Trauma and Stressor-Related

Disorders

MARLENE D. VALERA MAN, RN

 LEARNING OBJECTIVES
At the end of the teaching-learning activities,
students will be able to:
1. Discuss the characteristics, risk factors, and
dynamics of immediate- and longer-term
individual responses to trauma and stressors

2. Examine the occurrence of various longer-term

responses to trauma and stress.

3. Describe responses to trauma and stressors,
specifically posttraumatic stress disorder
(PTSD) and dissociative identity disorder.
4. Provide education to clients, families, and
communities to promote prevention and early
intervention for trauma and stressor-related
responses.
5. Apply the nursing process to the care of
clients with trauma or stressor related
diagnoses.

6. Evaluate your own experiences, feelings,

attitudes, and beliefs about responses to
trauma and stress.
Posttraumatic Stress Disorder
(PTSD)
• is a disturbing pattern of behavior demonstrated by
someone who has experienced, witnessed, or been
confronted with a traumatic event,
such as:
> a natural disaster,
>combat, or an
> or an assault.
 Symptoms in PTSD
(Four subcategories)
1. Reexperiencing the trauma:
through dreams or recurrent and
intrusive thoughts.
2. Avoidance
> avoids stimuli associated with trauma.

> Reports losing sense of connection and

control over life.
• Avoidance behavior:

avoid any places

people
situations
that trigger memories of the trauma
3. Negative cognition or thoughts
> The victim feels a numbing of general
responsiveness.
4. Being on guard (hyperarousal)
>shows persistent signs of increased arousal.
such as:
Insomnia, hyperarousal or hypervigilance,

irritability, or angry outbursts.

• (Shalev & Marmar, 2017).

 PTSD
 PTSD symptoms :
3 months or more after trauma.

 Which PTSD distinguishes from Acute Stress

Disorder:
*symptoms last 3 days up to 1 month
 Treatment
• Counseling or therapy, individually or in
groups, for people with acute stress disorder
may prevent progression to PTSD.

• CBT and specialized therapy programs

incorporating elements of CBT are the most
common and successful types of formal
treatment.
• Exposure therapy
• Adaptive disclosure
• Cognitive processing therapy
Recap:
PTSD-
Four Subcategories:
1. Reexperiencing the trauma
2. Avoidance
3. Negative cognition or thoughts
4. Being on guard or hyperarousal
DISSOCIATIVE
DISORDERS
? DISSOCIATIVE DISORDERS
 Dissociation
is a subconscious defense mechanism that helps
the person protect his or her emotional self from
recognizing the full effects of some horrific or
traumatic event by allowing the mind to forget or
remove itself from the painful situation or
memory.
 DISSOCIATIVE DISORDERS

• is a disruption in the usually integrated

functions of consciousness, memory,
identity, or environmental perception.

• This often interferes with the person’s

relationships, ability to function in daily life
and ability to cope with realities of the
abusive or traumatic event.
TYPES OF DISSOCIATIVE DISORDERS
1. Dissociative Identity Disorder
(multiple personality disorder)
2. Dissociative Amnesia
3. Depersonalization/Derealization Disorder
1. Dissociative Identity Disorder
(multiple personality disorder)
 ? Dissociative Identity Disorder
(multiple personality disorder)
• The client displays two or more distinct
identities or personality states that
recurrently take control of his or her
behavior.
Alter Personality
 Alter personalities
• is the disruption of marked discontinuity in
sense of self and sense of agency, accompanied
by related alterations in affect, behavior,
consciousness, memory, perception, cognition,
and/or sensory-motor functioning. Which
describes the presence of distinct personality
states.
 DID
• is accompanied by the inability to
recall important personal
information.
DID
• The key element in diagnosing is the
presence of at least two distinct and
separate personalities within an individual.

• Although multiple personalities (alters)

exist within a single person, only one is
manifested at a time; each with its own
memories, behaviors and life preferences.
 Symptoms of DID
The most commonly observed symptoms include:
• Inability to recall large memories of childhood;
• Lack of awareness of recent events, and if they
do remember, inability to explain them,
for example not being able to explain how the
patient got somewhere, or how he acquired a
possession;
• “lost time,” or frequent memory loss;
DID
• Flashbacks or sudden return of memories;
• Feelings of disconnection or detachment
from body or thoughts;
• Hallucinations or voices;
• So called “out of body ” experiences;
DID
• Self-harm or suicidal thoughts;;
• Changes in handwriting;
• Functional changes: from nearly disabled to
highly functioning
• Less commonly observed manifestations
observed in patients with DID:
Mood swings or depression;
DID
• Anxiety, nervousness, panic attacks or
phobias;
• Eating and food issues;
• Unexplained sleep disorders;
• Headaches or general body pain;
• Sexual issues, sex addiction or sexual
avoidance.
(AAMFT, 2014).
 DID
Presentation
• DID is typically manifested in females, often in their
3rd decade of life.
• Onset of dissociative symptoms appeared between the
ages of 5-10,
• appearance of alters by the age of 6.
• As the patient ages, the numbers of alters increases.
 DID
• Adult patients - up to 16 separate and distinct
alters.

• Adolescents - as many as 24 alters have been

reported, though in both cases, many of these
will fade, if effective treatment is provided
(Gillig 2009).
DID

• A reported history of childhood abuse is

common, with a high frequency of sexual
abuse.
• Suicidal ideation with attempts at suicide is
commonly reported.
DID
• While sexual promiscuity is unremarkable,
many patients report a decreased libido and
inability to reach orgasm. Further to that,
patients sometimes dress in clothing
appropriate for the opposite gender or state
that they, themselves, are of the opposite
gender
(Gillig 2009).
DID
• Patients with DID sometimes experience
hallucinations, report hearing voices,
amnesia and periods of depersonalization.
On many occasions, when referring to
themselves,
• they may use the plural “we” instead of
“I”
(Gillig 2009).
2 Dissociative Amnesia
2. Dissociative Amnesia
• The client cannot remember personal
information. (usually a traumatic or
stressful nature).
• (Dissociative Amnesia: Deeply Buried
Memories)
 Dissociative Amnesia
• recurrent memory problems, often
described as "losing time", these gaps
in memory can vary from several
minutes to years
 Dissociative Amnesia
• Dissociative fugues
 A fugue experience where the client
suddenly moves to a new geographic
location with no memory of past events.
 Often the assumption of a new identity
 Dissociative Amnesia
• Dissociative fugues,
which involve travel to an unusual place without any
memory of the journey or its purpose, are common.
People suddenly find themselves "coming to" at the
beach, hiding in a closet at home, in a nightclub, or in
bed without any memory of the "lost" time.

 Dissociative fugue is now a specifier of dissociative

amnesia — rather than as a separate diagnosis.
3. Depersonalization/Derealization
Disorder
Depersonalization/ Derealization disorder

• The client has a persistent or recurrent feeling

of being detached from his or her mental
process or body (depersonalization) or
sensation of being in a dream-like state where
the environment seems foggy or unreal
(derealization).
Depersonalization/Derealization Disorder
• depersonalization is a sense of detachment or
disconnection from one’s self, this can include
feeling like a stranger to yourself, feeling
detached from your emotions, feeling robotic or
like you are on autopilot, or feeling like a part of
your body does not belong to you.
 Some people self-injure when
depersonalized, for example in order to feel "real".
Depersonalization/Derealization Disorder
• derealization is a sense of disconnection from
familiar people or one’s surroundings, for
example, close relatives or your own home may
seem unreal or foreign.

Episodes of derealization may happen during

flashbacks; you may suddenly feel much
younger and feel your present environment is
unreal during this time.
Depersonalization/Derealization disorder
is accompanied by intact reality testing; the
client is not psychotic or out of touch with
reality.
 CLINICAL VIGNETTE:
Posttraumatic Stress Disorder
• Julie’s friends didn’t seem to want to be
around her anymore because she was often
moody and couldn’t seem to enjoy herself.
Sure, they were supportive and listened to
her for the first 6 months, but now it was 2
years since the rape. Before the rape, she
was always ready to go to a party or out to
dinner and a movie with friends. Now she
just felt like staying home.
• She was tired of her mother and friends
telling her she needed to go out and have
some fun. Nobody could understand what
she had gone through and how she felt.
Julie had had several boyfriends since then,
but the relationships just never seemed to
work out. She was moody and would often
become anxious and depressed for no
reason and cancel dates at the last minute.
Everyone was getting tired of her moods, but
she felt she had no control over them.
• Julie sat up in bed. She felt her heart
pounding, she was perspiring, and she felt
like she couldn’t breathe. She was gasping
for breath and felt pressure on her throat.
The picture of that dark figure knocking her
to the ground and his hands around her
throat was vivid in her mind. Her heart was
pounding, and she was reliving it all over
again, the pain and the terror of that night
• It had been 2 years since she was attacked
and raped in the park by a man she thought
was her friend, but sometimes it felt like
just yesterday. She had nightmares of panic
almost every night. She would never be rid
of that night.
• Lately, the dread of reliving the nightmare
made Julie afraid to fall asleep, and she
wasn’t getting much sleep. She felt
exhausted. She didn’t feel much like eating
and was losing weight. This ordeal had
ruined her life. She was missing work more
and more. Even while at work, she often
felt an overwhelming sense of dread.
Sometimes even in the daytime, memories
and flashbacks of that night would come.
 Treatment and Interventions
• Survivors of abuse who have dissociative
disorders are often involved in group or
individual therapy in the community to address
the long-term effects of their experiences.
Therapy for clients who dissociate focuses on
reassociation, or putting the consciousness
back together.
• This specialized treatment addresses
trauma-based, dissociative symptoms. The
goals of therapy are to improve quality of
life, improved functional abilities, and
reduced symptoms. Clients with
dissociative disorders may be treated
symptomatically, that is, with medications
for anxiety or depression or both if these
symptoms are predominant.