Page 13 Complete Your CE Test Online - Click Here Nursing consideration: When it is absolutely essential that health care professionals maintain a supportive, objective attitude. Judging, coercing, or belittling concerns and feelings of veterans and their families will significantly interfere with, and perhaps even permanently prohibit, veterans seeking the help needed (Durkin, 2013; National Center for PTSD, 2016; U.S. Department of Veterans Affairs, 2015). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013), diagnostic criteria for PTSD for adults, adolescents, and children older than six years of age include: Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: ○ ○ Directly experiencing the traumatic event or events. ○ ○ Witnessing the event(s) as occurring to others. ○ ○ Learning that the traumatic event(s) occurred to a close family member or close friend. Note that in cases of actual or threatened death, the death must have been violent or accidental. ○ ○ Experiencing repeated or extreme exposure to details of the traumatic events. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s) that began after the event(s) occurred: ○ ○ Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). ○ ○ Recurrent distressing dreams in which the content is related to the traumatic event(s). ○ ○ Flashbacks (referred to as dissociative reactions) in which the veteran feels or acts as if the traumatic event(s) were recurring. ○ ○ Intense or prolonged psychological distress when exposed to internal or external cues that are symbolic of or resemble an aspect of the traumatic event(s). ○ ○ Marked physiological reactions to internal or external cues that are symbolic of or resemble an aspect of the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s) that start after the event has occurred and is evident by one or both of the following symptoms: ○ ○ Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about the traumatic event(s). ○ ○ Avoidance of or efforts to avoid external reminders (such as people, places, or activities) that arouse distressing memories, thoughts, or feelings associated with the traumatic event(s). Negative alterations in cognitions and mood associated with the traumatic event(s) that begin or worsen after the occurrence of the traumatic event(s) as evidenced by one or more of the following: ○ ○ Inability to remember an important aspect of the traumatic event(s), usually because of dissociative amnesia and not other reasons such as head injury, alcohol, or drugs. ○ ○ Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world in general. ○ ○ Persistent distorted beliefs about the cause or consequences of the traumatic event(s). Such beliefs could cause the person to blame him/herself or others for the occurrence of the traumatic event(s). ○ ○ Significantly reduced interest or participation in significant activities. ○ ○ Persistent negative emotional feelings (e.g., anger, guilt, shame, fear). ○ ○ Feelings of detachment or estrangement from other people. ○ ○ Persistent inability to experience positive emotions. Marked alterations in arousal and reactions associated with the traumatic event(s) that began or worsened after the occurrence of the event(s) as evidenced by two or more of the following: ○ ○ Irritability and angry outbursts with little or no cause, usually expressed as verbal or physical aggression toward people or objects. ○ ○ Recklessness or behavior that is self-destructive. ○ ○ Hypervigilance. (Being abnormally aware of the environment, accompanied by intensity of behaviors that are designed to detect threats.) ○ ○ An exaggerated startle response. ○ ○ Difficulty concentrating. ○ ○ Sleep disturbances such as trouble falling or staying asleep. The length of the disturbance is more than one month. The disturbance causes distress or impairment that is clinically significant in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (such as alcohol) or another medical condition. For detailed diagnostic information consult the DSM-5. Since PTSD is associated with suicidal thoughts and suicide attempts, it is imperative that nurses teach veterans and their families how to monitor for suicidal thoughts and actions and what action to take if such thoughts or actions occur. Much of the discussion about the suicide of veterans has focused on veterans of the wars in Iraq and Afghanistan. However, data released in 2016 shows that 65% of all veterans who died from suicide in 2014 were 50 years of age or older, and 45% of veteran suicides in 2014 were aged 60 and older. Additionally, since 2001 total veteran suicide has risen by 32% (Berger, 2016). Nurses have an obligation to work with government agencies to increase research regarding veteran suicide and to apply evidence from such research to enhance their clinical practice and to help decrease the risk for veteran suicide. Treatment There are treatment options available at all VA medical centers (U.S. Department of Veterans Affairs, 2015b). There are also a variety of treatment options in civilian health care settings. PTSD treatment goals focus on reducing symptoms, preventing chronic disability, and promoting social and occupational rehabilitation (Durkin, 2013). The National Center for PTSD identifies several types of treatment including: cognitive processing therapy (CPT), prolonged exposure therapy, eye movement desensitization and reprocessing (EMDR), stress inoculation training (SIT), and medications (National Center for PTSD, 2016; National Center for PTSD, 2017). Cognitive Processing Therapy (CPT). CPT is an evidence-based treatment protocol that has been effective for the treatment of PTSD. It focuses on helping veterans understand how to cope with distressing thoughts, behaviors, and other symptoms. In CPT, the veterans learn how the traumatic event(s) change the way they view the world, themselves, and their friends, families, and colleagues, and how their behaviors have changed in response to these traumatic event(s) (Center for Deployment Psychology, 2016a; National Center for PTSD, 2016). CPT does not change the details of the traumatic event(s), but it does change the way veterans cope with such events (National Center for PTSD, 2016). CPT can be conducted in both individualized and group settings. It generally consists of four main components (Center for Deployment Psychology, 2016a; National Center for PTSD, 2016): 1. Teaching veterans about their PTSD symptoms and how treatment can help. 2. Helping veterans to become aware of how their thoughts, feelings, and behaviors are related to their efforts to cope with the traumatic event(s) they have experienced. This involves processing the trauma by identifying and allowing for the dissipation of the normal emotions related to the trauma, as well as identifying those thoughts and behaviors that are preventing recovery. Such inappropriate thoughts and behaviors are referred to as “stuck points” because they tend to keep persons stuck in PTSD. 3. Teaching veterans skills to cope with intrusive thoughts and feelings and inappropriate behaviors. This could involve focusing on thoughts and feelings of guilt and self-blame, such as “If I had only done… then my friend would not have been killed,” and restructuring such thoughts to the point of alleviating guilt and self- blame. This is referred to as cognitive restructuring. 4. Veterans are then helped to make plans for the future that include avoiding relapse and utilizing coping skills in their everyday lives. In addition to regular meetings with qualified therapists, veterans are given practice assignments to help them use their new coping skills outside of the therapy setting (National Center for PTSD, 2016).