought to the attention of the psychiatric community by Vietnam War veterans a definitive list of symptoms began to be developed (MacDonald, 2008).
According to the DSM in order for a person to be diagnosed with PTSD they must have first experienced, witnessed, or have been confronted with a traumatic event involving the death or harm of another person or themselves resulting in intense fear, horror, or helplessness. After experiencing a traumatic event the person must relieve the experience in one of the following ways through intrusive, distressing recollections, repeated, distressing dreams, flashbacks, hallucinations, illusions, or internal or external cues that symbolize or resemble the event. This results in physiological reactivity such as a rapid heart beat and elevated blood pressure (Morrison, 2003).
The individual must then exhibit three or more of the following avoidances attempts to avoid thoughts, feelings, or conversations concerned with the event, attempts to avoid activities, people, or places that recall the event, are unable to recall an important feature of the event, exhibit a marked loss of interest or participation in activities important to the individual, become detached or isolated from other people, become restricted in the ability to lover or feel strong emotions, or displays feelings that life will be brief or unfulfilled. They must also have at least two of the following symptoms of hyperarousal that were not present before the traumatic event. These symptoms are insomnia, irritability, poor concentration, hyperviligance, or increased startle response. These symptoms must last for more than a month and impair work, social, or personal functioning. There are no cardinal symptoms of PTSD (Morrison, 2003). Having defined borders gave scientist boundaries with which to exam if there were any predisposed indicators of the disorder.
The question remains with there being so many people who experience trauma why do some recover while others develop PTSD? To answer this question one must first examine PTSD from every angle. To begin with the sexes it has been found that women are more likely than men to meet the criteria for PTSD and for lifetime PTSD. Women usually experience PTSD following rape or physical assault while men usually experience PTSD after witnessing someone seriously injured or killed. Since PTSD is dependent upon the experience of a traumatic event there is no typical age of onset (Morrison, 2003). There also is no evidence to support that ethnicity plays a role in susceptibility for PTSD. However, one study found that PTSD symptoms have a heritable component. Another theory is that people who develop PTSD were susceptible because they have a previous history of psychological problems before experiencing a traumatic event. In the beginning researchers believed that the severe trauma caused neuron damage or loss of cells in the hippocampus producing PTSD symptoms but research has contradicted that theory. Studies have now found that PTSD sufferers have a smaller than average hippocampus. One theory is that as a result of this smaller hippocampus individuals had difficulty reacting to memories as past events and why they keep reliving them as the present. The critical component to all of this is that the differences in cognitive and neurological functioning had to exist before the trauma took place and PTSD was then triggered by the eventual traumatic experience (Tavris & Wade, 2008, p. 606).
Studies have also been done to examine the neurological aspect of PTSD. It has been found that neuropeptide Y, an amino acid released with noradrenalin on activation of the sympathetic nervous system, may play a role. Low levels of neuropeptide Y have been found in veterans with chronic PTSD. Other studies have found that individuals who are able to restrain the corticotrophin-releasing hormone (CRH) have an easier time recovering from a traumatic experience. Researchers have also been able to link increased levels of CRH in the cerebral spinal fluid to PTSD (Ahmed, 2007). Now that the biology of the disorder has been examined how is PTSD treated?
Many interventions have been tested in the treatment of PTSD with some being more successful then others. The most popular intervention, although not the most successful, is Critical Incident Stress Debriefing (CISD). CISD is an intervention where victims of a trauma go through a one to three hour “debriefing” immediately post trauma. In this debriefing they are expected to disclose their thoughts and emotions about the traumatic experience and the group leader warns them about the possible trauma symptoms that may occur. Research however, has found that this method is not only ineffective but can actually have long term adverse effects. CISD has actually had worse effects on the victims who receive the treatment than those who haven’t (Tavris, 2008, p. 659).
Another intervention that has been studied is cognitive behavioral therapy (CBT). “Trauma focused cognitive behavioral therapy is the most effective psychological treatment for PTSD” (MacDonald, 2008). Cognitive behavioral therapy requires the individual to challenge the self-damaging thoughts and beliefs about the event. It also helps them to develop a more reasonable outlook over their recovery. This treatment aids the individual in feeling more in control of their memories (MacDonald, 2008).
The last intervention to be discussed is eye movement desensitization and reprocessing (EMDR). This treatment is intended to specifically treat PTSD. It is recommended that it be used within the first month following the traumatic event, especially in with those with severe posttraumatic symptoms. During this treatment the patient is to make rhythmic eye movements that stimulate the information processing system in the brain. These eye movements assist the patient to process flashbacks and better understand the traumatic event (MacDonald, 2008). Although psychological interventions are the primary treatment pharmacotherapy is also used in treating posttraumatic stress disorder.
Pharmacotherapy should not be a first line of defense in treating PTSD but may aid in the process (MacDonald, 2008). Medication therapy is not used to cure PTSD but rather for aiding in the treatment of symptoms. For treating the core symptoms of PTSD antidepressants particularly those with serotoninergic properties have been effective when given at a higher dosage for at least five to eight weeks (Sutherland & Davidson, 1994). Two examples are paroxetine (Paxil) and sertraline (Zoloft). Paroxetine inhibits central nervous system (CNS) neuron uptake of serotonin but not of norepinephrine or dopamnine. It is recommended at a dose of 20 mg per day with a max of 60 mg per day in the treatment of PTSD (Skidmore-Roth, 2010, p 836). Sertraline inhibits the reuptake of serotonin in the central nervous system with no affect on dopamine or norepinephrine. The recommended dosage of sertraline in the treatment of PTSD is 25 to 50 mg per day. It may be increased to a maximum of 20 mg per day but should be done over an interval of greater than one week (Skidmore-Roth, 2010, p.981). For hyperarousal symptoms that do not respond to antidepressants, buspirone or benzodiazepines may be indicated (Sutherland, 1994).
Buspirone (Buspar) is an anti-anxiety, sedative that inhibits the action of serotonin. It is recommended at a dosage of 5 mg divided into 3 daily dosages with total maximum dose of 60 mg per day. “Benzodiazepines reduce anxiety by stimulating the action of the inhibitory neurotransmitter, gamma-aminobutric acid (GABA), in the limbic system. ” Common benzodiazepines include alprazolam, chlordiazepoxide, clorazepate, diazepam, lorazepam, and oxazepam (Skidmore-Roth, 2010, 69).
Phenelezine (Nardil) is another drug that has proven effective in treating PTSD symptoms. Phenelezine is used for treating depressive symptoms and also symptoms of autonomic arousal (Sutherland, 1994). Phenelzine is a mnoamine oxidase inhibitor. This class of drug blocks the metabolic destruction of epinephrine, norepinephrine, dopamine, and serotonin neurotransmitters in the pre synaptic neurons of the brain (Clayton, Stock, Harroun, 2010, p. 258). Other drug therapy options are lithium, carbamazepine, and beta-blocking drugs which aid in dealing with the symptoms of poor impulse control (Sutherland, 1994).
The nurse dealing with a patient with PTSD needs to be knowledgeable on the disorder and know where to obtain additional resources for the patient. It is also essential for the nurse to build a trusting relationship with the patient by using good communication and empathy. To promote a trusting relationship the nurse should utilize therapeutic or healing touch. The nurse should also be familiar with the signs and symptoms of drug or alcohol abuse as many patients may use that as a way to dull the symptoms of PTSD. It is important for the nurse to asses the patient for ongoing signs of PTSD such as avoidant behavior and disassociation (Ackley & Ladwig, 2008, p. 145).
In dealing with the ongoing signs and symptoms of PTSD the nurse should encourage the patient discuss their feelings surround the traumatic event. Promoting the patient to use positive thinking when examining the effects of their traumatic event will also help dampen the severity of them. Encourage the patient to focus on their strengths instead of their weakness. As the ongoing symptoms of PTSD may become overwhelming for the patient it is important for the nurse be able to identify signs of self harm. This would include being observant of poor self-concept, excessive grief, and hopelessness (Ackley, 2008, p. 623).
The nurse should also be aware that they patient may have trouble sleeping due to nightmares related to the traumatic event. Suggest the patient use relaxation techniques prior to going to bed. If the nurse is present at night time they could use a back massage to relax the patient and promote sleep. If the patient is in a treatment center the nurse should ensure that they keep the unit as quiet as possible during the night. This would include silencing alarms and speaking in quiet tones. If the patient is at home the nurse should suggest using calming music to promote a good night’s rest (Ackley, 2008, p. 757).
Post traumatic stress disorder is a serious anxiety disorder that can interfere with a person’s life for an extended period of time. It is imperative that the patient seek help as quickly as possible as the disorder can cause serious adverse affects to the person’s health and life. Psychotherapy interventions are the best method of managing a patients PTSD. The most effective of these interventions is cognitive behavioral therapy or CBT (MacDonald, 2008). Pharmacotherapy is often used in combination with psychotherapy methods to control PTSD. The most successful class of drugs in treating PTSD is antidepressants with serotoninergic properties (Sutherland, 1994). The final discussion in the management of PTSD is the role of the nurse. The most important aspect the nurse should have in helping a patient is to be able to build a trusting relationship with the patient. Through these interventions the patient should be able to live a life free of PTSD symptoms.