Post Traumatic

Psychological Disorder
Peranan Jururawat/Perawat
Sudirman Bin Othman RN, BSN, MRCNA
Dy Head, Community Resilience, Singapore Red Cross
Consultant, Holistique Health Pte. Ltd
Objectives
❏ Disaster and the Four Phases of Emergency Management
❏ What is PTSD?
❏ Signs and Symptoms of PTSD
❏ Complications, Treatment and Burden of PTSD
❏ Acute Phase of Emergency
❏ Rehabilitation and Recovery Phase
❏ Role of the Nurse
Aktiviti 1
Types of disaster
● There are smaller scale incidences that may cause PTSD
● But here, let us look at it at a disaster of mass scale
○ Human
○ Technological
○ Natural
Four Phases of Emergency Management
● Mitigation
○ Preventing future emergencies or minimising their effects
● Preparedness
○ Preparing to handle an emergency
● Response
○ Responding safely to an emergency
● Recovery
○ Recovering from an emergency

FEMA. (2014)
FEMA. (2014)
What happens after a disaster
● Drop/Loss in SES
○ Livelihood
○ Status
○ etc
● Loss of security
● Loss support
● Loss of infrastructure
What is PTSD?
● Do we all know what health is?
● According to WHO:-

“State of complete physical, mental and social well-being and not

merely the absence of disease or infirmity.”

- WHO

WHO (2017)
What is PTSD?
● WHO stresses that mental health is an essential aspect of health in
general
● Key for every individual to have good mental health

“Posttraumatic Stress Disorder (PTSD) is a psychiatric disorder that can

occur in people who have experienced or witnessed a traumatic event
such as a natural disaster, a serious accident, a terrorist act,
war/combat, rape or other violent personal assault” - DSM 5

DSM-V (2013) & Mayo Clinic (2018)

Sign and Symptoms of PTSD
● Based on DSM-V - Onset within 1 month but at times, may be years
before any of the symptoms appear
● 4 categories
● Intrusive thoughts
○ Repeated, involuntary memories, distressing dreams/flashbacks. As vivid as re-
living the whole scenario again
● Avoiding reminders
○ Places, things that ma remind them of the traumatic event
○ May not want to talk about what happened or how they feel

DSM-V (2013) & Mayo Clinic (2018)

Sign and Symptoms of PTSD
● Negative thoughts and feelings
○ May include ongoing and distorted beliefs about oneself or others
○ Disinterest in activities previously enjoyed
○ Feeling detached/ aloof/estranged from others
○ Other negative feelings
● Arousal and reactive symptoms
○ Irritable and may have angry outbursts
○ Behave recklessly/self-destructive
○ Easily startled
○ Problems
■ Sleeping
■ Concentrating

DSM-V (2013) & Mayo Clinic (2018)

Who is prone to PTSD?
● Exposed victims of the tragic incident
● Those socially isolated
● Women
● Children
● Elderly
● Disabled individuals
● Minority groups
Complications related to PTSD
● Dual Diagnosis (Rassool, 2008)
○ Can be due to pre-morbid or past disaster conditions
○ Linked with substance use or dependence, plus:
○ Other related mental health issues
● Decrease in physical state
○ Especially if client has pre-disaster medical conditions
Burden of PTSD
● Increase of incidence over time
○ Acute onset (with 1 month) - 9.2%
○ Delayed onset (above 6 months) - 19.7%
○ Hurricane Andrew (1992)
■ 6 months 26%
■ 30 Months 29% (Carr et al, 1997; van Griensven, 2000)
● Prevalence of PTSD amongst survivors
○ 40%
● General Population
○ 5-10%
● Dependent on exposure and injury/loss inflicted
● Women more prone - 10% difference
Neria, Y., Nandi, A., & Galea, S.(2008)
Treatment for PTSD
● Psychosocial Interventions to promote recovery
○ Individual Behaviour
○ Families
○ Communities
○ Societies
● Therapeutic Milieu
○ Providing a safe space
■ For client
■ People surrounding client
○ Environment
○ Appropriate or known staff working with client
Question
● Seems that addressing Mental Health issues/PTSD is important
● But should it be done during the acute or immediate phase of a
disaster?
● What if health services is not up yet?
● How can the client get assistance?
Treatment for PTSD
● Treatment and referral to a mental health facility should be sought
as soon as possible.
● Once the health services are back online, and soon after the acute
phase
● Keep the patient close to the current health facility
● Invoke family support - be mindful of the information that you give
out. Patient confidentiality/consent is important
Maslow Hierarchy of Needs
During the acute phase
● Promote recovery
○ Plan and promote normal recovery for majority
○ Promote basic forms of support - with emphasis on natural recovery process:
survival, safety, shelter, reunification
○ Formally intervening may be inappropriate- for the majority this is not required
● During acute emergency phase, interventions should mostly be
social
● Certain issues need to be taken into consideration regarding
psychological interventions
During the acute phase - Social Interventions
● Establish and disseminate flow of information that is credible
● Family tracing
● Organise shelter
● Consult community regarding re-establishment establishment of
activities
● Brief volunteers about typical grief reactions
● Re-establishment of normal events - religious, schools, recreational
During the acute phase - Psychological Interventions

● Managed within primary health care

● Ensure availability of essential psychotropic medications
● Those with urgent mental health problems will likely have pre-
existing conditions
● Mnetal health treatment sought because of extreme stressors of
emergency - best managed without medication / formal
psychological intervention
During the acute phase - Psychological Interventions

● On-to-one sessions not advisable

● Interventions should be preceded by planning for for local context
● Interventions should involve collaboration with Government and
NGOs
● Accessible to whole community
PSS Pyramid

UNISDR. (2011)
Rehabilitation and Post Recovery
● Key issues
○ Mental health promotion framework
○ Long term approach
○ Responding to people who develop a mental health problem
Rehabilitation and Post Recovery
● Mental Health Promotion Framework
○ Focus of interventions are on promoting mental health of a community - not on
specific mental issues
○ Mental health is determined by a wide range of social and environmental factors
○ There are effective public health interventions (eg minimising exposure to
violence) that can be used in emergency situations
○ Whole of community approach
○ Relies on strong intersectoral collaboration
Rehabilitation and Post Recovery
● Long Term Approach
○ Response to trauma varies over time – immediate response is not a good
predictor of long term response
○ Continued mental health interventions from acute phase from
○ Provides an opportunity to restructure existing mental health system
Rehabilitation and Post Recovery
● Responding to mental health issues
○ Most of population will not develop a mental health problem – but health
professionals will need to assess and support those that do
○ Health professionals need skills in assessment and treatment – ideally these
should be developed prior to the emergency
○ Role will also depend on the availability of specialist mental health services
Skills of The Nurse
● Knowledge of people’s psychological reaction emergency situations
- ability to differentiate between ‘normal’ responses and emergence
of serious mental illness
● Active Listener
● Understand available resources
● Techniques for working with traumatised people
● Recognising own response to emergency situation
Reflection/Support
● May come from outside the community – so need good information
before they arrive about the needs of the community
● Ensure that they have realistic objectives
● Ensure cultural and religious sensitivity
● Prepare a ‘Safe Space’ for them to pour out their feelings or just
have a chat
Psychosocial Support Nursing - Nurse as Counsellor

● Establish a rapport
● Obtained an understanding of client’s current situation
○ What/Who he/she has lost
○ His thoughts/feelings currently
○ His stressors
● Information on pre-morbid condition
○ Mental health and medical
● His current lifestyle or coping mechanisms (if any)
● Perform a mental status exam, if possible
● Formulate a plan of care
● Utilise data - subjective and objective
● Corroborate data with friends and family
Nursing Diagnosis - PTSD
● Posttrauma Syndrome
● Risk for Other-Directed Violence
● Dysfunctional Grieving
● Anxiety
● Ineffective Coping
● Disturbed Sleep Pattern
● Ineffective Health Maintenance
● Social Isolation
● Situational Low Self-Esteem
● Ineffective Role Performance
● Risk for Suicide
Sample Care Plan - Posttrauma Syndrome
● Sustained maladaptive response - related to a traumatic event (ie
disaster)
● As evidenced by
○ Flashbacks, nightmares, possible depression, (poor)projection of feelings, low self
esteem, fears - displaced/generalised, abuse (sexual or otherwise), substance
abuse etc
Sample Care Plan - Posttrauma Syndrome
● Expected outcomes
○ Immediate
■ Acknowledge/identify the event
■ Demonstrate decreased physical symptoms
● To address immediately if needed
■ Verbalise need to grieve loss(es)
■ Establish adequate balance of rest, sleep and activity
■ Involve social inclusion exercises
Sample Care Plan - Posttrauma Syndrome
● Expected outcomes
○ Stabilisation
■ Begin the grieving process
■ Express feelings directly and openly in non-destructive ways
■ Identify strengths and weaknesses realistically
■ Demonstrate an increased ability to cope with stress
■ Eliminate substance use, if any
○ Community
■ Demonstrate initial integration of the traumatic experience to the family first,
then community
■ Identify support systems
■ Implement plans for follow up
● Upon re-establishment of mental health services
Sample Care Plan - Posttrauma Syndrome
● Implementation
○ Approach in non-threatening and professional manner and Active Listener
○ Be open and non judgemental
○ View client holistically
■ Gather as much information (subjective and objective)
■ Identify support systems (within family and the community)
■ The losses of the client
■ Substance abuse present?
■ Pre-morbid condition
○ Encourage client to talk
■ Make client comfortable
○ Make realistic plans based on
■ Resources available
■ Health services
Nursing Diagnosis - Dual Diagnosis
● Noncompliance
● Disturbed Thought Process
● Disturbed Sensory Perception
● Deficient Diversional Activity
● Chronic Low Self-Esteem
● Impaired Social Interaction
Role of the Nurse
● Providing supports for meeting basic needs
● Working with and supporting community supporting processes -
building resilience
● Mobilizing and supporting nurses
● Providing direct nursing service/care
● Providing psychosocial supports
● Providing advocacy
● Provides development and capacity builds
● Participate in Disaster Risk Reduction Support Initiatives
Nurse as an Advocate / Lobbyist
● The mental health response in a disaster should The mental health
response in a disaster should based on five core principles (IASC,
2006):
○ Human Rights Promotion and Protection
○ Participation
○ Multilayered Support
○ Do no harm
○ Integration

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Nurse as an Educator
● Participate and contribute in the prevention and preparedness of
future emergencies
● Capacity building of fellow nurses and the community in the
elements of identifying clients with possible PTSD
Four Phases of Emergency Management
● Mitigation
○ Preventing future emergencies or minimising their effects
● Preparedness
○ Preparing to handle an emergency
● Response
○ Responding safely to an emergency
● Recovery
○ Recovering from an emergency

FEMA. (2014)
FEMA. (2014)
Summary
● Psychological and social well-being are integral parts of health being
are integral parts of health
● When psychosocial and emotional functioning is adaptive, the ability
to carry out tasks of physical recovery is increased
● Conversely , when tasks of physical recovery are able to be carried
out, people tend to feel better, more in control and less
overwhelmed
Summary
● Expect normal recovery in disasters and emergencies
● Revise knowledge and understanding on normal grief reactions
● Identify vulnerable group and ensure support
● Do no harm avoid early formal interventions
● Support community resilience through basic support
● Natural recovery process may include some fluctuations but watch
for prolongation watch
References
● Cohen, R. E. (2002). Mental Health Services for Victims Disasters. World Psychiatry,1(3), 149-152. Retrieved April 20, 2018.

● Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington: American Psychiatric Publishing.

● FEMA. (2014, October). The Four Phases of Emergency Management. Retrieved April 21, 2018, from https://training.fema.gov/emiweb/downloads/is10_unit3.doc

● Fullerton, C. S., Ursano, R. J., & Wang, L. (2004). Acute Stress Disorder, Posttraumatic Stress Disorder, and Depression in Disaster or Rescue Workers. American Hournal of Psychiatry,2004(161), 8th ser., 1370-1376.

doi:10.1016/s0084-3970(08)70138-5

● Hughes, F. (n.d.). ADDRESSING MENTAL HEALTH ISSUES IN EMERGENCY AND HUMANITARIAN EMERGENCY AND HUMANITARIAN SITUATIONS SITUATIONS – HOW CAN WE CONTRIBUTE HOW CAN WE

CONTRIBUTE AND WHAT IS THE EVIDENCE? AND WHAT IS THE EVIDENCE? Retrieved April 21, 2018, from http://www3.ha.org.hk/haconvention/hac2008/proceedings/pdf/Symposium/S7-1 Hughes.pdf

● Hughes, F. (n.d.). ADDRESSING MENTAL HEALTH ISSUES IN EMERGENCY AND HUMANITARIAN EMERGENCY AND HUMANITARIAN SITUATIONS SITUATIONS – HOW CAN WE CONTRIBUTE HOW CAN WE

CONTRIBUTE AND WHAT IS THE EVIDENCE? AND WHAT IS THE EVIDENCE? Retrieved April 21, 2018, from http://www3.ha.org.hk/haconvention/hac2008/proceedings/pdf/Symposium/S7-1 Hughes.pdf

● IASC Guidelines Mental Health Psycho Social Support. (2006). Retrieved April 19, 2018, from https://www.scribd.com/document/45787867/IASC-Guidelines-Mental-Health-Psycho-Social-Support

● Neria, Y., Nandi, A., & Galea, S. (2008). Post-traumatic stress disorder following disasters: A systematic review. Psychological Medicine,38(04). doi:10.1017/s0033291707001353

● Post-traumatic stress disorder (PTSD). (2017, October 25). Retrieved from https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

● Rassool, G. H. (2008). Dual diagnosis Nursing. Oxford: Blackwell Publishing.

● Schulz, J. M., & Viedebeck, S. L. (2005). Lippincott's Manual of Psychiatric Nursing Care Plans(7th ed.). New York: Lippincott Williams & Wilkins.

● The Role of the Nurse in Emergency Preparedness. (2012). Nursing for Womens Health,16(2), 170-172. doi:10.1111/j.1751-486x.2012.01726.x

● UNISDR. (2011). Disaster Risk Management for Health: Mental Health and Psychosocial Support. Retrieved April 21, 2018, from https://www.unisdr.org/we/inform/publications/19982

● Varcarolis, E. M. (2000). Psychiatric Nursing Clinical Guide: Assessment tools and diagnoses. Philadelphia: W.B. Saunders.