Learning Objectives
By the end of this section, you will be able to:
- Outline the causes, symptoms, and interventions for a person with body dysmorphic disorder
- Outline the causes, symptoms, and interventions for a person with hoarding disorder
- Outline the causes, symptoms, and treatment approaches for a person with trichotillomania
- Outline the causes, symptoms, and treatment approaches for a person with excoriation
- Outline the causes, symptoms, and treatment approaches for a person with post-traumatic stress disorder
- Outline the causes, symptoms, and treatment approaches for a person with acute stress disorder
- Outline the causes, symptoms, and treatment approaches for a person with attachment disorder
There are a range of disorders that are induced by trauma and stress. Post-traumatic stress disorder (PTSD), for instance, has gained attention because of veterans of wars who suffer from it. Hoarding has also captured media attention. Other disorders remain somewhat less known and private in that they do not attract national attention, including body dysmorphic disorder, trichotillomania, excoriation, acute stress disorder, and attachment disorder.
Body Dysmorphic Disorder
The mental disorder in which a person is preoccupied with perceived defects or flaws in their appearance is called body dysmorphic disorder (BDD). For example, people with BDD may believe they look unattractive, their skin is too oily, or their nose is too big or crooked. They often obsess over these perceived flaws and attempt to disguise them with clothing or makeup. People with BDD are often highly self-critical and may fear being judged by others. BDD can cause significant distress and interfere with daily functioning. It can also lead to social withdrawal, occupational difficulties, and suicidal thoughts (Jaroszewski & Wilheim, 2022).
BDD is thought to be related to low self-esteem, anxiety, and depression. Treatment for BDD typically involves a combination of psychotherapy, medications, and lifestyle changes. CBT is the most commonly used type of psychotherapy for BDD. It helps people to identify and challenge unhelpful thoughts and behaviors related to their appearance. Medications like Selective serotonin reuptake inhibitors (SSRIs) may also reduce anxiety and associated depression (Jaroszewski & Wilheim, 2022).
Causes of Body Dysmorphic Disorder
BDD is not simply a case of being self-conscious. It is a mental health disorder that can cause significant distress and impairment in daily functioning. The causes of BDD are not entirely understood, but the disorder is likely due to a combination of biological, psychological, and environmental factors. Brain imaging studies suggest that people with BDD may have differences in how their brains process information (Buchanan et al., 2013). Psychological factors may also play a role, as people with BDD often fear negative evaluations from others. Environmental factors, such as having experienced teasing or bullying, may also influence the onset of BDD (Jaroszewski & Wilheim, 2022).
Onset and Course of BDD
The onset of BDD typically occurs in late adolescence or early adulthood. It is estimated that up to 2.4 percent of the population may be affected by BDD, with higher rates in higher socioeconomic groups (Jaroszewski & Wilheim, 2022). The course of the disorder can be chronic and often coexists with other mental health conditions, such as depression and anxiety disorders (Phillips et al., 2005).
Prevalence
BDD is more commonly found in young adults, with a mean age of onset of fifteen to sixteen. In addition, BDD is more commonly seen in women, although signs and symptoms may be seen more frequently in men as they age (Jaroszewski & Wilheim, 2022). The exact prevalence of BDD is challenging to estimate due to the shame and secrecy surrounding this condition. As a result, BDD often goes undiagnosed or misdiagnosed. Individuals with BDD may be reluctant to seek help or they present with other symptoms consistent with other mental health conditions, such as depression, social anxiety, or eating disorders (Enander et al., 2018).
Signs and Symptoms of BDD
Signs and symptoms of BDD include preoccupation with an imagined or exaggerated physical flaw, such as a blemish, scar, or other perceived defect; engaging in repetitive behaviors, such as checking mirrors multiple times a day, excessive grooming, or skin picking; avoiding social activities, such as going to the beach, because of embarrassment over perceived flaws; spending excessive amounts of time comparing oneself to others; wearing heavy makeup, hats, or clothing to hide perceived flaws; engaging in cosmetic surgery or other medical treatments in an attempt to fix perceived flaws; seeking reassurance from friends and family about perceived flaws; and experiencing anxiety, depression, or suicidal thoughts related to perceived flaws (Jaroszewski & Wilheim, 2022).
Link to Learning
The video titled Because I’m Ugly: Body Dysmorphic Disorder and Me explores the challenges of living with BDD through the real-life testimony of Elias, a seventeen-year-old boy with the disorder.
Diagnosing BDD
BDD can be complex and requires a comprehensive assessment by a mental health professional. It is crucial to assess the client’s emotional response to their perceived flaws, the time spent focusing on them, and the impact on daily functioning. Treatment history, family history, and comorbidity with other disorders, such as anxiety and depression, should also come up during the diagnostic process (Thanveer & Khunger, 2016).
Treating BDD
There are several treatments for BDD, ranging from psychotherapy to medication. CBT, especially when tailored specifically to BDD, has been found to be highly effective in reducing symptoms (Veale et al., 2014). Alongside CBT, SSRIs have proven beneficial for some individuals (Castle et al., 2021). An integrative approach that involves collaboration between therapists, psychiatrists, and other health-care providers, such as nurses, can result in more effective care (Harrison et al., 2016).
Cognitive Behavioral Therapy
CBT is a talk therapy that helps people identify and change negative thoughts and behaviors. It is often used to treat BDD, as it can help people learn to challenge distorted thoughts about their appearance and replace them with more realistic ones. CBT also helps people learn to manage their anxiety, practice healthy self-care, and reframe their relationship with their bodies (Harrison et al., 2016).
Exposure/Response Prevention
Body dysmorphia exposure and response prevention (BD ERP) is a form of CBT used to treat BDD by exposing the client to their feared body image so they can learn how to manage their reactions to it. The first step in BD ERP is for the individual to identify and then confront their fears around their body image. The therapist will then help the individual gradually face these fears by exposing themselves to the feared body image. Next, the individual will learn how to manage their anxiety and distress when exposed to the feared body image, such as by using relaxation techniques. During treatment, the individual will engage in activities and behaviors that challenge their negative beliefs about their appearance. These could include participating in activities they have previously avoided due to their body image concerns, such as looking in the mirror, going to the beach, or wearing certain clothing. The ultimate goal of BD ERP is for the individual to accept and manage their body image without feeling extreme distress or anxiety (Reid et al., 2021).
Medications
Medications can help treat BDD, but they are typically used in conjunction with therapy, such as CBT or other forms of psychotherapy. Some medications that may be used to treat BDD include SSRIs, which can help alleviate the symptoms of depression and anxiety often associated with BDD; they may also help reduce obsessive-compulsive symptoms common in BDD (Mayo Clinic, 2021b). SSRIs are not a cure for BDD. They can only help reduce the severity of some symptoms.
Antipsychotic medications can help manage symptoms of delusions or paranoia that may be present in some individuals with BDD. They may also help reduce obsessive-compulsive symptoms. There is no antipsychotic medication specifically designed to treat body dysmorphia, though certain antipsychotic medications, such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), clozapine (Clozaril), and aripiprazole (Abilify), have been used (Castle et al., 2021).
Self-Help Resources for BDD
Self-help strategies can be helpful in the treatment of BDD. Online self-help programs, incorporating psychoeducational materials and interactive exercises, can help individuals with mild to moderate symptoms (Enander et al., 2014). Additional self-help resources include:
- Body Dysmorphic Disorder Foundation: Visit the BDD Foundation website for information, resources, and support.
- Distraction techniques: Develop strategies to help focus attention away from perceived flaws and on other activities, such as exercise, hobbies, or spending time with friends and family.
- Support groups: Connect with others with body dysmorphia or similar mental health concerns. Support groups can provide a safe and nonjudgmental environment to share experiences and learn from others.
- Healthy coping skills: Find healthy ways to cope with body dysmorphia, such as journaling, yoga, mindfulness, art, and music.
Nursing Interventions
Nurses can assess the client’s perception of their body image, assist the client with associated distress or impairment, and help with the condition’s impact on their daily lives. Nurses can also educate clients on the nature of BDD, its symptoms, and its effect on their mental health, which can alleviate feelings of shame or guilt. Nurses may assist the client to develop healthy coping mechanisms to manage negative feelings associated with body dysmorphia. Nurses can monitor the client’s progress, manage any medications, evaluate the effectiveness of interventions, and adjust the treatment plan as needed to help clients achieve their treatment goals and improve their overall quality of life (Perkins, 2019).
The concept of offering self is important for clients dealing with BDD. A nurse offers self by spending time with the client and building a relationship to ensure the client becomes comfortable discussing sensitive issues. Therapeutic communication with a client with BDD is a critical skill for nurses, as it forms the foundation of effective care for individuals struggling with this complex condition. Effective communication requires a nonjudgmental and empathetic approach, recognizing that the client’s concerns about appearance are intensely real and distressing to them. Open-ended questions and reflective listening can facilitate understanding of the client’s feelings and thoughts without reinforcing the distortions associated with BDD. Encouraging and supporting clients in expressing their feelings about their appearance without agreeing with their distorted self-image helps in building trust (Perkins, 2019). Nurses can encourage clients to develop a positive body image by focusing on their strengths and abilities, engaging in positive self-talk, and engaging in activities that promote self-care and well-being. Nurses may also encourage the client’s engagement in social support networks, such as family, friends, or support groups. These types of engagement can help the individual feel less isolated and provide a safe space to discuss their concerns (Perkins, 2019).
Hoarding
The mental health condition characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value is hoarding disorder. Hoarding behavior can lead to cluttered living spaces that can be hazardous or unsanitary and can interfere with daily activities, such as cooking, cleaning, and sleeping (American Psychiatric Association, 2021).
Causes and Incidence of Hoarding Disorder
The incidence of hoarding disorder in the general population is not well established, but it is believed to affect between 1.5 percent and 6 percent of adults. Hoarding disorder is more common in older adults, with prevalence rates increasing in those over sixty-five. Women are also more likely than men to develop hoarding disorder (Postlethwaite et al., 2019). While the exact cause of hoarding disorder is unknown, it is thought to be associated with various factors, such as genetics, brain structure and function, and life experiences. Individuals with a hoarding disorder tend to have a history of traumatic or stressful events, such as the loss of a loved one, divorce, or physical abuse, which may contribute to the onset or exacerbation of hoarding behaviors (Fontenelle et al., 2021). A family history of hoarding and underlying genetic factors may also play a role in the development of this disorder (Dozier & Ayers, 2017). Traumatic early life experiences can shape attachment to possessions and difficulty discarding items. Individuals who grew up in a cluttered home or experienced parental deprivation have been shown to form unhealthy attachments to items (Kehoe & Egan, 2019). Interpersonal difficulties and social isolation are often both a cause and consequence of hoarding, leading to a vicious cycle that reinforces the behavior. In addition, individuals with hoarding disorder may also be more likely to have other psychiatric conditions, such as anxiety, depression, or obsessive-compulsive disorder (American Psychiatric Association, 2013).
Signs and Symptoms of Hoarding Disorder
Individuals with hoarding disorder experience distress or anxiety at the thought of discarding possessions. They feel a sense of attachment or emotional significance to the items they hoard. Hoarding behavior can lead to social isolation, because individuals may be embarrassed or ashamed of their living conditions and avoid inviting others into their homes (Mayo Clinic, 2018a). Physical symptoms of hoarding disorder may include respiratory problems and evidence of falls or other injuries. The accumulation of items and neglect of household maintenance can lead to dust accumulation, mold growth, and poor air quality, all of which can exacerbate or cause respiratory problems. Difficulty maneuvering through cluttered spaces may lead to falls and other injuries (American Lung Association, 2021). There is also an increased risk of fire or other hazards due to the cluttered living environment (Mayo Clinic, 2018a).
Diagnosing Hoarding Disorder
The diagnosis of hoarding disorder is based on a thorough clinical assessment of the individual’s symptoms and behaviors. Diagnostic criteria for hoarding disorder include persistent difficulty discarding or parting with possessions, regardless of their actual value, and cluttered living spaces that interfere with daily activities. To be diagnosed with hoarding disorder, an individual must experience significant distress or impairment due to hoarding behavior. Diagnosis may also involve ruling out other conditions contributing to the individual’s symptoms, such as obsessive-compulsive disorder or major depressive disorder. Diagnostic assessments for hoarding disorder may include interviews with the individual and their family members and observation of their living environment. The diagnosis of hoarding disorder can be complex and may require a multidisciplinary approach involving mental health providers, primary care physicians, and other specialists as needed (American Psychiatric Association, 2013).
Several assessment scales evaluate the severity of hoarding disorder and track symptom changes over time:
- Saving Inventory-Revised (SI-R): The SI-R is a self-report measure that assesses the severity of hoarding symptoms and related features, such as indecisiveness, clutter, and excessive acquisition.
- Hoarding Rating Scale (HRS): The HRS is a clinician-administered tool that assesses the severity of hoarding symptoms and associated features, such as functional impairment and distress.
- Clutter Image Rating (CIR): The CIR is a visual rating scale that assesses the severity of clutter in the individual’s living environment.
- Home Environment and Living Inventory (HEAL): The HEAL is a comprehensive assessment tool that evaluates the individual’s living environment and functional ability, including mobility and social support.
These assessment scales can be used to inform treatment planning and evaluate the effectiveness of interventions over time. No single assessment scale is definitive, however, and it is essential to perform a thorough clinical assessment that considers the individual’s unique circumstances and needs (International OCD Foundation, 2023).
Treating Hoarding Disorder
Treatment for hoarding disorder typically involves a combination of medication and psychotherapy, such as cognitive behavioral therapy or exposure therapy. In addition, environmental interventions, such as professional organizing or cleaning services, may also help address the physical aspects of hoarding behavior (American Psychiatric Association, 2013).
Cognitive Behavioral Therapy
CBT is a commonly used treatment approach for hoarding disorder. CBT for hoarding disorder typically involves a combination of individual and group therapy sessions and aims to address the underlying beliefs and thought patterns that contribute to hoarding behavior. In CBT, individuals learn to identify and challenge negative thoughts and beliefs about possessions and develop new, more adaptive ways of thinking. CBT may also involve exposure therapy, in which individuals are gradually exposed to the anxiety-provoking situations associated with discarding possessions. In addition, CBT may incorporate skills training in areas, such as organization, decision-making, and time management, to improve the individual’s ability to manage their living environment and daily activities. While CBT is generally considered an effective treatment for hoarding disorder, it may not be effective for all individuals (International OCD Foundation, 2023).
The Effectiveness of Medication
Medication treatment for hoarding disorder often accompanies psychotherapy. The Food and Drug Administration (FDA) has not approved any specific medication for the treatment of hoarding disorder, but medications commonly used to treat other psychiatric conditions may effectively reduce the symptoms of anxiety and depression that are often associated with hoarding disorder. These medications may also help to reduce urges to acquire possessions and may improve decision-making around discarding possessions. Other off-label medications to treat hoarding disorder include atypical antipsychotics and mood stabilizers, although there exists limited evidence for their effectiveness (International OCD Foundation, 2023).
Interventions Involving the Family
Hoarding disorder can significantly impact the afflicted individual’s family and loved ones. Family members may experience distress or frustration due to the individual’s hoarding behavior and may feel overwhelmed or helpless in their efforts to intervene. Thus, family involvement in treatment can be an important component of hoarding disorder management. Family may participate in education about the disorder and its impact on the family, training in communication and problem-solving skills, and involvement in the individual’s treatment planning and decision-making. Family members may also play a role in the practical aspects of hoarding disorder treatment, such as assisting with decluttering or organizing the individual’s living space. It is important to approach family involvement in hoarding disorder treatment in a collaborative and nonjudgmental manner and to consider each individual and family’s unique needs and circumstances (International OCD Foundation, 2023).
Nursing Interventions
The nurse’s role in assessing and managing hoarding disorder may involve client education, counseling, and referral to specialized mental health providers as needed. A nurse must perform a thorough assessment of mental and physical health, including evaluating the living environment and its potential impact on physical health, and educate the client about the disorder (Millen et al., 2017). Educating clients about the disorder, including symptoms, causes, and treatment options, can reduce stigma and promote engagement in treatment. Building trust through empathetic and nonjudgmental communication is vital. Nurses can reinforce therapeutic strategies taught in CBT and manage medications (Bodryzlova et al., 2019). Nurses can work with clients to create a safe living environment (Rodriguez et al., 2016). Linking clients with community resources, support groups, or specialized hoarding interventions can further support treatment (Weir, 2020). Nurses must recognize the complexity of the disorder and approach care with dignity, empathy, and an understanding of the unique challenges faced by individuals with this disorder.
Trichotillomania
The mental health disorder trichotillomania is characterized by a chronic need to pull out one’s hair. This disorder falls under obsessive-compulsive and related disorders and can lead to distressing physical and emotional symptoms (American Psychiatric Association, 2013). Understanding trichotillomania is essential as clients may present with noticeable hair loss, skin damage, and related complications, such as infection.
Causes and Risk Factors for Trichotillomania
Trichotillomania occurs in 1.7 percent of the population, equally in males and females (Grant et al., 2020). The causes of trichotillomania are believed to be genetic, environmental, and psychological factors. Research suggests that trichotillomania may be associated with abnormalities in brain structure and function, including alterations in neurotransmitters, such as dopamine, serotonin, and glutamate. Trauma, stress, and other life events may also contribute to the development of trichotillomania. A family history of trichotillomania or other psychiatric conditions may increase an individual’s risk of developing the disorder, suggesting a genetic component to the disorder. Age is also a potential risk factor for trichotillomania, with onset typically occurring in childhood or adolescence, although the disorder may also develop in adulthood. Stress and other environmental factors may trigger or exacerbate symptoms of trichotillomania, although researchers do not yet understand the exact nature of these factors and their relationship to the disorder. Stressful life events, such as trauma, abuse, or changes in family or work situations, may contribute to the development or worsening of trichotillomania symptoms (American Psychiatric Association, 2013).
Symptoms of Trichotillomania
Individuals with trichotillomania may pull hair from any body part, including the scalp, eyelashes, and eyebrows. Hairpulling may be accompanied by feelings of tension or anxiety before pulling and a sense of relief or pleasure after pulling. The hairpulling may be intentional or automatic and may occur in response to specific triggers or situations. In addition to hair loss, individuals with trichotillomania may experience a range of physical symptoms, including skin damage, infections, and scarring, as well as emotional symptoms, such as distress or embarrassment about their appearance or behavior. There may be noticeable hair loss or bald patches, or the individual may chew on the hair they pull out. The disorder can lead to significant distress and social or occupational impairment (American Psychiatric Association, 2013).
Diagnosis of Trichotillomania
The diagnosis of trichotillomania is based on a thorough clinical assessment that includes a detailed history of the individual’s hairpulling behavior, physical examination, and assessment of any associated symptoms or psychiatric conditions. To meet the diagnostic criteria for trichotillomania, the hairpulling behavior must result in hair loss and significant distress or impairment in social, occupational, or other important areas of functioning. The hairpulling must also not be attributable to another medical condition or substance use and must not be better accounted for by another mental disorder. In some cases, laboratory tests or imaging studies may rule out other potential causes of hair loss (American Psychiatric Association, 2013).
Treatment Approaches for Trichotillomania
Trichotillomania is a challenging disorder, and no single “gold standard” treatment works for everyone. Treatment typically involves a combination of medication and psychotherapy to reduce hairpulling behavior, minimize hair loss, and improve overall functioning and quality of life. SSRIs and other medications that affect serotonin and dopamine levels in the brain may work to treat the underlying anxiety and mood symptoms associated with trichotillomania. Psychotherapy, such as CBT or habit reversal training (HRT), can help individuals learn to recognize and control the urge to pull their hair and develop alternative coping strategies to manage their anxiety and stress. In addition, support groups and educational resources can help promote coping and self-management strategies. Treatment for trichotillomania should be tailored to the individual’s unique needs and circumstances and may require ongoing monitoring and adjustment over time (American Psychiatric Association, 2013).
HRT is a specific form of CBT that is often used in the treatment of trichotillomania. HRT involves identifying the triggers or situations that lead to hairpulling and developing alternative responses or behaviors to replace the hairpulling. For example, an individual is taught to recognize the urge to pull their hair and instead squeeze a stress ball or engage in a relaxing activity. HRT also involves increasing awareness of hairpulling behavior, tracking the frequency and severity of hairpulling, and addressing any underlying emotional or psychological factors that may contribute to the behavior. HRT has been shown to be an effective treatment for trichotillomania and may be used alone or in combination with medication and other forms of therapy (Morris et al., 2013).
Nursing Interventions
Nursing interventions may involve education about trichotillomania and its impact on the individual’s health and well-being, as well as strategies for managing hairpulling behavior and promoting self-care. Nurses can also assist individuals in developing coping strategies and self-management techniques, such as mindfulness meditation or relaxation exercises, to help reduce anxiety and stress. In addition, nurses can work with individuals and their families to address any personal issues related to the disorder, such as stigma, social isolation, or relationship difficulties (Anderson, 2011).
Excoriation
Skin picking disorder, or excoriation, is a psychiatric condition classified under the obsessive-compulsive and related disorders category that involves repetitive and compulsive picking at the skin, leading to tissue damage, scarring, and sometimes serious medical complications like infections. The behavior is often driven by anxiety, stress, or underlying emotional conflicts and can become a chronic problem affecting various body areas (American Psychiatric Association, 2013). Clients may present with various physical manifestations, ranging from mild redness to severe wounds. A client-centered approach that thoroughly assesses the physical symptoms, underlying psychiatric conditions, and the psychosocial context is vital (Anderson & Clarke, 2017) (Figure 17.9).
Causes of Excoriation
The causes of excoriation are not fully understood, but it is believed to be related to genetic, environmental, and psychological factors. Research suggests that excoriation may be associated with abnormalities in brain structure and function, including alterations in neurotransmitters such as dopamine, serotonin, and glutamate. Trauma, stress, and other life events may also contribute to the development of excoriation. In addition, excoriation is often associated with other psychiatric conditions, such as anxiety, depression, or obsessive-compulsive disorder, and individuals with a family history of these conditions may be at increased risk of developing excoriation (American Psychiatric Association, 2013).
Signs, Symptoms, and Incidence of Excoriation
Individuals with excoriation may pick skin from any body part, including the face, arms, legs, and back. Skin picking may be accompanied by feelings of tension or anxiety before picking and a sense of relief or pleasure after picking. Skin picking can range from mild to severe and may lead to various physical and psychological symptoms. Physical symptoms may include skin lesions, scarring, infections, and other skin damage, as well as pain or discomfort. Psychological symptoms may include shame, guilt, anxiety, or depression and may interfere with social, occupational, or other areas of functioning (American Psychiatric Association, 2013).
The exact incidence of excoriation disorder is not well-established because it is often underdiagnosed and may be difficult to distinguish from other skin conditions or disorders. Some studies suggest that the prevalence of excoriation may be relatively high, particularly among individuals with other psychiatric conditions, such as obsessive-compulsive disorder or anxiety. For example, one study found that approximately 3.1 percent of adults aged eighteen to sixty-nine reported symptoms of excoriation in their lifetime. The disorder appears more common in females than males and often develops in adolescence or young adulthood (Grant & Chamberlain, 2020).
Diagnosis of Excoriation
The diagnosis of excoriation disorder is based on a thorough clinical assessment that includes a detailed history of the individual’s skin picking behavior, physical examination, and assessment of any associated symptoms or psychiatric conditions. To meet diagnostic criteria for excoriation, the skin picking behavior must result in skin damage and significant distress or impairment in social, occupational, or other important areas of functioning. The skin picking behavior must also not be attributable to another medical condition or substance use and must not be better accounted for by another mental disorder. In some cases, laboratory tests or imaging studies may rule out other potential causes of skin damage (American Psychiatric Association, 2013).
A commonality among those diagnosed with the disorder is the reported presence of stress and anxiety. Some individuals with excoriation disorder report that the act of skin picking provides temporary relief from emotional discomfort or distress (Kwon et al., 2020). Many individuals with excoriation disorder also struggle with other mental health conditions, such as OCD or depression, which can contribute to or exacerbate the skin picking behavior (Grant & Chamberlain, 2021).
Several types of excoriation disorders exist. They are classified based on the location and nature of the skin picking behavior.
- Acne excoriée is an excoriation that involves picking at acne lesions or other blemishes on the face, often resulting in scarring and discoloration.
- Dermatillomania is an excoriation that involves picking at healthy skin or minor imperfections, such as scabs or bumps, resulting in skin damage and scarring.
- Neurotic excoriation refers to a pattern of skin picking that occurs in response to anxiety or stress. An example of this would be an individual who, during stressful periods, picks, rubs, or scratches the skin to the point of scarring (Wong et al., 2013).
- Some excoriation is related to an underlying medical condition, such as pruritus or chronic skin conditions (American Psychiatric Association, 2013).
Treatment of Excoriation
The treatment of excoriation disorders typically involves a combination of medication and psychotherapy, CBT, and HRT. Medications that may be used to treat excoriation include SSRIs, commonly used to treat depression and anxiety disorders. Psychotherapy approaches may involve addressing underlying psychological or emotional factors contributing to skin picking behavior and developing alternative coping strategies and self-management techniques to reduce anxiety and promote relaxation. HRT may involve identifying triggers for skin picking, developing alternative behaviors or responses to these triggers, and tracking progress and success over time. In addition, support groups and educational resources may help promote coping and self-management strategies (American Psychiatric Association, 2013).
Self-care can be an important component of managing excoriation disorders and can help individuals reduce their symptoms and improve their overall quality of life. Some self-care strategies that may be helpful include maintaining a healthy and balanced diet. A balanced diet can help promote overall physical and mental health, which may reduce the frequency and severity of skin picking behavior. Engaging in regular exercise can help reduce stress and anxiety, which may be triggers for skin picking behavior. Techniques, such as mindfulness meditation, deep breathing exercises, or progressive muscle relaxation, can help individuals reduce stress and promote relaxation. Ensuring adequate sleep can help reduce stress and promote overall physical and mental health. Avoiding exposure to irritants, such as harsh soaps, chemicals, or allergens, can help reduce skin damage and irritation.
Nursing Interventions
Nursing interventions for excoriation disorder are an important component of the multidisciplinary care approach often used to manage this condition. Nursing interventions may include educating and supporting individuals with the disorder, developing coping strategies to manage triggers and reduce skin picking behavior, monitoring medication side effects, and promoting self-care strategies. Encouraging and reinforcing positive behaviors may also be an important nursing intervention. In addition, nurses may provide resources, such as support group referrals or educational materials, to help individuals with excoriation disorder manage their symptoms and improve their quality of life (Lochner et al., 2017).
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a terrifying event. The event may have been a threat to the safety or life of the person, or it may have been an event they witnessed. Although historically the condition may be most associated with soldiers returning from war, PTSD can occur in people who have experienced things like sexual abuse, rape, domestic abuse, natural disasters, or terrorist attacks. The person may suffer from chronic physical and emotional symptoms as they relive the trauma, and treatment usually includes psychotherapy and medications. Nurses are expected to be able to recognize the symptoms of PTSD and plan appropriate care for a person with PTSD wherever they might be working with them (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023).
Historical Perspectives of PTSD
PTSD is a relatively new diagnosis in the field of mental health; the Diagnostic and Statistical Manual of Mental Disorders (DSM-3) formally recognized it in 1980. Health providers have recognized and treated symptoms of PTSD for centuries under different terms, such as “shell shock” and “combat fatigue.” It was not until the Vietnam War that PTSD gained widespread recognition, as many veterans returning from the war exhibited symptoms of the disorder (Iribarren et al., 2005). The diagnostic criteria and understanding of PTSD have evolved since then, with a growing recognition of the impact of traumatic experiences on mental health and well-being (American Psychiatric Association, 2013).
Causes and Incidence of PTSD
According to the DSM-5, to be diagnosed with PTSD, a person must experience a life-threatening, traumatic event that evokes fear, helplessness, or shock. In addition, individuals report a persistent feeling of reexperiencing the event, avoid things associated with the event, and suffer persistent symptoms that indicate emotional arousal or stress response. These symptoms must last at least one month and cause significant impairment in functioning (American Psychiatric Association, 2013).
According to the National Center for PTSD (2023), approximately 5 to 6 percent of the U.S. population will experience PTSD at some point in their lives, with rates higher among certain groups, such as military veterans, first responders, and survivors of sexual assault or interpersonal violence. Women are more likely than men to develop PTSD.
Predisposing Factors
Several predisposing factors can increase the likelihood of developing PTSD after exposure to a traumatic event. Individuals who have experienced trauma earlier in their lives are more likely to develop PTSD after a subsequent traumatic event; exposure to childhood trauma, such as abuse or neglect, can increase the risk of developing PTSD later in life. A family history of mental illness, including PTSD, can increase an individual’s risk of developing PTSD after a traumatic event. Certain personality traits, such as neuroticism and anxiety, have been found to be associated with an increased risk of developing PTSD. People who lack social support or have few resources to cope with stress are at greater risk of developing PTSD after a traumatic event. The severity and duration of the traumatic event can also increase the likelihood of developing PTSD (National Center for PTSD, 2023).
Signs and Symptoms of PTSD
The symptoms and severity of PTSD can vary greatly from person to person and may change over time (American Psychiatric Association, 2013). Signs may emerge months or even years after the traumatic event, highlighting the importance of early intervention for individuals who have experienced trauma. The hallmark symptoms of PTSD are intrusive thoughts or memories of the trauma, avoidance of trauma reminders, negative changes in mood or thinking, and hyperarousal or reactivity (American Psychiatric Association, 2013). Intrusive thoughts and memories can take the form of flashbacks or nightmares, and individuals may avoid situations or activities that remind them of the trauma. Negative changes in mood or thinking may include feelings of guilt, shame, or anger and difficulty experiencing positive emotions or maintaining close relationships. Hyperarousal or reactivity may include symptoms such as hypervigilance, irritability, or difficulty sleeping. Individuals with PTSD may also experience physical symptoms, such as headaches, chest pain, fatigue, and changes in appetite, weight, and sleep patterns (Peterson et al., 2019).
Changes in Thinking
PTSD is associated with various cognitive changes and difficulties, including negative changes in mood, beliefs, and perception of oneself and others. For example, individuals with PTSD may experience guilt, shame, or self-blame related to the traumatic event and a sense of detachment or estrangement from others (American Psychiatric Association, 2013). They may also have negative beliefs or expectations about themselves, others, or the world, such as feelings of helplessness or a loss of trust in others. In addition, individuals with PTSD may have difficulty experiencing positive emotions or finding pleasure in activities they once enjoyed, which can contribute to a reduced quality of life. These changes in thinking and mood can be persistent and contribute to the overall complexity and challenges associated with treating PTSD.
Symptom Intensity and Complex PTSD
Symptom intensity and complexity are important factors to consider when evaluating the presence and severity of PTSD. Individuals with PTSD may experience a range of symptoms, from mild to severe, which can vary in intensity over time. In some cases, individuals may experience persistent and debilitating symptoms that interfere with their daily functioning and quality of life.
Complex PTSD, also known as developmental trauma disorder, is a subtype of PTSD that entails prolonged exposure to traumatic events, such as childhood abuse, neglect, or ongoing violence. Individuals with complex PTSD may experience a greater number and intensity of symptoms, including emotional dysregulation, self-perception and relational difficulties, and problems with impulse control (Giourou et al, 2018).
PTSD and Suicide
PTSD has been associated with an increased risk of suicide, particularly among individuals who have experienced trauma related to combat or sexual assault. In addition, studies have found that individuals with PTSD are more likely to report suicidal thoughts or behaviors than those without PTSD. This risk is further increased in individuals with comorbid depression or substance use disorders. The increased risk of suicide in individuals with PTSD highlights the importance of early identification and treatment of the disorder, as well as the need for suicide prevention strategies tailored to this population’s specific needs and experiences (Bentley et al., 2016).
PTSD in Children
PTSD in children is a serious mental health concern that can significantly impair their functioning, academic performance, social relationships, and overall well-being (Scheering & Zeanah, 2001). Children with PTSD often experience persistent and distressing memories of the event, avoid reminders, have negative alterations in mood and cognition, and experience hyperarousal symptoms, such as irritability or sleep disturbances (American Psychiatric Association, 2013).
Some of the most common traumas reported by children diagnosed with PTSD are sexual or physical abuse and violent crimes. Disasters, such as floods, tornadoes, hurricanes, or fires, may also precipitate PTSD. Other events reported include school shootings, car crashes, war, the suicide of a friend or family member, or witnessing violence firsthand (National Center for PTSD, 2023). Regardless of the cause, early intervention and appropriate treatment, such as trauma-focused cognitive behavioral therapy (TF-CBT), can help mitigate the impact of PTSD on a child’s life and foster resilience (Cohen et al., 2017).
The prevalence of PTSD in children varies depending on age, gender, type of trauma, and socioeconomic background. Girls are more likely to develop PTSD than boys, and the risk increases with the severity and frequency of the traumatic experience (Cohen et al., 2017). Research suggests that anywhere from 14 to 43 percent of children experience at least one traumatic event during childhood, and up to 15 percent of girls and 6 percent of boys who have experienced trauma develop PTSD (National Center for PTSD, 2023). Rates of PTSD are highest after traumas involving interpersonal violence, such as rape or child abuse (Kessler et al., 2017).
Treatment of PTSD
PTSD is a complex and challenging disorder, but evidence-based interventions help individuals manage their symptoms and improve their quality of life. Treatment approaches for PTSD typically include psychotherapy, medication, or a combination. CBT is a widely used and effective psychotherapy approach for PTSD—particularly exposure therapy, which involves gradually exposing the individual to the memories and situations associated with the trauma in a safe and controlled environment. Eye movement desensitization and reprocessing (EMDR) is another psychotherapy approach that has shown promising results in treating PTSD. Medications, such as SSRIs and SNRIs, are often used to treat symptoms of depression and anxiety that are common in individuals with PTSD. Other interventions, such as mindfulness-based therapies and complementary and alternative treatments, may also be helpful for some individuals with PTSD (National Institute of Mental Health, 2022c).
Cognitive Behavioral Therapy
Trauma-focused cognitive behavioral therapy (TF-CBT) is a structured psychotherapy approach designed to address the needs of individuals with PTSD and related symptoms. TF-CBT is a time-limited intervention that typically involves twelve to sixteen weekly sessions, and it includes a variety of techniques to help individuals manage their symptoms and improve their functioning. The therapy involves components, such as psychoeducation, relaxation techniques, cognitive restructuring, exposure therapy, and family involvement (Cohen & Mannarino, 2015). This type of therapy might be most beneficial for a veteran experiencing nightmares and flashbacks. Through gradual exposure, a therapist would assist the veteran in confronting memories and feelings related to the traumatic events in a safe and controlled environment. This gradual process would assist in reducing the emotional charge associated with those memories (Ennis et al., 2021).
Eye Movement Desensitization and Reprocessing (EMDR)
Eye movement desensitization and reprocessing (EMDR) is a psychotherapy approach that has been shown to be effective in treating symptoms of PTSD and related conditions. EMDR involves eye movements, hand tapping, or other bilateral stimulation techniques while the individual focuses on traumatic memories or triggers. The goal of EMDR is to facilitate the processing of traumatic memories and to reduce the intensity of associated emotional and physiological responses (Shapiro, 2014). EMDR typically involves a structured series of sessions and may include elements of CBT or other therapeutic approaches (National Center for PTSD, 2023).
Link to Learning
This short video from the Veterans Health Administration explains eye movement desensitization and reprocessing (EMDP) for treatment of PTSD, sometimes used with veterans.
Medications
Medication can effectively treat PTSD, particularly when combined with psychotherapy. SSRIs and SNRIs are the most commonly used medications for PTSD because they have been shown to be effective in reducing accompanying symptoms of anxiety and depression (National Institute of Mental Health, 2023). Other medications that may be used to treat PTSD include tricyclic antidepressants and atypical antipsychotics. Benzodiazepines are generally not recommended for the treatment of PTSD, as they can be addictive and may interfere with the processing of traumatic memories (Food and Drug Administration [FDA], 2020).
Alternative Therapies
In addition to traditional treatments, several alternative and self-help therapies may also help with PTSD symptoms. Some examples include mindfulness-based therapies, yoga and meditation, equine therapy, and art therapy (National Center for PTSD, 2023). Mindfulness meditation, for instance, involves being present in the moment and observing one’s thoughts and emotions without judgment. This practice can help individuals learn to regulate their emotions and reduce stress.
Self-help strategies can provide individuals with tools and techniques to manage their symptoms daily. Learning about PTSD, its symptoms, and its treatment can help individuals understand their experiences and feel more in control of their symptoms. Relaxation techniques, such as deep breathing, progressive muscle relaxation, and guided imagery, can help individuals reduce anxiety and stress. Regular exercise has been shown to be effective in reducing symptoms of PTSD, particularly depression and anxiety. Participating in a support group for individuals with PTSD can give them a sense of community and help them feel less isolated. Creative activities, like art or writing, can help individuals process their emotions and trauma-related experiences. These self-help strategies can be combined with traditional treatments to provide individuals with a holistic approach to managing their symptoms (National Center for PTSD, 2023).
Nursing Interventions for PTSD
Nurses play a critical role in the care of individuals with PTSD and can provide a range of interventions to support their recovery. For example, nurses can use standardized assessment tools to evaluate symptoms of PTSD and monitor changes over time. They can also provide individuals with information about PTSD and available treatments to help them understand their experiences and feel more in control of their symptoms. Nurses can help individuals with PTSD develop self-care strategies to manage their symptoms and can provide a safe and supportive environment for clients to express their feelings and process their experiences. Nurses can help individuals access appropriate treatments, such as psychotherapy and medication, and make referrals to other health-care providers as needed. By working closely with other health-care team members, such as psychiatrists and social workers, nurses can ensure coordinated and comprehensive care for individuals with PTSD (American Nurses Association, 2022).
Clinical Judgment Measurement Model
Applying the CJMM to a Person with PTSD
Estelle is a thirty-year-old female who was diagnosed with anxiety and PTSD following an incident when she was attacked and robbed in a parking garage three years ago. She lives alone and has asked to be readmitted to the psychiatric unit because she states that she is “starting to feel worse” and reports that the symptoms of her PTSD are starting to interfere with her work in the bank where she is employed. Her symptoms on admission appear to include intrusive thoughts, flashbacks, hypervigilance and avoidance behavior, disturbed sleep pattern, and persistent worry. Following the incident, she was prescribed Sertaline (Zoloft) for management of her anxiety, which she reports taking as prescribed.
Using the Clinical Judgment Measurement Model, the nurse can analyze the care planning for Estelle.
| CJMM Step | CJMM Data |
|---|---|
| Recognize Cues | Estelle has to be assessed for signs of her ongoing anxiety and PTSD. Active listening and observation are used to gather information from her and confirm her symptoms of hypervigilance, avoidance behaviors, intrusive thoughts, and manifestations of anxiety, such as palpitations, sweaty palms, dry mouth, and so on. |
| Analyze Cues | During interactions with Estelle, the nurse has to try and understand the factors that contribute to her anxiety and PTSD. Discussion should focus on her previous post-traumatic experiences, how she coped with them, the stressors that she is currently experiencing, and any support systems that might be available to her. |
| Prioritize Hypotheses | A potential nursing diagnosis for Estelle will be developed based on the cues she has provided, such as her anxiety related to a post-traumatic event and her ineffective coping mechanisms. The prioritizing of a hypothesis will be based on the severity her symptoms, the impact that they are having on her well-being, and her readiness to participate in the treatment plan that will be made for her. |
| Generate Solutions | A safe and supportive environment will be created for Estelle to encourage therapeutic communication. The interdisciplinary team will review her medications and decide if they have to be adjusted in light of her ongoing and worsening symptoms. She will be encouraged to develop her coping strategies through activities such as participation in relaxation techniques, exploring approaches to stress management, and discussions on promoting self-care. Support groups for people with PTSD, either online or near where she lives will be identified. |
| Take Action | The nurse should establish a rapport with Estelle in order to validate her feelings and the experiences she has gone through. The nurse will continually monitor for the effectiveness of medications prescribed for Estelle and be mindful to observe for side effects and report any that occur. Estelle will be encouraged to participate in deep breathing and progressive muscle relaxation exercises to help her to relax. The interdisciplinary care team may discuss the possibility of using exposure therapy with Estelle in an attempt to gradually desensitize her to triggering stimuli. |
| Evaluate Outcome | Estelle’s response to the interventions put in place for her will be evaluated. If these have been successful, she should demonstrate a reduction in her symptoms of anxiety, such as a decrease in the intrusive thoughts and avoidance behavior that she was having, as well as any physical symptoms of anxiety. Her overall mood should be more stable and her sleep quality improved. She should be able to identify her triggers effectively and manage any stress that she does develop more appropriately through the various techniques she has been practicing during her stay in the unit. She will have identified the community-based resources to assist in her long-term recovery and be at a level of social functioning that will enable her to return to her work at the bank. |
By applying the Clinical Judgment Measurement Model, nurses can effectively address the complex needs of clients with anxiety and PTSD. This care planning put in place for Estelle highlights the importance of clinical reasoning, therapeutic communication, and collaborative care in nursing practice.
Acute Stress Disorder
After a traumatic event, such as a natural disaster, serious accident, or violent crime, a person can develop the psychiatric condition called acute stress disorder (ASD). ASD is different from PTSD because it is a short-term condition. ASD symptoms typically begin within four weeks of the traumatic event and last for a minimum of three days and a maximum of one month. If symptoms persist beyond one month, the diagnosis may be changed to PTSD (American Psychiatric Association, 2013).
Causes of Acute Stress Disorder
The causes of ASD are multifactorial and likely involve complex interactions between biological, psychological, and environmental factors. For example, individuals who experience traumatic events may be at increased risk of developing ASD if they have a history of prior trauma, a preexisting mental health condition, or a lack of social support. In addition, neurobiological factors have been implicated in the development of ASD (Bryant & Harvey, 2000).
Diagnosis of ASD
The diagnosis of ASD is based on the presence of a cluster of symptoms—including intrusive thoughts or memories, avoidance of event reminders, and hyperarousal or hypervigilance—that occur in response to a traumatic event. According to the DSM-5, an individual may be diagnosed with ASD if they meet the following criteria: (1) exposure to a traumatic event; (2) presence of nine or more symptoms related to intrusion, negative mood, dissociation, avoidance, and arousal; (3) symptoms last for a minimum of three days and a maximum of one month; and (4) symptoms cause significant distress or impairment in social, occupational, or other areas of functioning (American Psychiatric Association, 2013).
Treatment for ASD
Treatment for ASD typically involves a combination of pharmacotherapy and psychotherapy. SSRIs and SNRIs are effective in reducing symptoms of anxiety and depression associated with ASD. Psychotherapeutic interventions, such as CBT and cognitive restructuring, are effective in treating ASD (Bertolini et al., 2020).
Trauma-Focused Cognitive Behavioral Therapy
Trauma-focused cognitive behavioral therapy (TF-CBT) is a type of psychotherapy that has been shown to be effective in treating ASD. TF-CBT is a structured intervention that involves several components, including psychoeducation, relaxation techniques, cognitive restructuring, exposure therapy, and trauma narrative development. TF-CBT aims to help individuals process the traumatic event, develop coping skills, and reduce symptoms of anxiety and depression associated with ASD (Bryant, 2022).
Cognitive restructuring, a key component of TF-CBT, has been shown particularly effective in treating ASD. Cognitive restructuring involves identifying and challenging negative or distorted thoughts and beliefs that may contribute to symptoms of anxiety and depression associated with ASD. For example, in cognitive restructuring, individuals learn to identify and challenge thoughts such as, “the world is a dangerous place” or “I am responsible for what happened,” and replace them with more realistic and adaptive thoughts, such as “the world is generally safe” or “I am not responsible for what happened.” Through this process, individuals can reduce symptoms of anxiety and depression and improve their overall functioning. Cognitive restructuring is typically used with other components of TF-CBT, such as exposure therapy and relaxation techniques (Bryant, 2022).
Medications
Medication treatment for ASD typically involves the use of SSRIs or SNRIs. These medications are commonly used to treat symptoms of anxiety and depression associated with ASD. In addition, providers may prescribe benzodiazepines over the short term to treat symptoms of anxiety and insomnia. Medications, such as imipramine, propranolol, morphine, hydrocortisone, and docosahexaenoic acid, have been administered to clients with ASD to help prevent escalation to PTSD (Bryant, 2022).
Nursing Interventions
Early intervention and ongoing support from nurses can improve outcomes for individuals with ASD and help prevent its evolution to PTSD. Nursing interventions for ASD typically involve providing emotional support and promoting coping strategies. Nursing intervention for ASD may include offering education on coping strategies, such as breathing techniques, guided imagery, mindfulness and meditation, laughter and humor relaxation techniques, deep breathing exercises, and mindfulness meditation (Felsenstein, 2024). Nurses can also provide referrals to mental health professionals for further assessment and treatment. In addition, nurses should be aware of the potential for comorbid physical health conditions, such as hypertension and cardiovascular disease. Therefore, they should monitor clients for signs and symptoms of these conditions (Mann & Marwaha, 2023).
Attachment Disorders
Also falling under the trauma umbrella are attachment disorders, a group of psychiatric conditions resulting from a disruption in the normal attachment process between a child and a caregiver. Children with attachment disorders may experience difficulties forming close, nurturing relationships and may exhibit avoidance, detachment, and aggression (American Psychiatric Association, 2013). Attachment disorders are thought to result from genetics and from environmental factors, including a history of neglect, abuse, or multiple placements in foster care (Chaffin et al., 2006). In addition, children with attachment disorders are at increased risk for other mental health conditions, such as depression and anxiety, and may have difficulties in academic and social settings (Turner et al., 2019).
Attachment Theory
Developed by John Bowlby, attachment theory is a psychological model that explains how early interactions between infants and their caregivers can shape the development of social and emotional functioning across the lifespan. In other words, the theory describes the importance of attachment in regard to personal development. Attachment plays a crucial role in an individual’s ability to form emotional connections and can greatly influence future relationships (Mcleod, 2017). According to the theory, infants develop a secure or insecure attachment style based on the responsiveness of their caregivers to their needs (Bowlby, 1969). Securely attached infants develop a sense of trust and confidence in their caregivers and are more likely to form close, nurturing relationships with others throughout life. In contrast, insecurely attached infants may develop anxious or avoidant attachment styles, resulting in difficulties forming close relationships and regulating emotions. Attachment theory has been widely researched and applied to various psychological and social phenomena, including romantic relationships, parenting, and mental health (Mikulincer & Shaver, 2016). There are four main attachment styles: secure, anxious, avoidant, and disorganized (Huang, 2020).
Secure Attachment
Secure attachment in adults is characterized by the ability to form close and trusting relationships, regulate emotions, and communicate effectively with others. Secure attachment is characterized by a child’s ability to trust and rely on their caregivers for comfort and support in times of distress (American Psychiatric Association, 2013). Securely attached children generally grow up to be emotionally available and responsive adults. Adults with secure attachment styles are comfortable with intimacy and rely on others for support during times of stress or distress. As a result, they can maintain a healthy balance of independence and dependence in their relationships (Mikulincer & Shaver, 2016).
Research suggests that individuals with secure attachment styles have better mental health outcomes, including lower levels of anxiety and depression and higher levels of life satisfaction (Mikulincer & Shaver, 2016). In addition, secure attachment has been associated with positive outcomes in various life domains, including academic achievement, career success, and social relationships.
Anxious Attachment
Anxious attachment is a type of insecure attachment characterized by a need for closeness and intimacy but with a persistent fear of rejection or abandonment. Children with anxious attachment styles may cling to their caregivers and become anxious or distressed when separated from them. While this is normal, expected behavior for children between approximately nine months and two years, it can be diagnosed as a malady in older children. They may become easily overwhelmed by stress and have difficulty regulating their emotions (Cassidy & Shaver, 2016).
In adults, anxious attachment can lead to various relationship difficulties, including clinginess, jealousy, and emotional volatility. In addition, adults with anxious attachment styles may have a negative view of themselves and be highly critical of their partners. They may also experience intense anxiety and distress when their partners are unavailable. Research suggests that anxious attachment styles are associated with a range of negative outcomes, including higher levels of anxiety and depression, poorer social functioning, and difficulties in regulating emotions (Mikulincer & Shaver, 2016).
Avoidant/Dismissive Attachment
Avoidant/dismissive attachment is a type of insecure attachment characterized by a need for independence and discomfort with intimacy and closeness. Children with avoidant/dismissive attachment styles may seem emotionally detached or indifferent to their caregivers and may not seek comfort or support during distress (Cassidy & Shaver, 2016). They may also be highly self-sufficient and resist being comforted by others.
In adults, avoidant/dismissive attachment can lead to a preference for emotional distance and independence in relationships. Adults with avoidant attachment styles may avoid close relationships and feel uncomfortable with intimacy or emotional expression. They may also need control and resist being vulnerable or dependent on others (Mikulincer & Shaver, 2016).
Research suggests that avoidant/dismissive attachment styles are associated with various negative outcomes, including difficulties in forming and maintaining close relationships, higher levels of anxiety and depression, and decreased emotional regulation (Mikulincer & Shaver, 2016).
Disorganized Attachment
Disorganized attachment is a type of insecure attachment characterized by inconsistent or unpredictable behavior in caregivers, leading to confusion and fear in children. Children with disorganized attachment styles may exhibit a range of behaviors, such as freezing or appearing dazed, showing fear or aggression toward their caregivers, or engaging in disorganized and confused behavior during interactions (Cassidy & Shaver, 2016).
Disorganized attachment can manifest in adults as a lack of relationship coherence or organization. Adults with disorganized attachment styles may struggle with emotional regulation and have difficulty managing their own emotional responses to stress and conflict. They may also experience confusion or fear in their relationships and have difficulty making sense of their own behavior or the behavior of others (Mikulincer & Shaver, 2016).
Research suggests that disorganized attachment styles are associated with various negative outcomes, including higher levels of anxiety and depression, difficulties in regulating emotions, and challenges in forming and maintaining close relationships (Mikulincer & Shaver, 2016).
Diagnosing Attachment Disorders in Children
Attachment disorders in children can manifest in various ways, including behavioral, emotional, and social difficulties. For example, children with attachment disorders may display aggressive or hostile behavior toward caregivers, peers, and authority figures. They may also be withdrawn, emotionally detached, or overly compliant. In addition, children with attachment disorders may have difficulty forming close relationships with others and struggle with social skills, such as sharing, taking turns, and cooperating with others. Emotional regulation may also be a challenge, leading to mood swings, tantrums, and difficulties with self-soothing. These difficulties can interfere with academic achievement, social development, and well-being (Ellis et al., 2022).
The DSM-5 includes two diagnoses related to attachment disorders in children: reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). Both can result from a history of neglect, abuse, or multiple placements in foster care and are associated with difficulties in emotional regulation, social skills, and overall functioning (American Psychiatric Association, 2013). The criteria for RAD include a consistent pattern of emotionally withdrawn or unresponsive behavior toward caregivers, a lack of positive attachments to caregivers, and limited social and emotional responsiveness to others (American Psychiatric Association, 2013). In addition, children with RAD may exhibit persistent fear, sadness, or irritability and may avoid or resist comfort from caregivers. The criteria for DSED include a pattern of indiscriminate, overly trusting behavior toward unfamiliar adults and an absence of appropriate wariness of strangers (American Psychiatric Association, 2013). Children with DSED may approach and interact with strangers in an excessively friendly or familiar manner without regard for their own safety.
Attachment Disorders in Adults
Attachment disorders can also occur in adults and may result from various factors, such as childhood trauma, disrupted family relationships, or the loss of a loved one. Attachment disorders can manifest as difficulties in forming and maintaining close relationships, emotional dysregulation, and self-esteem challenges. Adults with attachment disorders may struggle with intimacy and trust and engage in maladaptive behaviors, such as emotional withdrawal or overly dependent behavior. These individuals often appear disconnected or disengaged from other people’s feelings and tend to withdraw from connections. They may also have difficulty maintaining social relationships, whether romantic or platonic, and may struggle to show and receive affection. In addition, attachment disorders have been associated with various mental health conditions, such as depression, anxiety, and personality disorders (Mikulincer & Shaver, 2016).
Treatment of Attachment Disorders
The treatment for attachment disorders typically involves therapy. Therapeutic interventions may include attachment-based interventions, such as parent-child interaction therapy or play therapy, to improve attachment and promote positive interactions between caregivers and children (Zeanah et al., 2016). For adults, attachment-focused therapies, such as attachment-based psychotherapy or emotion-focused therapy, address underlying attachment issues and promote healthier relationship patterns (Brisch, 2014). While medication may target specific symptoms associated with attachment disorders, it is not considered a first-line treatment (Kobak et al., 2015).
Nursing Interventions
Developing a nursing care plan for clients with attachment disorders involves a comprehensive assessment of the client’s physical, emotional, and behavioral needs. The care plan should be individualized and based on the client’s specific symptoms and personal and cultural preferences. It may include therapeutic interventions to promote positive interactions between caregivers and children, such as providing a safe and nurturing environment and promoting healthy attachment. In addition, the care plan may include medication management, if necessary, and education and support for the client and their family (Mayo Clinic, 2022a).