PSYCHIATRIC DISORDERS RELATED TO ABUSE AND VIOLENCE
Posttraumatic stress disorder is a disturbing pattern of behavior demonstrated by someone who has experienced a traumatic event such as a natural disaster, a combat, or an assault. The person with PTSD was exposed to an event that posed a threat of death or serious injury and responded with intense fear, helplessness, or terror. Three clusters of symptoms are present: reliving the event, avoiding remind-ers of the event, and being on guard, or experiencing hyperarousal. The person persistently reexperiences the trauma through memories, dreams, flashbacks, or reac-tions to external cues about the event and therefore avoids stimuli associated with the trauma. The victim feels a numbing of general responsiveness and shows persistent signs of increased arousal such as insomnia, hyperarousal or hypervigilance, irritability, or angry outbursts. He or she reports losing a sense of connection and control over his or her life. In PTSD, the symptoms occur 3 months or more after the trauma, which distinguishes PTSD from acute stress disorder.
PTSD can occur at any age, including during childhood. Estimates are that up to 60% of people at risk, such as combat veterans and victims of violence and natural disas-ters, develop PTSD. Complete recovery occurs within 3 months for about 50% of people. The severity and dura-tion of the trauma and the proximity of the person to the event are the most important factors affecting the likeli-hood of developing PTSD (APA, 2000). One fourth of all victims of physical assault develop PTSD. Victims of rape have one of the highest rates of PTSD—approximately 70 percent (van der Kolk, 2005).
Dissociation is a subconscious defense mechanism that helps a person protect his or her emotional self from rec-ognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociation can occur both during and after the event. As with any other protective coping mechanism, dissociating becomes easier with repeated use.
Dissociative disorders have the essential feature of a disruption in the usually integrated functions of con-sciousness, memory, identity, or environmental percep-tion. This often interferes with the person’s relationships, ability to function in daily life, and ability to cope with the realities of the abusive or traumatic event. This distur-bance varies greatly in intensity in different people, and the onset may be sudden or gradual, transient or chronic. Dissociative symptoms are seen in clients with PTSD.
The DSM-IV-TR describes different types of dissociative disorders:
· Dissociative amnesia: The client cannot remember im-portant personal information (usually of a traumatic or stressful nature).
· Dissociative fugue: The client has episodes of suddenly leaving the home or place of work without any explana-tion, traveling to another city, and being unable to re-member his or her past or identity. He or she may assume a new identity.
· Dissociative identity disorder (formerly multiple person-ality disorder): The client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. This is accompanied by the inability to recall important personal information.
· Depersonalization disorder: The client has a persistent or recurrent feeling of being detached from his or her mental processes or body. This is accompanied by intact reality testing; that is, the client is not psychotic or out of touch with reality.
Dissociative disorders, relatively rare in the general pop-ulation, are much more prevalent among those with histo-ries of childhood physical and sexual abuse. Some believe the recent increase in the diagnosis of dissociative disorders in the United States is the result of more awareness of this disorder by mental health professionals (APA, 2000).
The media has focused much attention on the theory of repressed memories in victims of abuse. Many profession-als believe that memories of childhood abuse can be buried deeply in the subconscious mind or repressed because they are too painful for the victims to acknowledge and that vic-tims can be helped to recover or remember such painful memories. If a person comes to a mental health profes-sional experiencing serious problems in relationships, symptoms of PTSD, or flashbacks involving abuse, the mental health professional may help the person remember or recover those memories of abuse. Some mental health professionals believe there is danger of inducing false memories of childhood sexual abuse through imagination in psychotherapy (Rubin & Berndtson, 2007). This so-called false memory syndrome has created problems in fami-lies when clients made groundless accusations of abuse. Fears exist, however, that people abused in childhood will be more reluctant to talk about their abuse history because, once again, no one will believe them. Still other therapists argue that people thought to have dissociative identity dis-order are suffering anxiety, terror, and intrusive ideas and emotions and therefore need help, and the therapist should remain open-minded about the diagnosis.
Survivors of trauma and abuse who have PTSD or dissocia-tive disorders often are involved in group or individual therapy in the community to address the long-term effects of their experiences. Cognitive–behavioral therapy is effec-tive in dealing with the thoughts and subsequent feelings and behavior of trauma and abuse survivors. Therapy for clients who dissociate focuses on reassociation, or putting the consciousness back together. Both paroxetine (Paxil) and sertraline (Zoloft) have been used to treat PTSD suc-cessfully. Clients with dissociative disorders may be treated symptomatically, that is, with medications for anxiety or depression or both if these symptoms are predominant.
Clients with PTSD and dissociative disorders are found in all areas of health care, from clinics to primary care offices. The nurse is most likely to encounter these clients in acute care settings when there are concerns for their safety or the safety of others or when acute symptoms have become intense and require stabilization. Treatment in acute care is usually short term, with the client returning to community-based treatment as quickly as possible.