Ptsd

Thunderwolf thank you for your understanding. I have been crying all of last night and today. I just got married a month ago, and if my husband yells at me or says something which I perceive as hurtful, it triggers the PTSD , and the depression comes back for a while. I am starting in therapy tomorrow with a new therapist. I hope it goes well. You know I feel like I am better, and then a trigger comes, and for a while I feel like I am back where I started from. It is so scary. The thing that makes me feel better is my excitement about going back to school for my nursing masters in psychiatric nursing. I am starting in the spring and looking into programs now. I know I am not strong enough to work right now, but I feel I can handle going for an online MS in a subject that I am very interested in. My psychiatrist thinks it is a great idea for me and is pushing me towards it. I was hospitalized when the trauma first happened, and it was then that I decided that I wanted to be a psychiatric nurse. I did not like some of the poor care that I witnessed, and I want to make a difference in the field doing whatever I can do to help people with psychiatric and emotional problems. My psychiatrist works in the gerontology field, and he has offered to let me do some of my clinicals with him if the school I go to approves it. As I am writing about this I am already feeling better. Anyway, I think I want to work with a psychiatrist who specializes in psychiatric gerontology. I am very interested in changes that take place in the brain and psychiatric meds. I am also a very empathetic compassionate person, and I think I would really like talking to older people , listening, and trying to help. I don't think I am really interested in being a psychotherapist. I noticed that you have a master's in education. Is that nursing education? I have a master's in elementary education and worked as a teacher most of my working years. I left when I experienced the trauma that made me so ill, and I am looking forward to my new career. I was an RN with a BS before being a teacher. I hope I am not rambling, but you appear understanding and smart, and I just needed someone who understands PTSD to talk to this morning. Thanks Thunderwolf for any other opinions or advice you can share with me.

ELKMNin06 I was wondering how you are doing with your paper. I would be careful with the benzodiazapams. If you use them, I would suggest discussing the problems re. addiction. As someone stated, coming off them is murder. And if you suggest using them PRN, you have to take into consideration whether the person is in a state to only use them PRN. Also, does the patient have any history of substance abuse? Just some things I would bring up in the paper if I decided to use them for PTSD. Personally, I would have done the paper on antipsychotics and SSRI's. But that is probably personal, because that is what worked for me. and as I told you, I got addicted to Xanax and blacked out and overdosed from them. I think your prof. gave you a great assignment. I would love to see your paper when you are finished and what your prof thinks. I am really interested in this because of personal experience and because I will be starting a psychiatric nurse practitioner's program in the spring. good luck to you. Krisssy

Krissy!

Thanks so much for sharing your story! I glad you are on the way to recovery:) WEEELLLL...I gave my presentation today and am glad to say that everything went very well:) I am still working on the paper, its almost finished! I would be glad to forward it to you, maybe you can even give me some input before I turn it in.

I ended up using MAOIs and SSRIs and comparing the two in the treatment of PTSD. So far those two have worked really well since they are so similar but still have absolute differences. I know MAOIs are really a thrid line treatment order but I felt that they were better to compare with SSRIs which are the first line of pharmacotherapy. I did make the point in my paper and presentation that the treatment for PTSD is generally most effective when combined with psychotherapy. Anyway...thank goodness this semester is almost over! THREE MORE DAYS!:)

Congratulations on finishing your paper ELKMNin06. I would love to read it. Please do forward it to me, amd I will be glad to comment. What kind of program are you in? Tomorrow I go to my psychiatrist re. meds and my first appt. with my new therapist re. the PTSD-four years after it happened. Like I said, therapy did not work during the acute stage of PTSD. I am so much better, but triggers still bring back temporary symptoms. I am still on Paxil.

Krisssy

ELKMNin06:

Just noticed you are a buckeye!

:)

Have a question about PTSD: is it common to see BPD in the same patient?

Congratulations on finishing your paper ELKMNin06. I would love to read it. Please do forward it to me, amd I will be glad to comment. What kind of program are you in? Tomorrow I go to my psychiatrist re. meds and my first appt. with my new therapist re. the PTSD-four years after it happened. Like I said, therapy did not work during the acute stage of PTSD. I am so much better, but triggers still bring back temporary symptoms. I am still on Paxil.

Krisssy

Thanks:) I am in an MN program, its a general masters of nursing. I graduated June 2004 with my BA in psychology and then decided to pursue nursing...I found this general masters program that is 14 months long. Its a direct entry program for students with bachelors in other areas. Its accelerated. Its sort of a pre NP...all (or most of) of our credits will transfer to an MSN program and we would just need to complete the adv clinical portion of the program. All of our classes are accredited and at graduate level. I plan on becoming an NP but I wanted to get some experience first so this was the best way for me to do that. Ill be in school now for my MN for little over a year, then ill work for a few years then go back for my NP which should only take me another year. So we will see:)

For all of those so kind to reply, I have a question, or rather wanted to get your take on the subject. While researching SSRIs and MAOIs I came across several warnings about the drugs and an increase in suicidal ideation, early in the drug therapy. I have read that it may not be the drug that causes these but the increase in energy that the patient experiences in the early weeks after beginning therapy. I am just wondering if anyone has any more info on t his subject or has an expierience with it. Thanks so much again:)

ELKMNin06:

Just noticed you are a buckeye!

:)

Have a question about PTSD: is it common to see BPD in the same patient?

Yes I am a BUCKEYE: I graduated last June:)

I assume by BPD you mean Bi Polar Disorder? The two disorders manifest themselves in different ways. It is possible that someone with PTSD would have BPD, but PTSD isn't usually comorbid with BPD, atleast not in any literature I have ever read. PTSD occurs in response to a traumatic event. Both disorders have some similar symptoms as possibly anxiety and depression, but manic depressives usually have periods of mania and periods of deep depression. PTSD patients may be depressed but not in the same way a manic depressive would be.

And I thought she meant borderline personality disorder. Does anyone know how the two different conditions are differentiated when abbreviated? Krisssy

Have a question about PTSD: is it common to see BPD in the same patient?

Assuming you mean borderline personality d/o, the answer is a resounding "yes" for those patients who's PTSD is due to childhood sexual abuse. In adult survivors of profound abuse in childhood, usually sexual, and by parents, the common axis I diagnoses are:PTSD, Major Dep d/o, dissociative disorders, Eating disorders, OCD, Substance abuse. The most common axis II dx would be BPD. All of the above follow from the common substrata of an abuse hx.

Kissy: Bipolar is an Axis I dx, borderline is an Axis II.

Krisssy, BPD usually refers to the personality disorder. The Bipolars are usually written shorthand as Bipolar I or Bipolar II in order to not confuse with BPD.

ELKMNin06, congrats on your paper and presentation.

I agree with CharlieRN, PTSD has a strong affinity with other concurrent Axis I and Axis II diagnoses...which he listed above. However, knowing this is a two edge sword. It is important to assess for the presence of these possible concurrent disorders in order to understand how to best intervene and treat the individual. Along this line too is to realize that even in PTSD, like any disorder, the presentation for just THAT diagnosis may be different from one person to the next...that is why you have certain criteria in the DSM which list that a person must present with so much of this and so much of that...look at the criteria. Also, one needs to realize in assessment that the intensity of suffering/incapacitation may present lower or higher than others of the same diagnosis...in this case, PTSD. So, there are a lot of variables to consider in making a diagnosis...even with just one disorder. When you have several concurrent disorders at the same time, it may take a little time or several assessments/inpatient stays to tease it out. I know when I was afflicted with PTSD, it was my presenting issue. As a result of the disorder at the time, I later developed a significant Major Depression due to the impact the PTSD had on my life. I was not diagnosed with an Axis II diagnosis...outpatient or inpatient. However, like CharlieRN states, it is not uncommon to have a concurrent Axis II diagnosis...such as BPD. However, research tends to point out that females tend more frequently to obtain this diagnosis, whereas males tend to get the diagnosis of Antisocial PD. I guess what I'm trying to convey is that, yes, concurrent diagnoses may or could be present...so it must be assessed for and/or ruled out. The double edge of the sword is that it can become too easy for a clinician to overgeneralize...yes...it does happen and frequently. Overgeneralize... in that PTSD with childhood abuse, especially sexual, includes the diagnosis of BPD as an automatic. I was a psychiatric clinician inpatient and outpatient for 10 years...and the proof doesn't bare this out for many PTSD sufferers. Much of my graduate studies and clinical experience was in diagnostic assessment. Many PTSD sufferers, who may have childhood trauma, do not have BPD or APD. So, be careful in making a diagnostic impression regarding labeling a person with BPD/APD who presents with PTSD. There is also a tendency for effective treatment for PTSD to be sidetracked if a Personality Disorder MAY be present and is used to explain away or minimize the impact of the PTSD...ie, ah, she's just a BPD and ignore PTSD. When this is done, it is no wonder the person with BPD who also has PTSD presents over and over for repeat admissions...the PTSD is not adequately addressed. I'm not minimizing the role of a patient having a personality disorder...please hear that! For many folks, that IS their presenting problem and the disorder that needs addressed. In a somewhat joking way, I always said that patients with BPD where put on this earth to test the skill of clinicians...they will make you or break you...make you better or make you worse in your skills as a clinician. Burnt/naive clinicians tend to see all if not most patients with a PD...it effects their judgement. Seen it happen many times. Not all clinicians are the same...it largerly depends upon their professional training, their experience and their battle scars. Getting back to PTSD assessment, another thing to consider is when a person (before PTSD) may have had a fairly high GAF score of 80-90...whereas a personality disorder usually lives at the 60 range most of the time (chronic). This is also something to consider in your assessment. When a PTSD person had a previous GAF of 80-90 and now plummets to 40...something is quite wrong and the person does indeed suffer. A person with very severe PTSD may even develop psychotic features which even plummets their GAF to the 30's. So look at ALL the data and do not become a overgeneralist in your assessment...because it does effect treatment and patient outcome. I know this was long, but I hope it helped.

Assuming you mean borderline personality d/o, the answer is a resounding "yes" for those patients who's PTSD is due to childhood sexual abuse. In adult survivors of profound abuse in childhood, usually sexual, and by parents, the common axis I diagnoses are:PTSD, Major Dep d/o, dissociative disorders, Eating disorders, OCD, Substance abuse. The most common axis II dx would be BPD. All of the above follow from the common substrata of an abuse hx.

Kissy: Bipolar is an Axis I dx, borderline is an Axis II.

Yeah, I was referring to borderline personality disorder. Can these conditions you listed show up in second generation; that is, not the object of the abuse, but in his or her child?

The double edge of the sword is that it can become too easy for a clinician to overgeneralize...yes...it does happen and frequently. Overgeneralize... in that PTSD with childhood abuse, especially sexual, includes the diagnosis of BPD as an automatic. .

I found this very interesting. Do you find that the PTSD pt with more "insight" is less likely to manifest BPD? Is the severity of the abuse a factor, or possibly genetics? Timely intervention in early adulthood?

I found this very interesting. Do you find that the PTSD pt with more "insight" is less likely to manifest BPD? Is the severity of the abuse a factor, or possibly genetics? Timely intervention in early adulthood?

Insight is very helpful but only half of the coin. Half of most counseling or therapy is trying to gain it in order to really understand the disorder and how it impacts self. The other half of the coin is how does it sit with the person...that is coming to acceptance, which persons often struggle the most with. Even with insight, positive/healthy change is often self sabotaged if acceptance is not truly gained. Why? Effort and energy towards change often becomes half hearted. So insight and acceptance is the work of therapy. Behavioral change is what the person does on the outside when not in therapy or in the therapist's office...what the person does in the real world. When speaking of BPD...we are talking a life long pattern of perception and behavior that the person has come to rely on, which can often be difficult to change or give up. It requires learning new patterns of behavior and new ways to perceive one's world, others, and self. Not easy. But, it can be done, but it takes time. Often, persons with BPD mellow out with age, but we are often looking at in a person's 40's typically. So, you see why insight and acceptance work in therapy is important. New role models for healthy behavior make it more possible and also provides hope for change as well. Therapists/counselors are supposed to be one of those role models. Severity of the BPD illness is another factor. Not all BPDs are alike, although some/many clinicians may believe they are...again, this is often the case for clinicians who may be burned out or simply naive. So, even treatment for a person with BPD really needs to be individualized. You mention severity of prior abuse...sure, it is a factor to consider in one's assessment and knowledge base for that patient...but, again...don't lump all person with BPD this way. Believe it or not, many persons who have had significant and terrible childhood abuse do NOT have BPD. This is something to keep in mind. Don't equate childhood abuse with an automatic BPD. You really short change the patient that way and can commit a real bad therapeutic sin towards the patient. You mention genetics...Hmmm. More data is needed on that; however, I might tend to believe more that "dysfunctional patterns of behavior" by family members that are "passed on" and "learned by the patient" while young may have more a significant impact. If you live in a paranoid family, you tend to learn paranoia...get my meaning. Often personality disorders are seen budding while the person is in their teens...intervention really needs to begin there if diagnosed as causing difficulty in that teen's life. Again, we are talking patterns which are often growing root then. However, don't be tempted to assume all acting out teens are BPD. Many teens may demonstrate BPD behavioral "traits" which they soon or later outgrow (ie..such as acting and dressing Goth/Gothic, which comes to mind...also, drug abuse really needs ruled out here), while teens with genuine BPD tend to snowball and get worse. Lastly, another thing to consider also is that some folks with BPD may come from "healthy" families...if you want to use healthy as a term. In this, other things that may need to be considered is just individualized, poor self development of self, for what ever reason...drug abuse, physical illnesses, neonatal trauma/difficulty when born, other mental/emotional disorders being present, life events outside of family. In saying this, there may be MANY risk factors...not JUST child abuse. A naive clinician will tend to say/believe a disorder (any for that matter, not just BPD) is caused by ONE thing. Often what is MORE true is that a disorder develops as a result of many factors being present for that person which puts that person at risk to develop a disorder. A more seasoned or wise counselor/therapist acknowledges this. In saying ALL of this, I hope I make the point that "assessment really needs to be a thorough process" and "treatment needs to be very individualized" to be fair to the patient. I know, it is alot to think about and consider. I hope I did not throw too much at you or make it more confusing. But, I hope I was able to answer some of your questions.