Post Traumatic Stress and the Nursing Diagnosis; Part 2.


Emotional Responses vs. Responsive Pathology

It is important for an attorney to note that the key to determine whether or not a client is malingering to enhance the potential damage award is to review the therapeutic encounters. There must be a paper trail showing the process of diagnosis and attempts to assist the client in making improvements through thought, speech and action. Therefore it is imperative to understand the various conditions that result from a response to trauma and how they are treated.

The Diagnosis and Treatment of the Post Traumatic Stress Responses

As mentioned in the last issue, trauma is a sudden event that alters the course of a person’s life. The change can be temporary or permanent and affects every aspect of being. All goals and expectations developed over a lifetime are instantly stripped away with nothing to look forward to except pain and anguish. If that weren’t enough, the road to recovery is fraught with obstacles, i.e. harmful coping mechanisms and responses such as flash backs, recurrent nightmares, intrusive thoughts, sleep deprivation, chronic pain, alterations in body image, self esteem and social relationships, loss of independence, lower frustration tolerance, irritability, inappropriate startle responses to common sounds and alterations in danger perception. Additionally, as mentioned previously, most of us have experienced a traumatic event at on time or another and all human beings experience various emotional responses. However, given how the legal system has evolved, it is now crucial to be able to distinguish between resolvable responses and responsive pathology. Accordingly, we now turn our attention to understanding the dynamics of how legitimate therapists will identify and resolve those responses, so that the attorney can know when there is legitimate evidence of pathology indicating an extended period of pain and suffering that meets legal threshold requirements.

Flash Backs

Among all of its amazing functions the human brain is a flawless recording device. All input stimuli such as sound, light, color, wind, thermal changes, wetness, dryness, movement, etc. are recorded in the brain’s memory cells and remain for the duration. The faultiness of human memory is in the ability to recall. Nonetheless, everything that reaches the brain through the five senses gets recorded. Thus, one of the problems with trauma is that when there is an overwhelming sudden input of stimuli the brain records it exactly as it occurred with a larger-than-normal overlay. Hence, just as a disk as a limit to how much information it will hold, the memory cell can only hold a finite amount of “data”. So more cells  are employed to hold the memory of an event that generated more than the usual amount of stimuli to which the person was accustomed. Therefore, the brain kicks into an “auto-replay” mode and stays there. This phenomenon is called a “flash back”.Accordingly, people who experience flash backs describe reliving the incident over and over again, with the frequency and timing of the repetitions being unpredictable. Thus this response usually keeps the victim from being able to carry out his or her usual activities. Most patients that I have spoken to said that it’s like being hooked up to a virtual reality computer and being stuck in a programming loop. This condition differs from having recurrent nightmares in that by definition, it only occurs when the patient is awake. Consequently, this trauma response is very disturbing and requires some coaching in how to handle it. It most cases this natural phenomenon is self correcting of a brief period of time.

Recurrent nightmares

Recurring nightmares are more of an insidious problem than flashbacks because they are occurring at a time when we relinquish control over our bodies. Aside from the many spiritual and psychological interpretations of dreams, they are most often a manifestation of thoughts and desires occurring during the previous day. This is why we often find ourselves doing things in our dreams that we would never think of doing for real. By the same token, the victim, who usually has morbid thoughts about different possible scenarios related to the incident, will often relive the occurrence, while dreaming, in ways that are much worse than what actually happened.On the other hand, the nightmare itself is of no consequence. The actual problem is in how the person responds to it after waking up. Most people awake from such episodes with a high level of stress with increased heart, respiratory rates, blood glucose levels and blood pressure. There is some release of adrenalin and other hormones that are supposed to be triggered only when there is danger. The usual emotional response to the dream is feeling upset and engaging in more thought about the traumatic incident. Hence, the key to resolution is learning that such dreams must be disregarded as being of no importance and are a mere reflection of what a person was thinking of during the day. Therefore, if we subscribe to this theory as truth, we know that reducing the amount of time one spends thinking about the incident will reduce the frequency and intensity of the nightmares.

Obsessive Thoughts

Obsessive or intrusive thoughts are the means by which the harmful emotional reactions perpetuate. The thought process gives rise to all of the above mentioned emotional responses i.e. anger, anxiety, depression, etc. In the dichotomy of the human condition (emotion versus intellect), the negative emotional component of the mind-body has equal access to the reasoning apparatus of the brain. Hence thoughts often emanate from this negative side. Additionally, negative feelings such as anger, sorrow and anxiety have a natural tendency to dissipate just as boiling water turns to steam and empties itself from the vessel. Therefore, it takes a considerable effort to perpetuate those harmful responses. Moreover, as part of the natural human condition, there is a negative component of every human that has an agenda to accomplish immediate gratification at any cost and it does not have the capacity to weigh in with the unintended consequences. This “side” is perpetually at war with the intellect which fights to maintain control in view of the unwanted consequences of transforming impulses into action. Hence every decision is an answer to the question “Should I or shouldn’t I?”

Therefore, the astute professional teaches the client to focus on good thoughts. Which begs the question, “How is it possible to think only good thoughts with all of the hurt and anguish and with financial problems looming on the horizon?” Although it is no easy task, one can begin by taking inventory. Obviously, after a personal disaster, there are likely to be some permanent losses. So, what is the most logical thing to do first? Take stock of the remaining assets to see what there is to work with. The one obvious thing that most people overlook is, “I have survived. I am still alive.” The survivor needs to be both happy and grateful for that one fact. This is a crucial element, because there can be no progress otherwise. The presence or absence of this dynamic in any therapy session culminating in an expert’s report is a good test for weeding out malingerers.

Sleep deprivation

Sleep deprivation is a response to a series of responses. Pain, anxiety, depression and anguish to name a few are all contributory to robbing a person of his or her sleep. We all need a certain amount of natural slumber to function when things are going well. It becomes even more important when one is recovering from trauma. The lack of sleep interferes with healing on every level. Therefore, the road to recovery must begin with getting restful sleep despite all of the factors that thwart it. This leaves the victim in a quandary because all of the mind-body responses that prevent sleep are intensified by the lack of it.Therefore, professional help is required in most cases, even when the physical injuries are relatively minor. However, most attending physicians will resort to prescribing drugs that induce sleep and the patient gets little or no chance to verbalize. The current system of medical care does not allow much time for verbal interaction with health professionals. Even nurses, who are specifically educated for diagnosing and treating post traumatic responses rarely have the time to provide therapeutic counseling in institutional settings. Thus, most hospitalized trauma victims do not have access to appropriate treatment for negative sleep-depriving responses during the early part of their recovery.Consequently, it is left to family members, significant others and/or private therapists to provide a supportive environment. This requires spending the time needed to allow the patient to share his or her concerns and complaints. Although there are a few drug-free techniques for inducing sleep such as biofeedback, relaxing sounds and soothing music, the most effective relaxation inducer is a reassuring voice.

Alterations in Self Image (Body Image and Self Esteem)

Alterations in body image and self esteem are frequent responses to trauma. The common denominator is how a person defines his or her identity with regard to physical description, persona, earning capacity and role. We spend most of our lives constructing this public image and then setting up defenses to protect it. In view of that, trauma rips away all fortifications and the person is left feeling vulnerable and alone. Thus, it is like “The person that I know to be me has just vanished and the banged-up, helpless one lying in this bed is a total stranger!”

To examine this loss of self more closely, the above scenario begs the question, “Why does our personal identity concept that we worked so hard to develop over the years evaporate so easily? One little jolt and poof! gone.” The answer is that the self image is not reality. It is merely an illusion arising out of either an accurate perception of feedback from others, self-deception or a mixture of both. So it should be no surprise that in the moment of a life-altering event, the person we remembered ourselves to be is gone. We are now dealing with somebody different. Ah, but it is in fact such a shock that it takes months or years to adjust to the change. This is so because we all fail to remember two basic principles of life: first, we have no control over the circumstances of our being; and second, we forget that, like the prices of gasoline and airline tickets, life subject to change without notice.Accordingly, the client had to come to understand that self-awareness is mere perception. Therefore, even when trauma occurs causing permanent injury there is no real alteration or loss of self at its core. There is only a perceived change in the physical manifestation in response to the traumatic impact. Therefore, since the quintessential human being is spiritual in essence, a broken mirror changes the reflection, but the reflected object remains unscathed. This concept is the root of understanding the distinction between impairment and disability.

Alterations in social relationships

Each individual is a link to several communities such as family, work, school, social club, athletic team, political affiliations, and house of worship, etc. We play a role in each of these groups such as member, leader, child, parent, spouse, worker, boss, friend and so forth. When a person becomes sick or injured, he or she is unable to fulfill the roles that had been established and the relationships change. Usually it translates to some form of role reversal between family members. The person upon whom others depended is now dependent upon them.Consequently, there are a number of emotional responses arising out of unfulfilled expectations, i.e. frustration, anger, resentment and the like. Although some people rise to the occasion and are happy to provide the extra services needed to care for a loved one, most often relationships between family members deteriorate as a result of the emotional responses of the trauma patient. The usual complaint from the spouse or other family member is that the injured person became irritable, nasty and sometimes verbally abusive. The deterioration of the family relationships is a consequence of inherent destructive behavioral impulses that exists in potentia all humans. These problems arise because the injured person in such cases displays the characteristics of a self centered insensitive boor who needs to control others. This is how many people dealing with fear and anxiety.Therefore, the trauma patient who has victimized his or her family members must employ a distinction called “taking responsibility”. This is a difficult concept to grab onto because the nature of the “sick role” is to be absolved of accountability. Thus the verbally abused family member takes the tongue lashing and tries to remain stoic until he or she loses it, strikes back and ultimately leaves convinced of the need for self preservation.

Invasion of Privacy and Loss of Independence

Being injured always results in two major changes: Invasion of Privacy and loss of independence. My first professor in the nursing program that I attended said, “To learn to be a good nurse you must first learn what it’s like to be a patient.” Thus our first lesson was about invasion of privacy and embarrassment. The main highlights were that private functions and body parts were on display. In a teaching hospital, during grand rounds, the attending physicians accompany a group of eight or ten interns and residents (physicians-in-training) to see each assigned patient. Each doctor conducts a physical examination in front of his or her colleagues and teacher and articulates the findings and treatment plan. I have had many clients complain that it was like being on display in Macy’s window.Although this scenario has its justifications, it cannot be interpreted as anything other than an invasion of privacy. The hospitalized person has to give up his or her need for modesty and tolerate public uncovering in order to derive the therapeutic benefits of diagnosis and treatment. However, as well intentioned as it may be, the sudden unveiling of ones body in the presence of several observers causes humiliation and embarrassment, which in turn results in increased stress and retards healing. This problem also occurs to a lesser degree in the doctor’s office and in the home.On the other hand, while the onus is on professionals and other care givers to remain sensitive to a person’s need for dignity, many people are able to block the stress-inducing embarrassment response. They simply make a decision to accept that in a medical setting people have only a clinical interest and that the actions are all intended to benefit the patient. In fact, any bashfulness exhibited in such a setting would be a false modesty because the person would be acting against his or her own interest.Regarding the loss of independence, this is closely tied in with the invasion of privacy issues because injured people have to rely on care givers to perform private functions like using the toilet. The individual usually has to do this at the bedside and wait for some one else to carry it away and provide personal hygiene. Adjusting to this is more of a problem because, even when the embarrassment issues have been resolved, there usually remains a strong resentment against depending on others for things that we normally do without thought. What bothers some is the loss of control and others harbor a fear of becoming a burden.One effective way that therapists help their clients cope with this dilemma is for the dependent person to learn that he or she is making a contribution to the care giver’s well being. People want to feel needed. The dependency of another person evokes the expression of love and instills a sense of purpose. Therefore, when one person has a need that is fulfilled by another the receiver is actually making a larger contribution than the giver. Given this distinction, the dependent person can learn to accept the services with a sense of joy and gratitude.

Lower Frustration Tolerance

Frustration tolerance pertains to the length of time that a person is willing to wait for the fulfillment of wants and needs before having a temper tantrum. Regardless of the reasons, the actual behavior appears as though the affected person has a license to be bad-mannered and belligerent. It can also be characterized as regressive and child-like. Furthermore, there is a host of negative consequences in causing damage to others and wrecking relationships as previously mentioned. This can be very costly.Another unpleasant reality is that trauma does not create a new person. It merely strips away the facade and allows the subsurface well controlled objectionable traits to manifest in the mind-body. The injured person with low frustration tolerance winds up screaming at those who are doing their best to provide service. Although this is undesirable behavior, in most cases it is not the usual conduct of the victim and thus there is a way of bringing the animal back under control.


Although there is some overlap between irritability and low frustration tolerance, the former does not necessarily involve giving oneself permission to be offensive. This symptom speaks more to the way the mind-body respond to stimuli such as light and sound. The soul, which is a spiritual entity, interacts with the physical world through the mind-body. When a person becomes irritable in response to trauma or other source of mind-body changes, the mechanism for reaction to stimuli is in overdrive.For example, when we are awake and going about our mundane activities, conversations taking place in normal tones do not normally cause a problem. However, if you have to listen to the same conversation while you are trying to sleep, that is a different story. You will get angry and find yourself telling the perpetrators, “shut up!” The irritable person reacts to normal conversations and other sounds in much the same way all of the time. Nevertheless, in most cases it is a temporary situation relieved by a quiet environment.

Instantaneous Conditioned Reflexes

To understand the nature of the instantaneous conditioned reflexes and how to resolve them, we need understand the distinction that in response to stimuli, there are two types of action; that which is thought dependent and that which is not.For the mind-body, every stimulus invokes a response that results in a change. Thus, the soul’s action can be altered. For instance, if your car hits a pothole that knocks the front wheels out of alignment, your steering will be affected because you will have to adjust the car’s new tendency to veer off to the left or right. Going further, if nothing happens other than the addition of a memory, that alone constitutes a permanent alteration. Hence, the spiritual essence, which is concerned to keep its vessel on course to carry out its mission, will make a decision whether or not to employ the thought, speech and/or action to respond.However, there is also the reflex arc which is the ability to respond to stimuli without prior thought. This is where the body has learned to react a certain way to minimize injury. The nerve impulse never reaches the brain because there is a preprogrammed response ready for action the moment the impulse reaches the spinal cord. The reflex arc is a tool for defense. It functions at the basic animal level because it is there purely for self-preservation. This concept pertains to the ability to quickly withdraw the hand from a hot object without thinking about it first. Therefore, this discussion is concentrated on the sudden alteration of all of the learned responses to stimuli developed over a lifetime by desire, learning and forming habits. As with any other existing or potential health problem, the resolution for undoing the sudden change imposed by trauma lies in how the relationship between the spirit and the mind-body was affected.

Inappropriate Startle Responses

Inappropriate startle responses are a serious health threat because they cause inordinate amounts of stress. Being startled is a stark reaction to an unexpected occurrence. There is a sudden release of adrenalin with an increase in heart rate and blood pressure. With this condition the trigger can be any environmental sound or sight that would otherwise not produce any effect, such as closing a door, shutting a kitchen cabinet or dropping the toilet seat. The cause of this is not well understood.However, the nature of trauma is such that it always happens without warning and there is usually a particular sound or sight associated with it like street noise or the sound of the crash. In this vein, the mind-body learns at the moment of impact to associate any sudden unexpected stimuli with immanent danger.Moreover, during normal activity we can receive a lot of input through our five senses without being overwhelmed. Thus we are able to retain our own familiar way of being or make a conscious effort to adopt different reactive behaviors. However, during a traumatic event we are bombarded with intensified stimuli that make a lasting impression, like a meteor that slams into the earth creating a crater that is much larger in diameter than the cosmic missile.The resolution is fairly simple. The victim needs to re-learn how to respond to various sites and sounds. One effective method is to have family members repeatedly make noises in the house while making certain the injured person is aware of when it is going to happen. One lady that I counseled, who was “jumping at every noise” realized that she only recoiled from unexpected sounds. Thus, at my suggestion, she got her husband and children to tell her before they made their usual noises. After a few weeks she became re-accustomed to the various household clatters and was no longer being startled.

Inappropriate Fight or Flight Responses

The process of developing “learned” autonomic responses is one of memory. The brain “remembers” the stimulus and records a “programmed” response. This causes the person to go into action without prior thought whenever that particular trigger shows up again. These “stress activators” can be any site, sound, touch, smell or type of “feel” that bears a similarity to the injurious event. Hence the victim perceives danger and the mind-body responds accordingly with an adrenalin rush that produces rapid heart beat and respirations, elevated blood pressure and intense emotional excitement which can result in a panic attack. Most often the threat is not real and if this condition perpetuates it can become a psychotic delusion.In various cases, I have treated people who were terrified of driving to the extent that they thought that they were going to crash and burn while the car was still in the driveway. Additionally, there was a lady mail carrier who had been mauled by a German shepherd and was frightened of dogs and the building inspector injured by an exploding boiler who was petrified of turning on his stove or oven. These reactions were all the result of instantaneous conditioned reflex. The trauma produced such an overwhelming impression in the memory cells of the brain, which “taught” the mind-body that the incident was going to happen again any second. the mail carrier believed that every dog was a vicious man eater; and the building inspector was convinced that any heat producing appliance was about to explode.Therefore, the solution is to learn not to be scared of those triggers, such as a car, a dog, or a stove. Although the resolution may be simple it is not easy. Learning to discard these trauma-induced condition reflexes is a tedious task but must be accomplished or the victim’s quality of life will be permanently and severely impaired.First, since we are creatures of habit, the intellect gains strength by repetition. If you articulate something often enough you will start to believe it. Therefore, the victims need to repeatedly state out loud that there is nothing to fear and that it was only a single act of the Almighty (some would prefer to call it a “freak accident”).Second, the person who is scared to drive a car needs to go into action and get behind the wheel. However, this must be a step-by-step process. The victim should not start driving right away. There is a radio talk show personality in

South Florida by the name of Joyce Kaufman who recently became severely injured in a motorcycle accident. She called it “a life-altering event” and was wondering whether she should ever get back on her motorcycle again. When she came back on the air, many listeners called in saying that a person scared of driving after an accident should get into the car and start driving immediately to overcome the fear. That would be a terrible mistake because a person who is nervous and jittery would be a danger to self and others on the road. The person must do this gradually and rebuild some self-confidence. It has to be like learning to drive all over again.Finally, in the case of the mauling victim, learning to be comfortable around dogs again is more problematic, but can be accomplished. For this, one would need to have limited exposure to a very docile animal. I would pick a very old dog that can’t do anything but lie around all day. Although this person may never become a dog-lover, the victim needs to be able to walk down the street without being terrorized in the presence of other people’s dogs. Any unleashed strange animal should be cause for alarm, but the former bite victim can develop some comfort level in the presence of dogs locked in behind a fence or held on a leash.

Wrap up

Coping with trauma is much more than recovering from broken bones, sprains, bruises, lacerations and concussions. Every aspect of life is adversely affected and dealing with the after effects requires a cooperative effort between the victim and every significant person in his or her life. The attorney needs to have evidence that there was a series of responses for which the client received professional help and that there was a concerted effort to resolve the problems. In this way the attorney would know whether the client’s claim of post traumatic stress causing a long term deterioration in the quality of life is real or contrived.

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