7.10 Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is diagnosed in individuals who have been exposed to a traumatic event with chronic stress symptoms lasting more than one month that are so severe they interfere with relationships, school, or work. Anyone can develop PTSD, which is triggered by events that are perceived to be life-threatening. This perception disrupts the general sense of safety that allows individuals to function in the world and can vary from individual to individual.^[1]

The following experiences put clients of any age at risk for developing PTSD:

• War
• Trauma
• Physical or sexual assault
• Abuse
• Accident
• Disaster
• Seeking refuge
• Danger or harm to a friend or family member
• Sudden, unexpected death of a loved one

Symptoms of PTSD typically begin within three months of the traumatic incident, up to years afterward. The course of the illness varies; some people recover within six months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

Symptoms are classified in four categories called “re-experiencing,” “avoidance,” “arousal and reactivity,” and “cognition and mood.”

Re-experiencing symptoms include the following:

• Flashbacks (i.e., reliving the trauma over and over, including physical symptoms like a racing heart or sweating)
• Bad dreams
• Frightening thoughts

Re-experiencing symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms. Sights, sounds, smells, feelings, and discussions are examples of reminders. For example, thunder may remind a client of an explosion. Being touched may be a reminder of a past trauma. Re-experiencing symptoms may cause problems in a person’s everyday routine and relationships.

Avoidance symptoms include the following:

• Staying away from people, places, events, or objects that are reminders of the traumatic experience
• Avoiding thoughts or feelings related to the traumatic event

These symptoms may cause a person to change their personal routine. For example, after a car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include the following:

• Being easily startled
• Feeling tense or “on edge”
• Hypervigilance
• Having difficulty sleeping
• Having angry outbursts

Arousal symptoms are usually constant instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry and can make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Hypervigilance, being on the alert for danger, is a characteristic sign of PTSD. Vigilance, meaning being on the lookout, is a normal behavior that prepares us to react to threats. When a client experiences hypervigilance in PTSD, the danger is usually not real, yet it is perceived as dangerous, and the client is constantly scanning the environment for danger. Behaviors such as sitting facing the door or not allowing others to be behind you are examples of hypervigilance. Other signs are increased heart rate and perspiration, restlessness, or worry. Over time, hypervigilance is exhausting because of the overstimulation of the nervous system. It can also lead to trouble sleeping.^[2]

Cognition and mood symptoms can begin or worsen after the traumatic event and make the person feel alienated or detached from friends or family members. Cognition and mood symptoms of PTSD are as follows:

• Trouble remembering key features of the traumatic event
• Negative thoughts about oneself or the world
• Distorted feelings like guilt or blame
• Loss of interest in enjoyable activities

PTSD is often accompanied by other mental health conditions like depression, substance abuse, or anxiety disorders.

Assessment (Recognizing Cues)

Nurses assess for and document “re-experiencing” symptoms, “avoidance” symptoms, “arousal and reactivity” symptoms, and “cognition and mood” symptoms described in the previous subsections.

To be diagnosed with PTSD, an adult must have the following types of symptoms for at least one month:

• At least one “re-experiencing” symptom
• At least one “avoidance” symptom
• At least two “arousal and reactivity” symptoms
• At least two “cognition and mood” symptoms

PTSD in Children and Adolescents

Children and teens can have extreme reactions to trauma, but they may exhibit different symptoms than adults. Symptoms of PTSD can be seen in young children (less than six years old) and may include the following:

• Bedwetting after having learned to use the toilet
• Forgetting how to talk or being unable to talk (i.e., selective mutism)
• Acting out the scary event during playtime
• Being unusually clingy with a parent or other adult

Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Hypersexual behavior may occur if the trauma was related to a sexual assault. Older children and teens may also feel guilty for not preventing injury or death in certain traumatic situations and may have thoughts of revenge.

Treatment of PTSD

For people with PTSD, treatments include medications, psychotherapy, or a combination of both. Clients can also be treated for related problems, which include panic disorder, depression, substance use disorder, and suicidal ideation.

Medications

Antidepressants such as paroxetine and sertraline may be prescribed to help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Review information about these medications in the “Psychotropic Medications” section of this chapter.

MDMA (also referred to by the illicit drug name Ecstasy) may be prescribed and administered under direct observation, along with psychotherapy. MDMA allows clients to process issues in an altered state of mind, with follow-up psychotherapy. MDMA therapy is short, compared to daily dosing of SSRIs.

Psychotherapy

Many types of psychotherapy may be prescribed to help people with PTSD. Some target the symptoms of PTSD directly, whereas other therapies focus on social, family, or job-related problems. Effective psychotherapies emphasize key components such as education about symptoms, identification of triggers or symptoms, and skills to manage the symptoms.

Cognitive behavioral therapy (CBT), combined with exposure therapy, helps people face and control their fear by gradually exposing them to the trauma they experienced in a safe way. Cognitive restructuring helps individuals create new thought patterns about the trauma. Animal-assisted intervention (AAI), also referred to as animal therapy, is a commonly used complementary treatment for PTSD. It most often includes dogs or horses.1 Read more about CBT in the “Psychotherapy” section of this chapter.

Nursing Interventions

In addition to teaching clients about the symptoms of PTSD, prescribed medications, and other treatments, nurses teach clients how to manage stress and anxiety associated with PTSD. Review the “Applying the Nursing Process to Promote Healthy Coping” in the “Mental Health Concepts” chapter for additional methods to help individuals manage arousal and reactivity symptoms of PTSD.