PSychology and Psychiatry in Nursing
Posttraumatic Stress Disorder
Although originally considered an anxiety disorder, the DSM-5 removed PTSD from the classification of anxiety disorders and included it in a new chapter, Trauma- and Stressor-Related Disorders. PTSD was once considered a psychological condition of combat veterans who were “shell shocked” by and unable to face their experience on the battlefield. Individuals with PTSD were labeled as weak, faced rejection from their military peers and society in general, and were removed from combat zones or discharged from the military. Today we know that PTSD is a psychobiological mental disorder associated with changes in brain function and structure and can affect survivors of combat experience but also survivors of terrorist attacks, natural disasters, serious accidents, assault or abuse, and even sudden and major emotional losses (National Institute of Mental Health, 2014a). Scientists are focusing on genes that play a role in creating fear memories as well as studying parts of the brain that deal with fear and stress (Clapp, 2016). The DSM-5 criterion for PTSD has been expanded to include both direct and indirect exposure to potentially traumatic experiences (Uher et al., 2014).
Prevalence
Most of the research on PTSD has been conducted with male veterans of military combat. In the cohort of Vietnam veterans (now in the “baby boomer” cohort), 3 out of 10 experience PTSD. Among Afghanistan and Iraq veterans, 11% to 20% experience PTSD (United States Department of Veterans Affairs, 2014). Only recently realized is the fact that many World War II veterans have lived most of their lives under the shadow of PTSD without realization of their disorder. PTSD occurs increasingly in women, although research is scarce. Rape, child abuse, and domestic violence are the most likely traumas that will result in PTSD in women. With more women serving in the military, combat-induced PTSD among women is expected to increase (Kaiser et al., 2014a). Prevalence rates of PTSD among older adults have not been adequately studied, but estimates are that between 3% and 5% of individuals older than age 60 experience PTSD. Many older individuals may not meet the full criteria for a PTSD diagnosis but may still exhibit symptoms (partial or subsyndromal PTSD) (Chopra et al., 2014). The percentage of older individuals with subclinical levels of PTSD symptoms ranges from 7% to 15% (Kaiser et al., 2014a). Current estimates may underrepresent the prevalence of PTSD in older adults (Clapp, 2016). In addition to military combat, seniors in our care now have also experienced the Great Depression, the Holocaust, and racism events that also may precipitate PTSD. Although they may have managed to keep symptoms under control, a person who becomes cognitively impaired may no longer be able to control thoughts, flashbacks, or images. This can be the cause of great distress that may be exhibited by aggressive or hostile behavior. Older individuals who are Holocaust survivors may experience PTSD symptoms when they are placed in group settings in institutions. Bludau (2002) described this as the concept of second institutionalization. Older women with a history of rape or abuse as a child may also experience symptoms of PTSD when institutionalized, particularly during the provision of intimate bodily care activities, such as bathing. Box 24.6 provides some clinical examples of PTSD.
Symptoms
The DSM-5 includes four major symptom clusters for diagnosis of PTSD:
(1) reexperiencing;
(2) avoidance;
(3) persistent negative alterations in cognition and mood;
(4) alterations in arousal and receptivity (including irritable or aggressive behavior and reckless or self-destructive behavior) (American Psychiatric Association, 2013).
Individuals often reexperience and relive the traumatic event in episodes of fear and experience symptoms such as helplessness, flashbacks, intrusive thoughts, dreams, images, avoidance of thoughts or situations that remind them of the traumatic event, poor concentration, irritability, increased startle reactions, and numbing of emotional responsiveness (detachment, flattened, or absent affect) (Clapp & Beck, 2012; Khouzam, 2013).
Implications for Gerontological Nursing and Healthy Aging
Assessment
PTSD prevention and treatment are only now getting the research attention that other illnesses have received 317over the years. The care of the individual with PTSD involves awareness that certain events may trigger inappropriate reactions, and the pattern of these reactions should be identified when possible. Knowing the person's history and life experiences is essential in understanding behavior and implementing appropriate interventions. Research on resiliency may lead to ways to predict who is most likely to develop PTSD following highly stressful events (National Institute of Mental Health, 2014a). Assessment of trauma and related symptoms should be routine in older patients because they may not report traumatic experiences or may minimize their importance. The Hartford Institute for Geriatric Nursing recommends the Impact of Event Scale–Revised (IES-R) (Christianson & Marren, 2013) (Box 24.7). Similar to other mental health concerns, elders may be more likely to report physical concerns, pain, sleep difficulties, or cognitive problems rather than emotional problems. Asking about issues or concerns may prompt a description of emotional reactions. Reports of physical issues should be followed with questions about changes in mood and activities. Cognitive screening for delirium/dementia is important, as well as assessment for depression and suicide (Kaiser et al., 2014b). Box 24.7
Interventions
The understanding of how to treat PTSD among older adults is still developing (Clapp & Beck, 2012) but recommendations are that older patients can benefit from CBT and prolonged exposure (PE) therapy (Kaiser et al., 2014b). Other therapies shown to improve PTSD symptoms include cognitive processing therapy, eye movement desensitization and reprocessing, and narrative exposure therapy (Agency for Healthcare Research and Quality [AHRQ], 2013). Pharmacological therapy is also used, and sertraline and paroxetine have received approval by the U.S. Food and Drug Administration (FDA) to treat PTSD. Careful monitoring of these medications is necessary in older patients (see Chapter 9). Cognitive therapy aims to isolate dysfunctional thoughts and assumptions about the trauma that seem to cause distress. Individuals are encouraged to challenge the truth of the beliefs and to substitute them with more balanced thoughts. Exposure therapy involves recalling distressing memories of the trauma/event via controlled exposure to reminders of the event. Exposure can be done by imagining the trauma, reading descriptions of the event, or visiting the site of the trauma until distress associated with the memory lessens and your body and mind are retrained to view the situation less dangerous than it was perceived to be. Therapies should be individualized to meet the specific concerns and needs of each unique patient and may include individual, group, and family therapy (Khouzam, 2013). Further research is necessary to understand the various presentations of PTSD in late life and validate and improve the effectiveness of available treatment approaches (Bottche et al., 2012; Thorp et al., 2009).