Image:DFB Leprosy (also known as Hansens Disease) is a chronic, infectious disease involving the skin and nerves of infected

individuals. Pale patches on the skin are usually the first sign of the disease they are painless and do not itch, so are often ignored by the patient. In the past, nerve damage and other complications occurred as the disease progressed. The numbness and lack of feeling in the limbs often led to festering wounds on the hands and feet, and then to the characteristic deformities of the face and limbs. In many communities this led to stigma towards those affected and their families, causing them to be shunned and even excluded from everyday life. Fortunately, antibiotics can now quickly kill the bacteria (germs) that cause leprosy, so the disease can be completely cured with a few months of treatment. If this is started at an early stage, most patients need never suffer the terrible complications which used to be common. Nerve damage does still occur in some patients, but it can often be reversed with other medical treatment. When it cannot be reversed and the person remains with some disability, there are many different strategies of rehabilitation to help them live as normal a life as possible.

How do you catch leprosy?

Leprosy is probably spread like the common cold, but is much less contagious than the cold, or influenza. You really have to live for some years in an endemic area, where new cases of leprosy are continually being detected, to run the risk of catching it. In a study of new cases being put on treatment in the United Kingdom, it was found that all of them had lived abroad in a country with leprosy for at least eight years.

Wasnt leprosy common in Europe at one time?

Evidence of leprosy has been found in skeletons from the ancient Near East and it became a common disease in Europe in medieval times. The disease died out in most of Europe for reasons

which are not clear, more than 200 years ago, although there were significant numbers of new cases in Norway until the early years of the 20th century.

Where does leprosy occur nowadays?

Leprosy remains endemic in poorer parts of the world. In 2006 there were approximately 260000 new cases reported world wide. India currently has about 54% of all the new leprosy cases in the world, followed by Brazil with about 17%, then Indonesia with about 7%. Other countries reporting more than 1000 new cases in 2006 include: Angola, Bangladesh, China, The Democratic Republic of Congo, Madagascar, Myanmar, Nepal, Nigeria, The Philippines, Sri Lanka and Tanzania. In considering the impact of leprosy it is not only the numbers of new cases being detected and treated that has to be taken into account. Many of those cured of the disease will have to live with the consequences of leprosy. It is estimated that probably at least 3 million people are living with some permanent disability due to leprosy, although the exact figure is unknown.

Leprosy research has been given a great boost by the decoding of the genome of Mycobacterium leprae, the causative organism. This gives hope that more effective ways of managing the disease and its complications will be developed and that effective methods of prevention can be found. In the meantime, efforts are being made everywhere to change attitudes, so that leprosy is seen as a disease like any other, which can be treated through the general health services, just as other diseases are.

Leprosy is caused by a bacterium, Mycobacterium leprae, which is closely related to the organism causing tuberculosis. The mechanism of infection is not fully understood, but it is generally thought to be by droplet spread through the upper respiratory tract. The incubation period is long, usually between 2 and 8 years, but it can be up to 20 years in some cases. Casual contact with a person affected by leprosy does not seem to lead to infection. The evidence suggests that residence for several years in an endemic area is needed before the risk of infection

becomes appreciable. The current strategy to control leprosy involves early case finding and treatment with antibiotics, with the aim of stopping transmission of the disease to new contacts. WHO gives an overview of leprosy and leprosy control activities around the world. ILEP Member Associations support leprosy activities on a country-by-country basis throughout the world. In the USA, the Center for Disease Control (CDC) , gives general information about leprosy. The Report of the ILA Technical Forum (394KB), held in Paris in 2002, reviews much of the scientific evidence underpinning current efforts to control leprosy.

Evidence of leprosy has been found in ancient skeletons from the Near East and it was probably present in Western Europe more than 200 years ago. It became a common disease in Europe in medieval times. The disease died out in most of Europe for reasons which are not clear, more than 200 years ago, although there were significant numbers of new cases in Norway until the early years of the 20th century. UNESCO's Memory of the World has extensive archived material from this well-documented epidemic in Norway. An online database of material on the History of Leprosy is available, although unfortunately few of the resources listed in the databases are themselves online. The severe stigma attached to leprosy usually meant that people affected were driven into segregated settlements know as "leper colonies". Fortunately, most of these have either been closed or developed into normal communities.

Image: DFB Leprosy is essentially a clinical diagnosis, although a laboratory test (the slit skin smear) is important in some cases. Normally, the diagnosis rests on finding any one of three cardinal signs, which are fully explained in ILEP's Learning Guide One (526KB):

one or more hypopigmented, anaesthetic skin patches, typical of leprosy; one or more thickened peripheral nerves; or a positive skin smear.

WHO emphasizes the first of these signs for use by junior health workers in endemic areas and gives a clear description of how to examine the skin. Photographs of early skin lesions are available. The place of slit skin smears in the diagnosis of leprosy and technical guidelines for doing the test are contained in ILEP's Learning Guides Three (440KB): As with many diseases, the most accurate diagnostic test is a biopsy, with subsequent staining and histopathological examination of the tissues. One major topic for research at present, is the development of new diagnostic tests, which may allow leprosy to be diagnosed with confidence at a much earlier stage; this would mean that treatment could begin early, resulting in less disability and probably also in less transmission of the disease to contacts.

As a bacterial infection, leprosy can be very effectively treated with certain antibiotics; the bacillus can be easily killed. If there has already been damage to the nerves, however, antibiotics alone will not restore function and other forms of treatment will be needed, including physiotherapy. The first antibiotic to be widely used for leprosy was dapsone , from around 1950 onwards. Dapsone meant a major breakthrough for millions of patients who, until then, had been considered incurable. However, many patients still had to take medicines for life. In 1981, when resistance to dapsone was becoming widespread, WHO introduced Multi-Drug Therapy (MDT) which consisted of two regimens: rifampicin and dapsone for PB leprosy and rifampicin , clofazimine and dapsone for MB leprosy. (Note: rifampicin is also known as rifampin, especially in the USA). MDT has been remarkably successful: there have been very few side effects associated with its use and over 13 million people have been cured of leprosy following its introduction. A useful and detailed review article of leprosy treatment is available. See also the ILEP Learning Guide One (526KB).

Nerve involvement starts quite early in a few cases, but in others occurs only late in the disease, especially if it is left untreated. It commonly leads to weakness of various muscles and loss of sensation in the hands and feet, so that the person no longer feels hot or cold, or even pain - this leads to unintentional damage, ulceration, infection and eventual destruction of fingers and toes, and the well-known deformities of untreated leprosy. The muscles around the eye may also be affected and blindness is another important complication of untreated disease. Efforts to prevent disability in people who already have some nerve damage due to leprosy therefore concentrate particularly on the eyes, hands and feet. Fortunately, the complications of leprosy, such as nerve involvement and eye damage, can themselves be treated, so that the problem may sometimes be reversed completely, or, if that is no longer possible, further deterioration can be prevented. As may be expected, more severe damage requires more complex and lengthy treatment, and is more likely to leave some residual disability or deformity. See ILEP Learning Guide Two (475KB) .

Health Education for POD in Mozambique. Image: Sunil Deepak, AIFO

Image: CIOMAL Some people who get leprosy are unfortunately left with some residual disabilities after the infection itself has been cured. The eyes, hands and feet are the parts commonly affected. In addition, many also face long-term problems within their family and community, simply because they once had leprosy. Rehabilitation involves a whole range of interventions that attempt to restore the person affected to as normal a life as possible. There are two major categories of rehabilitation, although most programs now try to provide both in a holistic manner. Firstly, physical rehabilitation seeks to help people with their normal

daily activities; the methods include physiotherapy and occupational therapy, and sometimes specialized forms of reconstructive surgery to improve the functioning of the hands or feet; special treatment of certain eye problems may also be possible. The aim is to help with the physical demands of daily life.

Image: Georgina Cranston, TLMI The second major category is socio-economic rehabilitation, which seeks to help people rebuild their lives, including their relationships and household economies, both of which are often severely disrupted by having leprosy. Many people with leprosy face the loss of their jobs and divorce or other forms of rejection by society. Rehabilitation involves informing and reassuring the families and communities of the facts about leprosy, as well as developing specific interventions that help to restore dignity to those affected. One of the major aims is to empower individuals, enabling them to have more control over their own situations. A comprehensive paper on the whole field of disability and rehabilitation in leprosy (with references), was written by one of the leaders in the field, Dr H. Srinivasan , in 1998. There are also very detailed and comprehensive training manuals on community-based rehabilitation (CBR) available from WHO (these are all large PDF files) (The ILEP Learning Guide Four is aimed at field staff working with those affected by leprosy.) Description of Articles in Leprosy Facts

Leprosy

Leprosy is a complex infectious disease caused by an infection with the bacteria Mycobacterium leprae. This eMedTV article discusses the disease in detail, including its history, transmission methods, the various types, treatments, and prevalence.

Cause of Leprosy

This eMedTV article discusses the cause of leprosy in detail (the bacteria Mycobacterium leprae) and explains factors that can affect how the bacteria are transmitted, such as genetics and environmental conditions.

Mycobacterium Leprae

Leprosy is caused by bacteria called Mycobacterium leprae. This selection from the eMedTV Web library provides an overview of the bacteria, including history, possible transmission methods, recent statistics, and more.

How Leprosy Spreads

Factors discussed in this eMedTV article that may influence how leprosy spreads include genetics, the degree of susceptibility, and the extent of exposure. This article also looks at the likelihood of transmitting leprosy to household contacts.

Symptoms of Leprosy

People with possible signs and symptoms of leprosy, as this eMedTV resource explains, may experience a symmetrical skin rash, muscle stiffness, or eye problems. Symptoms can also vary based on the type of leprosy a person has, among other factors.

Leprosy Diagnosis

This eMedTV article explains the process doctors use to make a leprosy diagnosis. For example, the doctor begins with a physical exam and questions about the patient's medical history. If needed, a skin biopsy is performed to check for the bacteria.

Treatments for Leprosy

This eMedTV resource discusses various treatments for leprosy, such as antibiotics and supportive care. It also explains possible reactions to treatment, the expected prognosis, and why antibiotics are often combined when used for leprosy.

Effects of Leprosy

This eMedTV article discusses the effects of leprosy in detail (such as muscle weakness, a skin rash, and enlarged nerves). The article also explains factors that can affect the type of symptoms a person has and their severity.

Cures for Leprosy

This eMedTV article lists the most common antibiotics used as cures for leprosy: rifampin, dapsone, and clofazimine. It also explains the success rate with these drugs and what happened to people prior to their development.

How Do You Prevent Leprosy?

How do you prevent leprosy? As this segment of the eMedTV archives explains, the best way to prevent leprosy is to have yearly examinations -- especially if you live with someone who already has the disease.

Leprosy in the United States

There are 200 to 250 new reported cases of leprosy in the United States each year. This eMedTV page explains how 175 of these are cases diagnosed for the first time. The page also lists the states and populations where the disease is often found.

nteresting Facts About Leprosy

By Elisa Lavelinos on December 01, 2011 0

There are many rumors about leprosy, that it seems like a mortal to make - even fatal - illness. But as with any disease, a thorough knowledge will help you distinguish fact from fantasy. Here are some basic and some interesting facts about leprosy.
1. Leprosy is also known as Hansen's disease. This is in honor of Gerhard Armauer Hansen, the first doctor to study the causative agent of leprosy. 2. According to Medical Subject Headings or MeSH (created by the United States National Library of Medicine), the leprosy in three species, namely classified. tuberculoid, borderline and lepromatous; lepromatous leprosy is the most severe, hile Borderline leprosy is the most frequent and of moderate severity. 3. Around 150 new cases of leprosy are detected each year in the U.S. alone, while 250,000 new cases of leprosy detected each year around the world. Around 3 to 4,000,000 people who have suffered from leprosy ongoing care of the disabled left to treat the disease form 4. Young children are more susceptible to leprosy than adults. 5. Leprosy is caused by the bacterium Mycobacterium leprae. The bacterium is pleomorphic (ie, the bacterial cell appears in more than one structural / morphological form during its life cycle) and not by Gram-staining process color (because of the thick outer layer of wax around the cell). The bacterium stains with carbol fuchsin stain, making it a so-called "acid fast" bacteria. 6. The disease has a long incubation period. Incubation period is the initial phase of a disease in which no symptoms are observed. The incubation period of leprosy varies widely, from a few weeks to up to 30 years (asobserved in ex-soldiers)! Average incubation period is about 3 to 5 years (that's a long, long time). This essentially makes the leprosy dangerous, because it was detected until a person to have been infected, he / she may have transmitted the infection to other people. 7. Leprosy is easily contagious. The infected person leads the bacteria by sputum, and the bacterium spread by aerosols generated by a sneeze or cough. However, it is considered to be still slightly contagious due to the fact that a single exposure is insufficient opportunity to develop the disease prolonged exposure is not required. 8. One of the characteristic symptoms of leprosy (as well as its effect) are skin lesions. The lesions manifest at the extremities of the body first - the digits, limbs, ears, nose, etc. If left untreated, the lesions are progressive and can cause curling of the skin. The cartilage is internalized, and the structure of the affected body part is changed. Disfigurement due to skin lesions is a cause of great physical and mental anguish, the infected person. 9. Another painful effects of leprosy is muscle weakness and loss of touch. If the disease progresses, there is loss of sensitivity to an extent, so that a person numb to touch. The numbness is characteristic in the lesions. The loss of sensitivity is difficult due to nerve damage. 10.A common rumor in connection with leprosy is that "fall off" the body parts, such as leprosy progresses. That's not true. The loss of sensation in extremities especially makes one feel like a body part is missing, but the body part actually not "fall"!

11.The common drugs used to treat leprosy are rifampicin, clofazimine, dapsone, fluoroquinolones, minocycline, and macrolides. The treatment immediately after diagnosis ofLeprosy is crucial for several reasons. One of the reasons is that even within 2 weeks of treatment of leprosy is not contagious, as the infectivity of the bacterium is lost. This in turn reduces the quarantine of leprosy patients. This can be great positive psychological impact on the patient. This is essentially why the leprosy research focuses on finding new ways for early diagnosis of the disease. 12.During the treatment phase, the body reacts to the dead / dying bacteria. One effect of this reaction is severe pain and swelling in various parts of the body. Other features of this reaction include fever, redness and pain in the eyes, muscle pain, increased nerve damage, especially in the eyes, hands and feet. Almost half of the leprosy patients suffering from this reaction. However, an appropriate treatment of nerve damage to prevent this reaction. 13.In the old days, lepers were quarantined and continue to live in isolation in "leper colonies" for the rest of their lives. However, it has long been established that isolation is not required treatment.

One of the biggest challenges in relation to leprosy, the fear in the minds of the people removed. Lepers suffer enormous social stigma throughout their lifetime. Many people are not able to take lepers back into their lives, and they are placed under quarantine for life. It should not be so. Yes, the scars left behind in skin lesions acceptance of such people difficult. But you should remember these scars are equivalent to accident scars or wounds scars and nothing more. Within a few weeks of treatment, even leprosy is not contagious. But people still continue to treat the recovered leper with a difference. We should strive to do away with such prejudices.
Read more: Interesting Facts About Leprosy http://www.sooperarticles.com/healthfitness-articles/diseases-articles/interesting-facts-about-leprosy726019.html#ixzz1jg8cGbH8

What is Leprosy?
Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It affects the peripheral nerves and the skin. It does not affect the spinal cord or the brain. Leprosy has a long incubation period, on average 5-7 years, and is the most complex and the most chronic of all human bacterial diseases. Leprosy continues to be a serious challenge in most developing countries, contributing significantly to the physical and social disability of the patients afflicted. It remains a social and medical problem in most Pacific countries.

Is there a cure?
In the 1940s, Dapsone was used to treat leprosy. Since the 1980s, treatment has consisted of a combination of drugs known as Multiple Drug Therapy (MDT). Depending on the severity of their infection, patients receive treatment for periods ranging from 6-12 months. MDT is an effective cure for Leprosy but does not reverse its effects. MDT is provided free throughout the world by the World Health Organisation.

What of the sufferers left disabled and disfigured?

We can greatly improve the day to day lives of those affected by leprosy through your generosity. Please help the Pacific Leprosy Foundation to help them.

Post-Traumatic Stress Disorder Related to the Cancer Experience: Therapeutic Interventions for Post-Traumatic Stress Disorder
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Introduction Criteria for Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder and the Cancer Experience Risk Factors Symptom Responses Nursing Implications Therapeutic Interventions for Post-Traumatic Stress Disorder Resilience and Hope References Sidebar Like this article? Read medical news in 32 specialty areas with our Medscape App. Choose the specialties you want to follow.

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Therapeutic Interventions for Post-Traumatic Stress Disorder

The goals of treatment are focused on functional improvement or reduction of core PTSD symptoms (Foa et al., 2000). For patients with cancer, the oncology nurse is responsible for identifying patients at risk for PTSD by carrying out a thorough and comprehensive psychosocial

assessment of all patients at diagnosis, and repeating assessments throughout the cancer trajectory. Indications for referral and hospitalization may include the danger of harming self or others, the inability to function in life activities, or the need for a patient struggling with major psychological stressors to be evaluated in a secure environment. Treatment should be multidisciplinary with a commitment by all team members to collaborate regarding follow-up and outpatient services, a mandatory requirement for treatment success (Foa et al.; Kwekkeboom & Seng, 2002). Treatments for PTSD range from psychotherapy, cognitive-behavioral therapy, and selective serotonin reuptake inhibitors. Some research has shown success with the use of psychodynamic therapy, hypnotherapy, and eye movement desensitization and reprocessing (Foa et al.). Group therapy and self-help strategies also are effective (Foa et al.). As with other psychiatric disorders, a combination of treatments individualized toward targeting the patient's most pressing symptoms may prove the most promising. Particularly important for traumatized patients is the ability to form and maintain a therapeutic alliance with their caregivers, particularly in regard to trust and safety concerns (Foa et al., 2000). Perceived social support, including positive relationships between the patient and medical staff, has shown to be a protective factor against psychiatric symptoms (NCI, 2009). Oncology nurses are present for their patients at points of time that can foster communication and psychosocial assessment (e.g., chemotherapy administration, follow-up clinic appointments). Oncology nurses provide ongoing education regarding diagnosis and treatment, reassure patients, and can be an ally for their fears and anxieties about the unknown. Providing quiet and relaxing environments and incorporating relaxation techniques, guided imagery, art, and music therapy into treatments and procedures can decrease negative cues that later can be associated through flashbacks or nightmares.

Posttraumatic Stress Disorder (PTSD)

COURSE PRICE: $18.00 CONTACT HOURS: 2 This course is available until August 1, 2014. ACCREDITATION / APPROVAL Wild Iris Medical Education (CBRN Provider #12300) is approved as a provider of continuing education for RNs, LVNs, and respiratory therapists by the California Board of Registered Nursing. Wild Iris Medical Education, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
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Posttraumatic Stress Disorder (PTSD)

Copyright 2011 Wild Iris Medical Education, Inc. All Rights Reserved. By Persis Mary Hamilton, RN, CNS, MS, EdD COURSE OBJECTIVE: To provide information about posttraumatic stress disorder: its history, symptoms, underlying concepts, diagnostic features, treatment, prevention, and resources.
LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

Explain the relationship of trauma, stress, memory, and emotions to PTSD. Identify medical and nursing diagnostic features of PTSD. Evaluate the principle outcome goals of PTSD treatment. Discuss therapeutic approaches for achieving outcome goals.

AN ANCIENT MALADY

History is replete with accounts of individuals who have experienced or witnessed terrifying events; felt intense fear, helplessness, and horror; and suffered ongoing emotional distress.
One of the oldest records of such psychological torment was found in Egypt, circa 1900 B.C.E., where a physician described a peculiar response to earlier trauma (Veith, 1965). In 1606 A.D., Shakespeare portrayed the gruesome dreams, mental anguish, and hallucinations of Macbeth and his wife after the bloody murder of Duncan, King of Scotland. In 1864, John Erichsen published a medical study of people who had survived railway crashes and thereafter developed railway spine, an ongoing fear of speeding trains (Trimble, 1981). Following the Civil War (18611865), veterans who had developed emotional distress were diagnosed as having soldiers heart (Lamprecht & Sack, 2002). In 1901, a physician described a man who survived an industrial explosion and thereafter suffered traumatic reminiscences (Lamprecht & Sack, 2002). After World War I (19141918), veterans with ongoing emotional distress were said to suffer shell shock; following World War II (19391945), such distress was described as battle or combat fatigue (Jones, 2005).

In 1956, Hans Selye wrote The Stress of Life, in which he described how stressors such as extreme fear disrupt the normal balance of life in a process he called the general adaptation syndrome (GAS). Between 1959 and 1973, in the jungles of Vietnam, Laos, and Cambodia, U.S. soldiers fought a terrifying guerilla war in which 58,200 died and thousands suffered injuries. Ongoing psychological distress was common, but veterans had difficulty obtaining disability benefits because there was no accepted psychiatric diagnosis for such emotional and behavioral anguish (Jones, 2005). In 1980, in the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the American Psychiatric Association (APA) classified posttraumatic stress disorder (PTSD) as one of several anxiety disorders. In 1994 the APA further refined criteria for PTSD in DSM-IV, and in 2000 it reaffirmed those criteria in the Textural Revision (DSM-IV-TR). In 1989, because of a recognized need, the National Center for Posttraumatic Stress Disorder was established within the U.S. Department of Veterans Affairs. Its mission was and is to advance the clinical care and social welfare of Americas Veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders (National Center for PTSD, 2011). Beginning in 2001 in Afghanistan and 2003 in Iraq, military action brought increased evidence of the long-term effects of urban warfare and of other terrifying events upon the human psyche. As a result, posttraumatic stress disorder (PTSD) has become the focus of intensive scientific study.

UNDERLYING CONCEPTS

Even though PTSD has been described throughout human history, veterans groups and healthcare providers have been slow to acknowledge its existence or explore its dimensions. This reticence may have been due to the sigma of cowardice and weakness, or perhaps to the variability of symptoms. For whatever the reason, the disorder has been ill defined and its treatment inconsistent. Recently, scientists have begun to understand that people respond to terrifying events in different ways, intensities, and time frames. This response varies, not because of faint-heartedness or mental illness, but because of the complexity of the human brain as it adapts to internal and external stressors. Several complex factors are involved, namely trauma, stress and stressors, memory, and emotions.
Trauma

Trauma is the direct personal experience of an event that involves actual or threatened death or serious injury to ones physical integrity (APA, 2000). Trauma can alter the very foundations of a persons life and cause profound emptiness, loss of hope, trust, or caring for oneself or others. It can produce all manner of disorders, including depression, anxiety, somatoform disorders, substance abuse, psychosis, and personality disorders.
TYPES OF TRAUMA

There are two primary categories of traumatic events: widespread devastation and interpersonal terror.

Widespread Disasters

Widespread devastation affects many people all at the same time. These calamities include natural disasters such as earthquakes, hurricanes, and tsunamis; large-scale transportation accidents; explosions and fire; motor vehicle accidents; life-threatening epidemics; and radiation, terrorist attacks, and wars.
Natural disasters. These are environmental events that adversely affect a significant number of people and include earthquakes, floods, hurricanes, tornados, and tsunamis. Fearing for ones life or witnessing the injury or death of others is the traumatizing aspect of these events. Mass violence. These are vicious attacks on people by people, such as the systematic genocide of European Jews in Nazi death camps before and during World War II and the genocide of non-Arab peoples in the Darfur region of Sudan by Sudanese and Janjaweed militia. Large-scale transportation accidents. These include such tragedies as train derailments, airline crashes, shipwrecks, and auto accidents with multiple victims, high fatality rates, serious injuries, and long delays of rescue. Explosions and fires. These may be caused by gas explosions, regional firestorms, and careless use of candles, cigarettes, and matches. Fires are especially traumatic because they often cause serious injuries requiring reconstructive surgeries, long recovery periods, and ongoing pain and suffering. Motor vehicle accidents. About 20% of individuals in the United States experience one or more serious motor vehicle accident (Briere & Scott, 2007). Many victims go on to develop significant psychological distress, especially if the accident caused major injury or death. Grief and self-blame magnify the psychological aftermath of such events, and survivors may sustain traumatic brain injury, further complicating recovery. Life-threatening epidemics and radiation. Widespread infectious diseases and radiation are considered traumatic events when the diagnosis and treatment are accompanied by ongoing fear, further injury, threat of imminent death, and possibility of a prolonged recovery time. Terrorist attacks and war. Terrorist attacks and war involve a wide range of violent and traumatic experiences that cause injury or death.

Interpersonal Terror

Interpersonal terror includes such things as torture, rape, sexual assault, partner battery, stranger physical assault, kidnap/hostage prey, and child abuseeither as victim or witness.
Torture. Torture has been defined by the United Nations as an act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining information or confession and punishing or intimidating the person or a third person (Vesti & Kastrup, 1995). Methods of torture include beatings, sleep deprivation, electric shock, burning, near strangulation, drowning, crushing, breaking bones, being forced to engage in humiliating acts, sensory deprivation, and threats of death or mutilation. Victims of torture are at high risk for PTSD.

Rape and sexual assault. Rape is nonconsensual oral, anal, or vaginal sexual penetration of the victim, made possible with threats, physical force, or incapacitating drugs. Sexual assault usually refers to any forced sexual contact short of rape. In the United States, 14% to 20% of women and 2% to 4% of men report having been raped. Rape and sexual assault are risk factors for PTSD (Tjaden & Thoennes, 2000). Partner battery (spousal abuse, domestic violence). Partner battery is the physical or sexual assault by one adult of another in an intimate, sexual, and often cohabiting relationship. An amazing one fourth of individuals in the United States who live with a partner report at least one incident of physical aggression such as punching, kicking, or choking (Straus & Gelles, 1990). Stranger physical assault. Stranger assaults are violent acts such as beatings, stabbings, and attempted strangulation by a person who is not well known to the victim. The motive may be robbery or territorial dominance by a gang. Hence, more men than women suffer stranger physical assault. In one study, 64% of men who sought care in an inner-city emergency department went for help because of a physical assault (Currier & Briere, 2000). Kidnap or hostage prey. This is an especially traumatic event because hostages are in immediate threat of injury and death and are helpless to defend themselves. They may be held for hours, days, or even years and physically restrained, assaulted, and deprived of water and food. Whether hostages are alone or within a group, or whether they know their captor or not, they are at high risk for PTSD. Child abuse. Child abuse includes physical, sexual, and psychological violence, ranging from severe spankings to life-threatening beatings, fondling/rape, neglect, and abandonment. Trauma of this kind leaves its victims with major psychological scars and with a greater likelihood of being sexually or physically victimized later in life. Even when childhood sexual abuse does not involve violence or physical injury, it is classified as a traumatic event (Classen et al., 2005). Revictimization. Tragically, victims of interpersonal traumas such as child abuse, partner battery, sexual assault, and rape are at a statistically greater risk for further interpersonal trauma and victimization. Later traumas may lead to additional behaviors and responses that become risk factors for further trauma and complex mental health problems. This mix of multiple traumas and complicated symptomatic responses is well known to traumafocused clinicians, who may find it difficult to trace certain symptoms to specific traumas (Briere & Scott, 2007).

RISK AND RESILIENCE

People respond to trauma in remarkably different ways. When a group of unrelated individuals is exposed to the same traumatic event, one person may develop a full-blown stress disorder lasting for months or years, one may become depressed and suicidal, and another may experience only mild, transient symptoms. Researchers identify such variation of symptoms as risk factors and resilience factors for traumatic distress.

Risk Factors

The presence of any risk factors makes people more vulnerable and more likely to develop severe symptoms. Risk factors fall into at least three categories: (1) variables specific to the victim, (2) characteristics of the trauma, and (3) social response, support, and resources available to the victim after the event.
Victim variables. People who are more likely to develop posttraumatic symptoms are women, younger or older adults, African-Americans and Hispanics, people of lower socioeconomic status, those with prior psychological disorders, individuals with dysfunctional coping styles, people who have previous exposure to trauma, persons with a genetic predisposition, and individuals who express extreme distress during or just after a trauma (Briere & Scott. 2007). Characteristic of trauma. Posttraumatic symptoms are more common when the trauma is an intentional act of violence, produces physical as well as psychic harm, goes on for long periods of time, causes grotesque injury and death, involves sexual assault or rape, brings about the loss of a close friend or relative, and occurs suddenly without warning (Briere & Scott, 2007). Social response, support, and resources. The symptoms and intensity of posttraumatic stress are reduced when family, friends, healthcare providers, and aid agencies provide social support and resources after a traumatic event, including their presence, acceptance, nurturance, tangible assistance, and nonjudgmental empathy, no matter what the trauma.

Resilience Factors

As more is learned about PTSD, leaders in traumatic high-risk occupations are beginning to pay attention to the need for resilience in those who carry out the duties of their occupation. These include such professions as firefighters, emergency care providers, and police and military officers. The National Institute of Mental Health (2011) has suggested five specific actions and personal characteristics that increase resistance to PTSD, as follows:
Seek support from other people, such as friends and family Find a support group after a traumatic event Feel good about ones own actions in the face of danger Possess coping strategies to survive the traumatic event and learn from it Despite feelings of fear, act and respond effectively

Stress and Stressors

The concept of stress began with the pioneering work of Walter Cannon (18711945). He investigated the sympathetic nervous system as it reacts to threat and noticed that the body responds in a predictable sequence. Hans Selye (1991) carried on the work of Cannon, defining stress as the rate of wear and tear on the body and stressors as causative agents of stress. He found that stressors might be physical (such as extreme cold, infection, injury, and pain) or psychological (such as fear, sadness, anger, and disgust). He identified what he called a general adaptation syndrome (GAS) whereby the body maintains homeostasis, or balance (see box). GENERAL ADAPTATION SYNDROME

Alarm Reaction
1. A threat to survival message is conveyed by nerves to the hypothalamus in the brain, which chemically communicates with the pineal gland and pituitary gland, the master control center. 2. The pituitary gland begins mobilizing the release of adrenocorticotropic hormone (ACTH) and the release of activating hormones for the adrenal medulla. 3. The adrenal medulla pumps epinephrine, norepinephrine, and other catecholamines into the blood stream, which causes the: Heart rate and blood pressure to rise, increasing blood circulation and oxygen to the body Airways in the lungs to dilate to facilitate oxygenation of blood Plasma levels of glucose, triglycerides, and free fatty acids to give the body more fuel Platelet aggregation to increase to aid blood clotting Kidney clearance to reduce to prevent loss of water Blood flows to shift from intestinal smooth muscles to skeletal muscles to enable fight or flight (Brigham, 1994)

Resistance
1. Body systems stabilize. 2. Hormone levels return to normal. 3. Parasympathetic nervous system activates. 4. Individual adapts to stress and recovers. If the person does not,

Exhaustion sets in as the individual fails to adapt to stressors and becomes exhausted.
1. Physiological response occurs as in earlier alarm reaction. 2. Energy levels of individual decrease. 3. Physiological adaptation decreases.

Death occurs. Source: Adapted from Selye, 1991.

Memory

Memory is the retention of and ability to recall information, personal experiences, and procedures. It comprises a diverse set of cognitive capacities by which we retain information and reconstruct past experiences (Stanford Encyclopedia, 2010). Although the structure and function of the brain has been studied extensively, there is still no universal agreement about just how memory works. However, research-supported evidence tells us that:
Memory is a set of encoded neural connections that pass through various parts of the brain. The stronger the neural connection, the stronger the memory; the more traumatic an event, the more likely it will be remembered.

Recollections of an event can occur by a stimulus to any of the parts of the brain where there is a neural connection for its memory. If the brain is healthy and people are fully conscious when they experience a traumatic event, the likelihood that they will forget the event is nearly zero, unless they are very young or the brain is injured. Thinking and talking about an experience creates strong encoding by a process called consolidation. Such encoding enhances the chances of remembering the experience. There are distinct types and elements of memory involving different parts of the brain. For example, the hippocampus stores ongoing incidents (shortterm working memory); the amygdala stores emotional memories, mainly negative ones; the prefrontal cortex is involved in the consolidation of longterm memories; the cerebellum, though associated with motor coordination skills, may also be involved in remembering strong emotions, especially in the consolidation of long-term fearful memories. Memories are lost because they were never elaborately encoded. Perception is mostly a filtering and consolidation (defragmenting) process. Interests and needs affect perception, but most of what is available to remember will never be processed and what is processed will be forgotten (Capital Research Limited, 2009). Amnesia (forgetting) is not unusual. It is the standard condition of the human species. We do not forget simply to avoid being reminded of unpleasant things. We forget either because we did not perceive closely in the first place or because we did not encode the experience in the parietal lobes of the cortical surface (short-term memory) or in the prefrontal lobe (long-term memory), a process that requires elaborate encoding (Carroll, 2010). Emotions act on memory at all points of the memory cycle: perceiving, encoding (consolidating), and retrieval (Erk, 2010).

Emotions

Emotions play an important role in the memory of traumatic events. For this reason, caregivers of those who suffer from PTSD need to understand just what emotions are, how they are experienced, and what purpose they serve in the survival of human beings. An emotion is a complex sequence of events having elements of cognitive appraisal, feelings, impulses to action, and overt behavior; it is a feeling that accompanies an adaptive behavior for survival (Plutchik, 1991).
PRIMARY EMOTIONS

Studies of the emotions have identified four positive and four negative emotions relative to the pleasure or displeasure they bring.

EMOTIONS Primary Emotions Degrees of Feeling LifePreserving Functions

Source: Adapted from Plutchik, 1991. Acceptance (love) Anticipation Positi (hope) ve Surprise (shock) Adoration-acceptancetoleration Vigilance-anticipationhope Amazement-surprisedistraction Incorporatio n Exploration Orientation Reproductio n

Joy (happiness) Ecstasy-joy-pleasure Fear (terror) Anger (wrath) Negat Disgust ive (revulsion) Sadness (sorrow)

Terror-fear-apprehension Protection Rage-anger-annoyance Destruction

Loathing-disgust-boredom Rejection Grief-sadnesspensiveness Reintegratio n

Each emotion has varying degrees of intensity and may combine with other emotions to form more complex emotions, such as to jealousy (sadness, anger, fear) and optimism (joy and anticipation). Emotions serve life-preserving functions for the survival of the human species, including: incorporation of what is helpful, exploration of the environment, orientation for the sake of safety, reproduction for continuation of the species, protection against harm, destruction of danger, rejection of what may be harmful, and reintegration to wholeness when wounded. Though emotions may be called positive or negative, in themselves they are neither good nor bad. However, the actions people take when they experience an emotion can be harmful or helpful to others or themselves. For example:
Unmodulated joy may become mania. Uncontrolled anger may beget violence and cruelty. Unresolved sadness may lead to depression and suicide. Unfocused or inappropriate fear may become anxiety, phobia, and paranoia.

FEAR AND ANXIETY

Fear is a normal, protective response to a specific danger, such as an attack by an armed assailant or the sight of a black widow spider. When individuals recognize danger (cognition), feel the emotion of fear (feeling), and have an urge to act (impulse), then they take protective action (behavior) either to fight or take flight. When an event creates an intense experience of the emotion of fear, the event is encoded in memory and acute stress disorder or posttraumatic stress disorder may result. Anxiety is free-floating fear of a nonspecific danger. It creates the same physiological response as fear, yet because individuals do not know who or what is threatening them, they cannot take protective action. As a result, the fear response continues, following the physiological sequence described earlier as General Adaptation Syndrome, and in time individuals become exhausted. At milder levels, anxiety keeps humans alert and focused, which aids in the work of living. However, when anxiety increases, adaptive behaviors decrease, physical symptoms increase, social adaptation and occupational functioning decline, and anxiety disorders follow. Thus, PTSD is classified as one of the anxiety disorders.
Anxiety Disorders

Plotted in an ascending scale of severity, the continuum of anxiety disorders identified by the American Psychiatric Association (APA) is shown below. Note the relative intensity of posttraumatic stress disorder and acute stress disorder as they relate to other anxiety disorders.
ANXIETY DISORDERS Source: Adapted from Shoemaker & Varcarolis, 2006. Mild Modera te Severe Psychos is Anxiety levels that aid in the tasks of living Psychological factors affecting medical conditions Panic disorder Generalized anxiety disorder Obsessive-compulsive disorder Posttraumatic stress disorder (PTSD) Acute stress disorder Somatoform disorders Dissociative disorders Personality disorders Thought disorders Schizophrenia Cognitive impairment disorders

CASE

Alex Moore was brought to the ED by his sister. She had found him writing a suicide note at the kitchen table. The smell of alcohol was on his breath, and there were bottles of both pain and sleeping pills beside him. Five weeks earlier, Alex had left his wife in Texas and driven to his sisters home in California. Three weeks after that he wrecked his truck and became dependent on his sister for transportation. When she confronted him at the kitchen table, he said, Im no damn good to anyone. Youll all be better off without me. After much pleading, his sister talked Alex into going with her to the ED. In the ED Alexs manner was subdued but somewhat hostile, especially when the staff decided to admit him to the hospital as a danger to self. His sister gave further history: For several years Alex had been a fireman. His best friend and fellow fireman died in an explosion and fire that Alex survived. On the one-year anniversary of his friends death, Alex walked off the job and never went back. Since then, he has not been able to settle down or keep a job, has had frequent outbursts of anger, woman problems, troubled sleep, nightmares that he refused to discuss, inability to concentrate, and chronic fatigue. In the hospital Alex was passive, withdrawn, and irritable. He sat stone-faced in group meetings, refusing to participate. He was easily startled by sounds, avoided news programs and movies of violence, and wandered around the ward checking doors and windows. (Continues below)
ASSESSING PTSD

Although there is an increasing awareness of PTSD in servicemen and women returning from combat overseas, it is important to remember that many other individuals may be suffering from the disorder. These survivors may include the diabetic octogenarian in an extended-care facility, a new mother in a postpartum clinic, a non-English-speaking immigrant on dialysis, a high school teacher having a routine physical examination, or a firefighter visiting the emergency department. All patients should be assessed for symptoms of PTSD.
Recognizing Symptoms

Typically, the symptoms of posttraumatic stress disorder fall into three categories: (1) reliving the traumatic event, (2) detachment and avoidance, and (3) exaggerated responses (NCBI, 2010). Reliving the event to a degree that it interferes with normal life activities:
Flashbacks during which the event seems to happen again and again Recurrent distressing memories of the event Repeated dreams of the event Physical reactions to situations reminiscent of the event Emotional numbing, feeling that nothing matters Disengagement and loss of interest in usual life activities Inability to remember important aspects of trauma Avoiding places, people, or objects that bring memories of trauma Loss of hope

Detachment and avoidance:

Exaggerated responses:

Difficulty concentrating Exaggerated startle responses Hypervigilance and unusual awareness Irritability and/or outbursts of anger Sleep difficulties

Clinical Interview

The most common method for assessing individuals for PTSD is the clinical interview. In settings such as emergency departments and clinics, the interview focuses on the individuals immediate safety, emotional stability, and possible exposure to further trauma. The following guidelines may be helpful:
Establish a level of trust before asking about a specific trauma. Explore the persons reason for asking for clinical services. Show empathy as you ask questions. Avoid body language or statements that imply disgust or judgment. Use behavioral descriptions for clarity, such as Did someone do something sexual to you that upset you? rather than Were you raped? Remember, disclosure of trauma history may cause intense anger, guilt, and shame. Pay attention to client reactions to questions, noticing what they do or dont say as well as what topics they avoid, such as use of mind-altering drugs. (Briere & Scott, 2007).

The mnemonic ERRAND may be helpful when assessing for the specific criteria identified by the American Psychiatric Association in the DSM-IV-TR.
ASSESSMENT OF PTSD USING ERRAND Source: Adapted from Kaiman, 2003. Exposure to a traumatic event that occurred more than one month before assessment and involved intense fear, helplessness, or horror and was not merely E an upsetting event. (If trauma occurred less than four weeks before assessment, diagnosis may be acute stress disorder.) R Re-experiencing of a traumatic event in frightening nightmares; restless sleep wit diaphoresis.

Reliving or describing the traumatic event causes extreme distress. Various sights R and sounds remind survivor of traumatic event. Flashbacks of trauma, with visual, olfactory, tactile, and auditory hallucination. Autonomic hyperarousal with exaggerated startle response. Angry outbursts for Alittle reason, impatience, intolerance of crowds. Hypervigilance, sitting with back to walls, inspecting exits, patrolling at night.

Numbing and avoidance. Lack of interest in hobbies or activities. Poor concentration. Emotionally numb, detached, unable to endure strong emotional Nreactions. Feels hopeless, helpless, and worthless; suicidal ideation. Unable to recall important aspects of trauma. Avoids thoughts of people and places associated with trauma. Duration of symptoms. D Acute: one to three months Chronic: three months or more Delayed onset: begin at least six months after trauma

Formal Assessment Tools

Although informal mental status interviews can reveal many posttraumatic stress symptoms, their unstructured nature may overlook important symptoms. For this reason, some clinicians prefer more structured assessment tools.
Clinician-Administered PTSD Scale (CAPS).This 60-minute comprehensive interview covers all DSM-IV-TR criteria plus the impact of the disorder on occupational and social functioning, symptom severity, guilt, and dissociation (Blake et al., 1995). Brief Interview for Posttraumatic Disorder (BIPD). This 20-minute interview is less structured, but it covers all categories of PTSD, acute stress disorder, and brief psychotic disorder. It is less objective than CAPS but takes one third the time (Briere, 1998). Acute Stress Disorder Interview (ASDI). This brief tool (15 minutes) is especially useful when the issue is acute stress disorder (ASD) as opposed to PTSD. It evaluates effortful avoidance, dissociative, re-experiencing, and arousal symptoms (Bryant et al., 1998). Posttraumatic Stress Diagnostic Scale Davidson Trauma Scale Detailed Assessment of Posttraumatic Stress Trauma Symptom Inventory Trauma Symptom Checklist for Children Minnesota Multiphasic Personality Inventory, 2nd ed. Millon Clinical Multiaxial Inventory, 3rd ed. Symptom Checklist-90-Revised

Other trauma-specific tests include:

Generic tests include:

Physical Examination

Although it may seem obvious to healthcare professionals, people with acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) should have a complete physical examination to check for endocrine, cardiovascular, and neurologic disorders. Furthermore, patients should be

asked what over-the-counter drugs and mood-altering substances they are taking (e.g., alcohol, marijuana).
DIAGNOSIS Medical Diagnosis

A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The box below gives the American Psychiatric Association diagnostic criteria for PTSD. When individuals develop similar symptoms lasting 2 days within 4 weeks of a traumatic event, the diagnosis is acute stress disorder (ASD). APA DIAGNOSTIC CRITERIA FOR PTSD
A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. The persons response involved intense fear, helplessness, or horror
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions 2. Recurrent distressing dreams of the event 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feelings of detachment or estrangement from others 6. Restricted range of affect 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by two or more of the following:

1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hypervigilance 5. Exaggerated startle response
E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than 1 month F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify:

1. Acute: duration of symptoms is less than 3 months 2. Chronic: duration of symptoms is 3 months or more 3. With delayed onset: onset of symptoms is at least 6 months after trauma (stressor event).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Copyright 2000, American Psychiatric Association.
Nursing Diagnosis

Nursing diagnoses are words or phrases that describe an actual or potential human response to health conditions and life processes (NANDA International, 2011). CASE (continued)

Meeting with Alex in the ED, the nurse learns more about his case. She develops some likely nursing diagnoses:
Risk for suicide related to his feelings of helplessness, hopelessness, and worthlessness as evidenced by verbal and written statements Ineffective coping related to PTSD, as evidenced by his inability to keep a job, abruptly leaving his wife, and wrecking his vehicle Disturbed sleep pattern related to his recurring and distressing dreams of fire and explosion as evidenced by verbal statements, irritability, and chronic fatigue Dysfunctional grieving related to the death of his friend in a traumatic event as evidenced by quitting his job on the anniversary of death and verbal and written statements Anxiety related to PTSD, as evidenced by his inability to concentrate and angry outbursts

(Continues below)
PLANNING

Planning care involves establishing client-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by client safety, client desires, and nature of the treatment.
Goals and Outcomes

The number one, over-arching goal of treatment for people suffering from PTSD is reintegration, by which the traumatized person metabolizes or internally resolves distressing feelings, thoughts, and memories. This goal influences all therapeutic interventions. The intrinsic function of reliving these experiences appears to be the processing and integrating of disturbing material. This internal working-through activity builds on the innate tendency of humans to process trauma-related memories, adapt to new realities, survive, and even thrive. From the perspective that posttraumatic stress is adaptive, symptoms such as flashbacks, recurring images, and dreams can be considered recovery procedures, not pathological symptoms. Thus, nurses and other clinicians see traumatized individuals not as collections of pathological symptoms but as people who are at some level attempting to recover, albeit not always successfully (Biere & Scott, 2007). The second most important goal of treatment is personal growth. This is not to be interpreted as some platitude about growing stronger through testing or making lemonade from lemons. It does mean that not all traumatic events are inevitably tragic. Adversity can cause people to develop in ways they never would have imagined, such as acquiring new levels of resilience, greater self-knowledge, additional survival skills, increasing empathy for others, and a broader view of life. At first, people who have suffered great trauma need safety, attention to life support, and help with painful symptoms. Later in the recovery process, personal growth becomes evident (Biere & Scott, 2007). CASE (continued) In planning for Alexs treatment, the most urgent problem is his risk for suicide, followed by a disturbed sleep pattern that impairs thinking. His dysfunctional grieving, ineffective coping, and

anxiety should be addressed as he works through and resolves the distressing feelings and memories of the explosion, fire, and death of his friend. The goals and outcomes for each of Alexs nursing diagnoses are as follows:
Risk for suicide: Alex will refrain from attempting suicide. Ineffective coping: Alex will begin to follow through with promises and plans. Disturbed sleep pattern: Alex will sleep at least 7 hours per night without nightmares. Dysfunctional grieving: Alex will be able to talk about his lost friend in a therapy group. Anxiety: Alex will no longer pace the halls and will sit quietly in group.

(Continues below)
TREATMENT Basic Principles

To achieve reintegration and personal growththe primary goals of treatment for traumatized individualsclinicians follow these basic principles:
Respect and positive regard for survivors of trauma Hope and expectation of recovery Safety from further trauma Physical and emotional stability Consistent therapeutic relationships with caregivers Individualized treatment plans that are sensitive to gender and sociocultural issues, supported by every member of the treatment team, evaluated continually, and revised appropriately (Foa et al., 2000).

Elements of Treatment

A review of existing literature suggests that, regardless of the theoretical stance of therapists, effective treatment for PTSD includes: (1) provision of a healing environment; (2) education about trauma; (3) distress reduction and emotion regulation; (4) cognitive interventions; (5) emotional processing; (6) increasing identity and relational functioning; and (7) psychopharmacology.
HEALING ENVIRONMENT

A healing environment is a place of safety from physical and emotional assault. It is a haven of stability and order with a predictable schedule; adequate food and shelter; and an environment of human kindness, respect, and safety. It is a place where survivors of trauma receive unconditional positive regard, nonpossessive warmth, genuineness, and accurate empathy (Rogers, 1961; Carkhoff, 1977). In such a sanctuary, a consistent, therapeutic relationship is established where every individual is respected and taken seriously. Survivors are commended for the strength and courage they demonstrate by their mere presence and willingness to confront painful memories.

EDUCATION ABOUT TRAUMA

Education about trauma and its symptoms greatly facilitates healing. It not only gives survivors information about the nature of trauma and its effects, but it also validates their experience and helps them integrate relevant information into their overall perspective. Education about trauma is especially valuable for victims of interpersonal violence because their reality may have been distorted by their abusers, making them believe they deserved the abuse and are to blame for its consequences. Education for survivors of trauma focuses on the following topics:
The prevalence of trauma Common myths associated with the trauma Usual reasons why perpetrators engage in interpersonal violence Typical immediate responses to trauma Lasting posttraumatic responses to victimization Trauma processing and reframing symptoms Safety planning for at-risk victims

When education is imbedded in the therapeutic context, it becomes more relevant and better integrated into the understanding of survivors. In addition to planned education from clinicians, survivors learn from fellow members of a support group and from well-chosen, timely handouts and self-help books. Regardless of the source, all educational material should be monitored and evaluated for:
Accuracy and quality, making sure the information does not blame the victim or advocate from some social or religious perspective Language that fits individual reading and comprehension levels Cultural suitability that is free of prejudicial views of race, sexual orientation, gender, and customs Appropriateness for the stage of healing of survivors

(Sources of handouts and books are listed in the Resources section below.)
DISTRESS REDUCTION AND EMOTION REGULATION

Survivors of trauma often suffer chronic levels of anxiety and arousal and strong negative emotional responses to trauma-related memories. Such memories are easily triggered and difficult to manage. Because these feelings are so vivid and painful, survivors may rely on avoidance strategies, including substance abuse, dissociation, and unhealthy tension-reducing behaviors (such as binge eating, promiscuous sex, and self-mutilation). Avoidance measures hinder recovery and may cause survivors to drop out of therapy and give up. To help people cope with distress and increase their capacity to regulate negative emotions, clinicians use and teach stress-reduction activities, including grounding, breathing-relaxation exercises, and emotional regulation.
Grounding

In therapy sessions, when clients experience sudden panic, flashbacks, intrusive negative thoughts, dissociative states, or psychotic symptoms, the therapist may use a technique called grounding. At these times the clinician changes the subject from whatever was being discussed to the immediate therapeutic process. To reduce such overwhelming distress, the therapist may

lead the person in breathing or other relaxation exercises, or just sit quietly, acknowledging their pain. Grounding should be used judiciously to avoid implying that something has gone wrong.
Breathing-Relaxation Exercises

Slow, deep breathing lowers tension and leads to inadvertent muscle relaxation. When trauma survivors learn how to breathe deeply and relax, they have a tool they can use at any time and in almost any place. Such knowledge is empowering. Many therapists begin each session with breathing or relaxation exercises to foster a sense of control and safety in survivors. BREATHING EXERCISE This simple breathing-relaxation exercise can be led and modeled by a therapist, who asks survivors to:
Stand and stretch, then to sit in a comfortable position, close their eyes, take a deep breath, and slowly exhale Move their feet, then relax them and continue deep breathing Tense their leg muscles, then relax, and breathe deeply Successively tense and then relax their buttocks, abdomen, back, chest, upper arm, lower arm, and finger muscles and breathe deeply Note the pulse in their fingertips and move a finger when they do (This authenticates the exercise for clients and reveals their degree of participation.) Successively relax their neck, head, and finally, entire body Sit quietly until the therapist tells them to open their eyes and return to the wakeful world (5 to 20 minutes)

With relatively little practice, survivors can learn this deep breathing, self-relaxation exercise and by so doing gain a sense of empowerment and control.
Emotion Regulation

In addition to grounding and relaxation, therapists have identified several techniques to help trauma survivors tolerate and reduce negative emotions. These skills include learning to (1) identify and discriminate between emotions, (2) recognize and counter thoughts that trigger intrusive emotions, (3) notice triggers and intervene, and (4) resist harmful tension-reducing behaviors.
Identify and discriminate between emotions. Many survivors of trauma have trouble knowing exactly what they are feeling beyond a sense of feeling bad or upset. In addition, some individuals have difficulty differentiating anger from fear, disgust, or sadness. For example, survivors may not be able to say, I feel fearful, let alone say, I feel fearful because I feel threatened by. . . . Therapists can help survivors in this area by regularly discussing the emotional experiences of clients. Recognize and counter thoughts that trigger intrusive emotions. Not only do survivors need to identify feelings, they need to identify thoughts, especially thoughts that trigger strong emotional reactions. By becoming aware of triggering thoughts, survivors can lessen their impact by explicitly countering a thought, for example, Nobody is out to get me. As survivors

become able to identify such ideas, place them in a realistic context, and counter them with positive thoughts, they develop the capacity to prevent and regulate intrusive emotions (Biere & Scott, 2007). Notice triggers and intervene. By identifying triggers in the environment, survivors gain a greater sense of control and safety. They do this by (1) noticing particular thoughts or feelings that are trauma-related; (2) evaluating the specific feature of the thought or feeling that triggers traumatic memory, such as a personal characteristics of their abuser, the sound of a child crying, and the sight of an ambulance; (3) constructing an adaptive strategy, such as taking a time out, deep breathing, giving themselves positive self-talk, or using a distraction, such as reading a book. Resist harmful tension-relieving behaviors. Often survivors relieve their distress by engaging in harmful tension-reducing behaviors, such as binge eating, promiscuous sex, and self-mutilation. Although it would be best to prevent all such behaviors, in reality, stopping such behavior may be impossible, short of hospitalization. Since avoidance behaviors are survivalbased, they are not easily abandoned. However, victims of trauma may be able to delay or reduce the behavior. For instance, a survivor may be able to delay binge eating, tolerate brief periods of discomfort, and eventually overcome the behavior.

COGNITIVE INTERVENTIONS

Survivors of trauma, especially those who have suffered interpersonal violence, are prone to harbor negative beliefs and perceptions about themselves, such as shame and guilt. Cognitive therapy involves reevaluating those beliefs and perceptions and replacing them with more affirming and empowering views. The central goal of cognitive therapy is to assist clients to explore and think through their beliefs within the context of when and how those beliefs developed. The process involves talking about a traumatic event and gaining a better understanding of their reasoning. As they describe a traumatic event chronologically and analytically and place it in a larger context, clients experience an increased sense of perspective and reduced feelings of chaos (Meichenbaum & Fong, 1994). The retelling and the rethinking of a traumatic event somehow provides a degree of closure so that the event does not require further rumination and preoccupation. In this way, survivors develop a coherent narrative(logical story) of the trauma that upset them and are able to incorporate it into their ongoing life.
EMOTIONAL PROCESSING

Emotional processing of traumatic events involves exposure to traumatic memories at the same time the survivor is experiencing safety. Over time, the expectation of treatment is that the extreme fear and horror of the original trauma (the conditioned emotional response) lessens and gradually is extinguished. Eventually, the survivor is able to remember the event without reexperiencing the fear and horror associated with it. Emotional processing is said to follow a fivestage sequence: exposure, activation, disparity, counter-conditioning, and desensitization.
Exposure. The survivor is exposed to trauma-memory, either as a result of thinking, telling, or being reminded of the trauma from something in the environment.

Activation. The exposure activates emotional responses that were coencoded with and conditioned to these memories. Disparity. The activated emotional responses of fear and anger are not reinforced in the safety of the therapeutic setting. Counter-conditioning. The activated emotional responses of fear and anger are counter-conditioned by opposite emotional experiences as he relives the trauma. Desensitization. The counter-conditioning leads to extinction of the original memory-emotion association.

CASE (continued) Alexs healthcare provider believes that emotional processing is an appropriate treatment for him. In a group therapy session with other survivors, Alex talks about the fire and explosion that killed his best friend (exposure). Alex remembers his frantic efforts to see through the flames and smoke. He feels again the intense fear and frustration (anger) of entrapment and helplessness as he tries to find his way out of the debris (activation). Unlike during his traumatic experience, Alex is now sitting in a comfortable chair in a nonthreatening, well-ventilated, safe place with people who accept and care for him (disparity). He is not restrained and is free to move about as he wishes. The fear and anger Alex felt at the time of the explosion is directly opposite the safety, positive regard, acceptance, validation, and genuineness he now feels from the environment and fellow survivors (counter-conditioning). Over time, with repeated experiences of safety and emotional support, even as he tells his narrative of horror, Alex gradually experiences less and less fear, anger, and guilt. He no longer needs to avoid the triggers he once did, nor does he need drugs and alcohol to quell his emotional pain (desensitization). (Continues below) Because exposure of survivors to the horror of a traumatic event can be extremely upsetting, therapists seek to control the intensity of emotions within a therapy session. Ideally, at the beginning of a session survivors are not aroused. In the safety of the therapeutic setting, they may become aroused as they process the traumatic event. As the session draws to a close, the therapist seeks to lower the level of emotionality so that survivors can leave the session in as calm an affective state as possible. Exposure to traumatic memories may be contraindicated for some survivors, including clients who are severely depressed, extremely anxious, acutely psychotic, or overwhelmed by guilt or shame. Interventions for these clients include the affect regulation and cognitive interventions discussed earlier, psychiatric medication, and hospitalization.
INCREASING IDENTITY AND RELATIONAL FUNCTIONING

Many survivors of multiple traumas have great difficulty with self-identity and interpersonal relationships. This is particularly true of survivors of early and severe childhood trauma who have problems recognizing their own needs and entitlements, maintaining a consistent sense of self, and establishing an internal reference point in times of stress (Allen, 2001). As abused children, they may have concluded that all people are dangerous and that they themselves are intrinsically unacceptable and deserve punishment or disregard. Because of these entrenched problems with personal identity and interpersonal functioning, untreated survivors are more

likely to fall victim to multiple abusers, compounding their issues and leading them into further difficulties. Interventions for survivors with personal identity and interpersonal relationship issues are the same as for all victims of trauma, however a safe and nurturing environment in the presence of beneficent others is especially important. From caring relationships, they are able to gain a sense of personal identity and dignity and learn how to communicate assertively without submission or domination by anyone. Eventually, relating to others no longer triggers the same level of fear, anger, distrust, and avoidant behavior it once did and survivors are able to sustain positive interpersonal relationships.
PSYCHOPHARMACOLOGY

While supportive therapy is of enormous value for sufferers of PTSD, individuals may be so overwhelmed by the disorder they are unable to participate in therapy. In addition, they may suffer from other psychological conditions, such as depression, other anxiety disorders, and psychotic conditions. For this reason, psychotropic medications can be useful adjuncts to traumafocused therapies, especially in the early phase of treatment. Several classes of medications are effective in the treatment of anxiety disorders, including antidepressants, anxiolytics, and others. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment (Simon & Rosenbaum, 2003; National Center for PTSD, 2011). Results of many randomized, double-blind, placebo-controlled studies of SSRIs indicate that these drugs reduce symptoms in the three core symptom clusters of PTSD, namely re-experiencing, hyperarousal, and avoidance. SSRIs are preferable to tricyclic antidepressants because they have more rapid onset of action and fewer side effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if clients eat food containing tyramine. Sufferers of PTSD often self-medicate as a means to avoid or nullify their symptoms, misusing prescribed drugs or self-medicating with alcohol, marijuana, and various herbal preparations. For this reason, PTSD treatment centers advise their clients to refrain from use of nonprescribed substances. When medications are prescribed for clients, clinicians assume the responsibility to monitor both their symptom relief and their overall health status.
MEDICATIONS FOR PTSD Class Antidepressants Selective serotonin reuptake inhibitors Citalopram (Celexa) (SSRI) Duloxetine (Cymbalta) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) 1060 mg 40-60 mg 1080 mg 100300 mg 1060 mg 50200 mg Generic (trade) name Usual daily dose (mg/day)

MEDICATIONS FOR PTSD Class Generic (trade) name Usual daily dose (mg/day)

Venlafaxine XR (Effexor XR) 75225 mg Other serotonergic agents Mirtazapine (Remeron) Trazodone (Desyrel) Bupropion (Wellbutrin) Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Amitriptyline (Elavil) Tricyclic antidepressants Clomipramine (Anafranil) Desip Anxiolytics Alprazolam (Xanax) Chlordiazepoxide (Librium) Diazepam (Valium) Lorazepam (Ativan) Nonbenzodiazepine Buspirone (BuSpar) 0.252.0 mg 1575 mg 2.510 mg 0.56.0 mg 3060 mg 1545 mg h.s. 150600 mg 150300 mg 1519 mg 3060 mg 50300 mg 100250 mg

Benzodiazepines

EVALUATION

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. Evaluation questions include:
Are clients re-experiencing the traumatic event in flashbacks, nightmares, intrusive thoughts, and dissociation? If so, are these experiences less or more frequent?

Are clients exhibiting hyperarousal symptoms such as restless sleep, muscle tension, irritability, jumpiness, and concentration difficulties? If so, are these symptoms lessening or increasing? Are clients using avoidance measures such as binge eating or alcohol abuse to evade thoughts or feelings about their traumatic experience?

CASE (concludes) Six months after he began treatment, Alex meets with his healthcare provider. In evaluating his treatment, she determines that he has achieved most of his goals:
He has refrained from attempting suicide. He has begun to follow through and keep promises. He has fewer nightmares and is sleeping longer periods of time. He is able to talk about his lost friend in the therapy group. He no longer paces the halls and is able to sit quietly in group.

PREVENTION

Although natural disasters cannot be prevented, the damage they cause can be anticipated and sometimes mitigated. When such disasters do occur, official and charitable agencies can provide tangible assistance and emotional support. Some occupations, by their very nature, expose individuals to terrifying traumatic events. These include such dangerous professions as military service, firefighting, underground mining, and deep-sea exploration. To prevent or at least reduce the number of individuals who develop posttraumatic stress disorder, leaders in these professions have begun assessing potential candidates for risk of posttraumatic stress disorder. In addition, they are now providing resilience education for those who are accepted. (See also Risk and Resilience above). As the medical profession becomes aware of the widespread instance of posttraumatic stress disorder in the general population, greater attention will be paid to its prevention and to effective treatment for its victims.

RESOURCES

International Society for Traumatic Stress Studies http://www.istss.org/resources/index.htm Office for Victims of Crime, U.S. Department of Justice http://www.ojp.usdoj.gov/ovc/help/ David Baldwins Trauma Information Pages http://www.trauma-pages.com/pg4.htm United States Department of Veterans Affairs, National Center for PTSD http://www.ptsd.va.gov
REFERENCES

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