Understanding and responding to PTSD
Robert W. Figlerski, Ph.D.
I was recently asked to evaluate a skilled nursing resident who, in his short time at the facility, was presenting a confusing picture to staff. They perceived the resident's presentation as indicative of a psychiatric diagnosis (perhaps bipolar disorder or personality disorder). Their impressions were reasonable, considering his labile mood, outbursts and frequently oppositional and demanding behavior. However, following an in-depth interview it became clear that a more likely diagnosis was post-traumatic stress disorder.
During the evaluation, the resident related serving in the military for 20 years and experiencing significant combat exposure. He experienced additional trauma when his wife was killed in the World Trade Center attack of 9/11. He gradually began to withdraw socially, and prior to his admission was living alone in a mobile home in a rural area.
Beyond his behavioral presentation, other symptoms included frequent nightmares, sleeping problems and panic episodes. He often overreacted, and was unreasonably controlling around his care routine. Based on this additional information, his diagnosis and care planning began to move in a completely different direction.
While any individual can experience trauma, not just veterans, this case serves as a perfect example of why we treat the individual and not the symptoms.
To effectively manage these residents, is critical that skilled nursing staff understand trauma reactions, why they persist, and how to differentiate them from other mental health issues. Post-trauma reactions have multiple contributing factors, and helpful clinical responses must take them all into account and integrate not only medical management, but also psychological, interpersonal, and environmental efforts into the daily care routine.
Recognizing the need, the Centers for Medicare & Medicaid Services have initiatives that continue to set the expectation that nursing homes develop more robust behavioral health services. These expectations go far beyond the better management of psychotropic medication. For example, new guidance will require facilities to train staff about trauma-informed approaches to care (CMS 483.40, (a)). The primary goal is to minimize triggers, avoid re-traumatization, and identify unique needs to achieve person-centered care.
This guidance will require that facility personnel recognize and understand trauma reactions. The challenge is that acute and chronic post-traumatic stress reactions present with a range of symptoms that can be difficult to manage in a skilled nursing environment. The constellation of symptoms involved in post-trauma include neurological, physiological, behavioral and psychological reactions.
In the case of chronic PTSD, these symptoms are unbound by time and can persist for years after the initial trauma, frequently becoming worse as time passes. Chronic PTSD is often complicated by a significant disturbance in mood, avoidant behaviors, exaggerated reactions and an overlay of chronic substance abuse developed to alleviate painful symptoms, particularly anxiety.
The interdisciplinary care team should identify many red flags. Individuals who have experienced trauma will frequently experience sleep disturbance, depression, panic episodes, combativeness and social withdrawal. These reactions are often physiologically driven and can be induced by seemingly ordinary occurrences.
While psychotropic medication may have some benefit in managing acute trauma reactions, their helpfulness in managing chronic PTSD is limited. A failure to recognize and properly address trauma symptoms can lead to overmedicating a resident in attempts to treat each symptom separately, or generating multiple care plans when the resident needs a comprehensive care plan focused on emotional/behavioral issues related to trauma.
Staff also must be prepared for oppositional or combative behavior. Combativeness is often the result of fear and avoidance of perceived threats. Anxiety and anticipatory anxiety are significant components of trauma reactions.
A resident's physiological response drives and shapes perceptions and behaviors. The person is simply trying to maintain or escape to what they perceive as a safe environment. This maladaptive pattern contributes to social withdrawal and self-imposed isolation. As a result, trauma residents are often perceived as peculiar or difficult.
In this scenario, it is important to impress upon staff that anxiety and panic responses are not based on rational thought, therefore reasoning with a resident or asking them to calm down is usually little help when managing a difficult behavioral episode. There is a need to frequently remind staff that, as the intensity of emotions increase, the role of rational thought decreases. A better approach is to acknowledge the resident's feelings and provide non-judgmental support and reassurance.
The Substance Abuse and Mental Health Services Administration has provided some helpful guidance in improving how facilities anticipate and manage victims of trauma (Concept of Trauma and Guidance for a Trauma Informed Approach, July 2014). The overall emphasis is on understanding the effects of trauma, recognizing the symptoms, learning how to respond, and especially avoiding the re-traumatization of the resident. Start a dialogue to raise the level of awareness of staff about trauma symptoms, and to avoid treating trauma responses as separate symptoms.
Other central recommendations involve establishing an environment that fosters a sense of trust and safety. Staff members sometimes take for granted safety and trust, whereas residents who have experienced trauma are often hypervigilant and misinterpret ordinary interactions as potential threats. This explains why trauma residents are often anxious and can be combative in an effort to preserve personal safety. Essentially, their world view of a safe environment has been disrupted, and they perceive potential threats and safety concerns where staff do not. These reactions are not just based on a belief, but driven by physiology, which leads to heightened arousal states that then shape perceptions.
Skilled nursing staff members who are well-versed in recognizing trauma can also provide the type of support that trauma residents require. Patients will often express a feeling that they are going “crazy.” Empower staff to identify trauma reactions, build trust, and help the resident develop the correct interpretations and attributions of their symptoms. Here, as in the management of many complex behavioral issues in the SNF environment, psychologists are instrumental in driving staff education and training.
Effectively caring for SNF residents with post-traumatic stress is complex and can be challenging for facilities. It requires both an enhanced understanding of post-trauma reactions and an interdisciplinary approach to care that includes integrated medical, psychological, interpersonal and environmental efforts.