Study of Post Traumatic Stress

CHAPTER I

INTRODUCTION

Background of the Study

‘Stress is not what happens to us. Its our response to what happens and response is something we can choose'.

Maureen Killoran

Road traffic accidents are global problems affecting all sections of the society. In India about 250 people die everyday which is equivalent to plane crash having no survivors. In 2007, the number of motor vehicle accidents in main metropolitan cities of India were 89,826 and number of persons injured were 57,713. The highest number of people died in road traffic accidents in India till date on 2007 was 1,14,540.(Vidya Venkat,2007) The global annual cost of RTA is almost 230 billion dollars. 1.2 million people die every year due to Road Traffic Accidents. Every day, there are 3300 deaths and 6600 serious injuries on the road in the world. Trauma related death occurs in India every 1.9 minutes,1.27 million people in India sustain serious injuries, 1,20,000 people die on the road every year. A majority of major accident survivors are either confined to bed or wheel chair bound due to brain injury or spinal cord injury or being in psychiatric stress.(www.medindia.net,2010,May 07). Despite the improvement in road condition, vehicle safety and driver education over 3 million persons are injured in motor vehicle accident each year. Many of these persons develop post traumatic stress disorder that can become chronic. Patient typically experience distress related to the alteration in their physical and emotional health status, changes in their level of daily functioning and decreased social support or the loss of significant others.( Brunner 2004) Most survivors of trauma, especially those with adequate coping mechanisms can adjust to the incident and having no lingering effects However, some persons have stress reactions that do not abate and may worsen overtime. These reactions can develop into post traumatic stress disorder, which may be severe enough to have significant impact as their daily life as well as that of their spouses, family and significant others. It has demonstrated that witnessing is sufficiently stressful to cause post traumatic stress disorder. Any trauma, especially, when prolonged or repeated, may convert ordinary adaptive response of ‘flight or fright' into pathologic reaction.(Allen 2005) ‘Silent Killer' is the best term applicable for stress. The meaning of post traumatic stress disorder is to ‘Press tight'. It became known in the 70s due to adjustment problems of some vietnam veterans. It has been known by the other name such as ‘shell shock' in world war I, and ‘Battle fatigue' in world war II. Post Traumatic stress Disorder(PTSD) was first listed as a diagnostic category by the American Psychiatric Association in 1980. It can affect both children and adult, on various causes. (www.medicinenet.com,2010 ,June06) Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that occur after a person has experienced or witnessed life threatening events such as military combat, natural disaster, terrorist incidents, serious motor accidents or violent personal assaults. It can be acute (2 weeks-3months), chronic(3 months and longer) or delayed (after 6 months). Person perceive, experienced event as traumatic, night mares of event, inability to recall an important event, exaggerated started response, hyper arousal and hyper vigilant.(National centre for PTSD, 2006) Following a traumatic event, almost every one experiences at least some of the symptoms of Post Traumatic Stress Disorder. The symptoms of Post Traumatic Stress Disorder can arise suddenly gradually or come and go overtime. Everyone experiences Post Traumatic Stress Disorder differently , there are three main types of symptoms: Re-experiencing the traumatic event: Intrussive upsetting memories of the event, Flashbacks, Night mares, Feeling of intense distress when reminded of trauma and Intense physical reactions to reminders of the event (pounding heart, rapid breathing, nausea, sweating) Avoidence and emotional numbing: Avoiding activities; places; thoughts or feelings that remind of trauma, Inability to remember important aspects of trauma, Loss of interest in activities and life in general, Feeling detached from others and emotionally numb and Sense of a limited future. Hyper arousal: Difficulty falling or staying asleep, Irritability or outbursts of anger, Difficulty concentrating, Hyper vigilance (on constant red alert) and Feeling jumpy and easily startled. Other common symptoms: Anger and irritability, Substance abuse, Suicidal thoughts and Feelings of mistrust and betrayal.(National center for PTSD, 2006) There are good treatments available for Post Traumatic Stress Disorder . Cognitive Behavioural therapy (CBT) is one type of counseling. It appears to be most effective type of counseling for Post Traumatic Stress Disorder .In cognitive therapy, therapist helps the person to understand and thought about trauma and its aftermath. Cognitive behavioural therapy includes four individual sessions involving psycho education, muscle relaxation training, imaginal exposure and invivo exposure and finally cognitive restructuring. Each sessions may last from 30 to 75 minutes. CBT begins with education about the problems and how the treatment can help. Patient will learn about the specific symptoms and experiences. After becoming more aware of thought and beliefs, patient will learn about the common changes in beliefs that occur after going through trauma. Psychotherapy provide ways to cope with intense feelings about the past, and raise self esteem. Family therapy is provided involving whole family, which cope with tough emotions and maintain good relationships.(National center for PTSD, 2007) For trauma patients, psycho education helps to use of healthy coping strategies such as relaxation and mobilization of social support, about physiological basis for psychological phenomena such as mood instability, flash backs, memory problems, depression and allows them to see these as symptoms and not as personal failings.(Wessley et al 2008) Bisson, Mifarlane and Rose(2005) stated that psycho education is a way of providing traumatized individuals with a psychological map to understand their reactions. These may be adjuncts to other interventions, given in the review large from provision of brochures and face to face sessions. Elizabeth Scott (2005) stated that progressive muscle relaxation is a great technique for reducing overall body tension and stress by alternatively tensing and relaxing the muscles. With practice, the participant learns to completely release the body within seconds and keep from storing up tension and stress in the body. The goal of relaxation training is to produce a response that counters the stress response when this goal is achieved the action of hypothalamus adjusts and decreases the activity of sympathetic and parasympathetic nervous system. Progressive muscle relaxation entails physical and mental components involves the tensing and relaxing of muscle groups in sequential pattern. Tensing and relaxing various muscle groups throughout the body produces deep state of relaxation which found capable of relieving a variety of conditions, from high blood pressure to ulcerative colitis. The mental component focuses on the difference between the feelings of tension and relaxation. Thus, with practice patient learns how to effectively relax and deter stress when it becomes an unhealthy level.(www.wikipedia.com, 2010, Nov28) According to Neeraja (2008) the role of nurse for post traumatic stress disorder should be empathetic, sincere honest, trustworthy with effective communication skills and interaction skills. Directing the client in psycho education process allow the client to ventilate his feelings outwardly, motivate to discuss job and methods (plan of activities) to attain it, enhance the functioning levels, independence level of achievement. Promote clients interaction with group members and family members to enhance coping strategies. Assist client to divert mind from traumatic memory to useful activities. Train up the client in deep breathing exercises, relaxation excercises, healthy lifestyle.So educating the client is the utilization of alternative coping strategies to come out from post traumatic stress disorder.

Significance and Need for the Study

"Even to much sunshine can be devasting, while only with rain can growth occur. Accept both as part of the growing process in the garden of life."

- Donald S. Neviaser

Every day, there are 3300 deaths and 6600 serious injuries on the road in the world. Trauma related death occurs in India sustain serious injuries. 1,20,000 people die on the road every year. (www.medindia.com, 2010,June 4) A motor vehicle is a human made calamity. It angers and it raises question of blame. It can turn survivors into while knuckled drivers who live in fear of another accident. Accident phobia and post traumatic stress disorder frequently disabling. (Klaus Kuch et al;2006) The National centre for PTSD(2006) has described that the Post Traumatic stress disorder is an anxiety disorder that occurs after a person has experienced or witnessed life threatening events such as military, combat, natural disaster, terrorist incidents, serious motor accidents in violent personal assaults. The development of Post Traumatic Stress Disorder may be delayed from 1 week to 3 years and it is divided in to two stages. Stage 1 is associated with an adrenergic surge that occurs acutely, but persons rarely dwell long-term on the incident. It may last up to 1 month .Stage 2 is that if symptoms lasts for more than 6 weeks. The patient is considered to have entered stage characterized by sense of helplessness and loss of self control. Autonomic and somatic manifestations dominate in their stage moreover, It is accompanied by lifestyle personality changes. Post traumatic stress disorder is believed to be caused by either physical trauma or psychological trauma, or more frequently a combination of both. Post traumatic stress disorder symptoms may result when a traumatic event causes an overactive adrenaline response, which creates deep neurological patterns in the brain. Three areas of the brain whose function may be altered in Post traumatic stress disorder have been identified: the prefrontal cortex, amygdala and hippocampus. Cognitive Behavioural Therapy (CBT) have been proven to be an effective treatment for Post traumatic stress disorder , and is currently considered the standard of care for Post traumatic stress disorder by the United States Department of Defense...(www.wikipedia.com.2010,Nov 25). Post traumatic stress disorder is assumed to be an equivalent syndrome regardless of the type of traumatic event. When comparing the clinical profiles among civilian trauma: sexual assault, motor vehicle accident, and sudden loss of loved one;it may differ in trauma types which may lead to unique variants of the post traumatic stress disorder ,which may result from different etiological factors. So it may require different treatment approaches.(Kelley et al;2009) According to Maria Pease(2011)the prognosis for Post traumatic stress disorder depends upon the severity and length of time a person has suffered from the disorder. The majority of patients with Post traumatic stress disorder respond to psychotherapy. There are often residual symptoms, however, and we cannot yet predict who will respond best. There are significant risks to a person with Post traumatic stress disorder if they do not receive treatment. They may stay in a hyper aroused state, further damaging their brain. They may lose their job and/or family due to their irritability. Suicide is also a risk with untreated Post traumatic stress disorder. Moddern (2004) stated that cognitive behavioural therapy including sessions of psycho education, relaxation training, exposure therapy and cognitive restructuring is an effective treatment of choice for clients with post traumatic stress disorder. Benham (2005) stated that psycho education is crucial in the initial safe and stabilization stage because this is when problems related to trauma history are identified, expectations for future treatment are defined and coping skills that are necessary for delaying with painful memories or changing risky behavior are taught. Phoenix(2007) stated that the goal of psycho education in the aftermath of traumatic event are to help people understand the range of normal responses to such events, use coping strategies, and identify responses that warrant more intensive intervention. Relaxation therapies include a range of techniques such as autogenic training, deep breathing exercises, progressive muscle relaxation. The goal of progressive muscle relaxation is overall relaxation and stress reduction. Practice can produce a set of physiologic changes mat can result in showed respiration, lowered pulse and blood pressure and increase in alpha brain activity and possibly even reduction in the body's inflammatory response (www.mentalhealthwiki.org,2010.June 13) George and Lalitha (2006) stated that skill of relaxing using Jacobson's progressive muscle relaxation procedure is probably the easiest method to teach the client to use, sufficient instructions and practice proficiency can be acquired by any one. The focus on physical tension and relaxation gives excellent proper reception feedback and helps to focus the attention. Deborah Brauser(2010) conducted a small, phase pilot study on effectiveness of Methlylenedioxymethamphetamine (MDMA), also known as "ecstasy," added to psychotherapy in reduction of symptoms of posttraumatic stress disorder (PTSD) in patients who are resistant to other treatments. The study demonstrates that MDMA-assisted psychotherapy with close follow-up monitoring and support can be used with acceptable and short-lived side effects in a carefully screened group of subjects with chronic, treatment-resistant PTSD. They quoted that MDMA was found to be effective ,even though have a long way to go and don't have any clinical conclusions yet. Nursing care of patients with post-traumatic stress disorder becomes very difficult if the patient shows an extremely apprehensive response to the particular care procedure or treatment. So the nurse has to communicate with the patient in a clear and concise manner. Assume a consistent, non-judgmental, honest, and a positive attitude while providing nursing care to establish sense of trust and security and remove guilt in patient's mind. (wwwmedicinetips.com,2011,Jan 06) The nurse's efforts for post trauma patients are directed to life supporting interventions and to the inclusion of approaches aimed at the reduction of additional stressors like sleep deprivation. Nurses are in a unique position to assist individuals in identifying adaptive coping strategies. By this, patient will develop a sense of control with an increase in self esteem as the practices are incorporated into daily activities. Specific stress reducing activities include relaxation training, cognitive appraisal, music therapy, exercise, decision control, massage and humour. So the knowledge of stress and coping theories, provides the nurse with useful concept that are applicable to all phases of nursing process (Luckmann). Keegan (2003) stated that successful use of alternative and complementary therapies provided by nurse will help to decrease stress for critical care patients. The therapies included are aromatherapy, hydrotherapy, humour, music massage, imagery, relaxation therapy. Hence the investigator felt the need to perform experimental study to assess effectiveness of psycho education and progressive muscle relaxation training in reducing Post traumatic stress disorder.

STATEMENT OF THE PROBLEM

A quasi experimental study to assess the effectiveness of selected nursing interventions in reducing the level of post traumatic stress disorder among patients met with motor vehicle accidents admitted in Madurai Institute of Orthopedics and Traumatology Hospitals, Madurai.

OBJECTIVES

To assess the level of post traumatic stress disorder before and after selected nursing intervention in the experimental group. To assess the level of post traumatic stress disorder before and after routine treatment in the control group. To compare the level of post traumatic stress disorder between the experimental and control group after the nursing interventions. To assess the effectiveness of selected nursing interventions in reducing the level of post traumatic stress disorder. To determine the association between the level of post traumatic stress is experimental group with selected variables (age, educational status, marital status, marital status, occupational status, nature of accident, loss of body part and loss of family member during accident).

HYPHOTHESIS

All hypotheses were tested at 0.05 level of significance H1 - The mean post test level of post traumatic stress disorder in experimental group will be significantly lower than mean post test level of PTSD in control group H2 - The mean post test level post traumatic stress disorder in the experimental group will be lower than mean pretest level of post traumatic stress disorder after selected nursing interventions. H3 - There will be significant association between experimental group post test level of post traumatic stress disorder and with selected variables (age, educational status, marital status, nature of accident, loss of family member and loss of body part).

OPERATIONAL DEFINITION

Effectiveness : It is the most outcome of selected nursing intervention in producing reduction of post traumatic stress disorder in patients net with motor vehicle accident. It will be measured by the score obtained by the subjects in the PTSD Checklist Civilian version (PCL-C) Scale. Post traumatic stress disorder – It is an anxietic disorder that may develop with the patient after threatened death, assault, serious injury, motor vehicle accidents as meant to physical integrity of oneself or others, numbing of emotional response or hyper arousal. Hereafter it will be termed as PTSD. In this study, subjects who met with motor vehicle accidents were selected based on the Diagnostic and Statistical Manual of Mental Disorders(DSM)IV Criteria for PTSD. Selected nursing interventions: They are actions undertaken by a nurse to further the course of treatment for a patient In this study following interventions are taken to reduce post traumatic stress disorder. Psycho education : Education of subjects with psychological disturbance, regarding, common reaction have been found among those exposed to trauma and coping strategies, reestablish routines, avoidance of intrusive thoughts and relaxation techniques. It was provided for 20 minutes. Progressive muscle relaxation training- It refers to programme of relaxation with eyes closed, the muscles are tensed (10 seconds) are relaxed (20 seconds) in sequence and progressive pattern. This was provided for 30 minutes. Patients met with accidents- It refers to conscious patients admitted after motor vehicle accident with minimum hospital duration of 14 days,admitted in selected hospital during data collection period.

ASSUMPTIONS

Patients who have met with motor vehicle accidents will experience post traumatic stress disorder symptoms Progressive muscle relaxation training will have no adverse effects on patients who are practicing it. Patients who have received progressive muscle relaxation will not have difficulty in practicing it. Hospitalized patients will suffer from some sorte of stress.

DELIMITATIONS

The following delimitations were set for the study: Patients who have met with accidents with in a duration of one month, admitted in Madurai Institute of Orthopedics and Traumatology, Madurai. Patients with high level of post traumatic stress disorder during the period of data collection Data collection period is limited to six weeks. Progressive muscle relaxation training was administered for 30 minutes and psycho education for 20 minutes for 14 days.

PROJECTED OUTCOME

Research study findings will be very useful to the nursing practice because nurses can teach these simple intervention to their patients to reduce post traumatic stress disorder. Psycho education will enhance acceptance of symptoms and reduce level of post traumatic stress disorder among patients met with motor vehicle accidents. Progressive muscle relaxation will reduce the level of post traumatic stress disorder among patients met with motor vehicle accidents.

CONCEPTUAL FRAMEWORK

The conceptual framework of this study was based on Sister Callista Roy's Adaptation Model (1934), which involves four concepts-person,environment,nurses and health. The adaptive system has four components-Input (stimuli which may come from the environment) which can be focal (immediately confronting) contexual (all other stimuli that are present) or residual (non specific such as cultural beliefs):Throughput (which includes processes that a person uses as an adaptive system and effectors as physiologic function, self concept and role function) and Output ( positive or negative outcome of the adaptive system-person's behavior).. In this study,persons were patients with post traumatic stress disorder, reduction in the level of severity of post traumatic stress as the goal of nursing, health is considered an adaptation to post traumatic stress disorder and environment was defined as all the conditions affecting the development and behavior of person.Selected nursing interventions(psycho education and progressive muscle relaxation training) were considered to be regulator coping mecahanism.Factors in the environment that affect were categorized as focal,contextual and residual stimuli.In this study focal stimuli was refered to the physiological(heart pounding,trouble breathing,sweating,sleep disturbance,irritability) and psychological(memories.hyperarousal,numbing,poor concentration);contextual stimuli were age, sex, educational status, occupational status, marital status, loss of body part, loss of family member.Selected nursing interventions(psycho education and progressive muscle relaxation training) were considered to be regulator coping mecahanism.Output is the absence or reduction in the level of post traumatic stress disorder(Adaptive response) in both groups or no reduction in level of post traumatic stress disorder (ineffective response) is both groups which need to be given feedback by re-assessment process.

CHAPTER II

REVIEW OF LITERATURE

According to Polit and Hungler(1999) researchers often undertake a literature review to familiarize themselves with that knowledge base. The term literature review refers to the activities involved in identifying and searching for the information on a topic and developing an understanding of the state of knowledge on that topic. Related literature was reviewed in depth, so as to broaden the understanding of the selected problem. The idea was to develop a deeper insight into the problem area and to identify the level of post traumatic stress disorder among patients met with motor vehicle accidents and to evaluate effectiveness of psycho education and Progressive muscle relaxation training to reduce post traumatic stress disorder. The review of literature is organized under following headings: Studies related to post traumatic stress disorder Effects of psycho education on post traumatic stress disorder Effects of progressive muscle relaxation training on post traumatic stress disorder

Studies related to post traumatic stress disorder

Andresen (2010) investigated on post traumatic stress disorder: a history and a critique. The study explained that the history of PTSD has often been linked to the history of war, but the disorder has been frequently described in civilian settings involving natural disasters, mass catastrophes and serious accidental injuries. The diagnosis first appeared in the official nomenclature when Diagnostic and Statistical Manual of Mental Disorder (DSM I) was published in 1957 under the name gross stress reaction. When DSM III was developed in the mid 1980s the recent occurrence of the Vietnam war provoked a more thorough examination of the disorder. Post Traumatic Stress Disorder was defined as a stress disorder that is a final common pathway occurring as a consequence of many different types of stress including both combat and civilian stress. Barayani et al;(2010) has conducted a study to assess the relationship between post traumatic stress disorder, quality of life, social support and affective and dissociative status in severely injured trauma victims. The study was carried out in 52 severely injured accident victims 12 months after trauma. Respondents were given a questionnaire and structured clinical interviews. One fourth of respondents met all criteria for post traumatic stress disorder and another 21.2% had sub syndromal Post Traumatic Stress Disorder. Patients with Post Traumatic Stress Disorder showed higher severity of dissociative and depressive symptoms and major impairments in some dimensions of quality of life. Severely injured accidents victims seem to face a major risk of Post Traumatic Stress Disorder and impairments in health related quality of life. Frommberger et al;(2008) had conducted a prospective study on prediction of post traumatic stress disorder by immediate reactions to trauma among 179 unselected consecutively admitted road traffic victims were assessed a few days after the accident for psychiatric diagnoses and psycho pathology. At 6 months follow up assessment, 152(85%) of patients were interviewed again of the patients, 18.4% fulfilled the criteria for post traumatic stress disorder (DSM III R) within 6 months after the accident. Patients with PTSD were injured more severely, stayed significantly longer in the hospital than other patients.A regression analysis revealed that the length of hospitalization was mainly due to diversity of factors such as severity of injury, severity of accidents and premorbid personality. Chen, Liu and Zheng (2006) conducted a study on Post Traumatic stress Disorder after road traffic accidents in forensic medicine. 156 victims of road traffic accidents were recruited, who applied to court for cost order. The victims were examined for psychiatric diagnosis by psychiatrists and for rank of impairment by experts in forensic clinical medicine. 51.92% fulfilled criteria for PTSD (ICD 10). Morbidity difference in male and female were significant . The scores in World Health Organization Quality of life were higher in PTSD group than in non PTSD group. Acquirement of awarded costs could obviously prevent Post Traumatic Stress Disorder, and higher incidence of Post Traumatic Stress Disorder existed in road traffic accidents victims who applied to court for costs order. Watts (2006) had assessed the prevalence of post traumatic stress disorder caused by surviving serious road accidents, 29 people were selected. Their high vulnerability was clearly established 41% had PTSD and 52% with severe intrusion or avoidance phenomena, which included 31% who had both the occurrence of psychological sequelae was not associated with being currently distressed by another event, not with age, gender or acquaintance with people killed in the accident. Stretch et al;(2006) had assessed the prevalence of risk for development of post traumatic stress disorder symptoms among active duty and reserve veterans from Pennsylvania and Hawaii who either deployed (N-1,524) or did not deploy (N-2727) to the Persian Gulf as a result of Operational Desert Storm. All participants anonymously completed a survey questionnaire but included the impact of event scale and brief symptom inventory. Results indicate the likelihood of post traumatic stress disorder symptoms in appropriately 8.0% of active duty verterans and 9.3% of reserve veterans who deployed to the Persian Gulf. Cairo et al; (2010) had investigated the prevalence of post traumatic disorder among adult earthquake survivors in Peru(magnitude 80). The cross-sectional study was conducted using demographic questions, PTSD checklists and a translated version of Harward Trauma Questionnaire.298 adult earthquake survivors were interviewed and detected 75 cases of PTSD (Prevalence 25.52%;95% confidence interval,20.2%-30.1%).In the bivarial analysis,PTSD was significantly associated with female sex, loss of relative, food and water shortages joblessness,lack of clean drinking water or appropriate sleeping conditions. Thavichachart et al;(2009) conducted a cross-sectional community survey on Post traumatic stress disorder prevalence among Tsunami survivors in Thailand.3,133 samples had been conducted in two phases from the same sampling group. The first phase was concerned with prevalence of PTSD, depression and related factors. The second phase included 2,573 samples from first phase and focused on Post traumatic stress disorder and other mental disorders. The 3,133 samples used in the first phase showed that 33.6% suffered from Post traumatic stress disorder, 14 .27% with depression and 11.27% suffered from both. Elkit and Christiansen (2010) had investigated the prediction of post traumatic stress disorder through the presence of acute stress disorder in a population of 148 female rape victims who visited a center shortly after the rape or attempted rape regardless of whether cases were classified according to full Post traumatic stress disorder status or accessing to meeting the criteria for the three Post traumatic stress disorder core symptoms clusters, the classification was correct in approximately two thirds of cases. A regression analysis based on Acute Stress Disorder severity and sexual problems following the rape accounted for 48% of post traumatic stress disorder severity variance. Susan et al;(2009) had done study on analysis of symptoms presentation and sampling for post traumatic stress after childbirth. 1423 women after birth were selected via the community (n=502) or internet (n=921). Demographic, obstetric and trauma history variables were also measured.Full post traumatic stress disorder diagnostic criteria were endorsed by 2.5% of women from the community and 21% of women on the internet. Factor analysis found two post traumatic stress disorder symptom clusters of re experiencing and avoidance and numbing and arousal 60% of post traumatic stress disorder cases were correctly identified by parity, delivery type and the interaction between sexual trauma and delivery type. Dao et al;(2010) performed a retrospective survey to assess the effect of clinical depression, post traumatic stress disorder as risk factors for in hospital mortality after Coronary Artery Bypass Grafting surgery. Nationwide inpatient sample database providing information on 8 million US inpatient stays from about 1000 hospitals. Patients were more likely to have had depression (alive, 24.8% deceased,60.3%, P<0.0001) post traumatic stress disorder (alive 13.4%; deceased 56.1%, P<0.001) and comorbid depression and post traumatic stress disorder (alive 7.8%, deceased 48.5%, P< 0.001) Two findings were note worthy. First,depression,post traumatic stress disorder are prevalent is patients undergoing coronary artery bypass grafting procedures. Second, depression and post traumatic stress disorder increase the risk of death by magnitudes comparable with well established physical health risk factors after CABG. Schelling (2008) stated that Post traumatic stress disorder has been described in patients after multiple trauma,burns or myocardial infarction, ARDS or septic shock.Studies in long term survivors of ICU treatment demonstrated clear and vivid recall of different categories of traumatic memory.A high number of these traumatic memories from the ICU has been shown to be a significant risk factor for the later development of Post traumatic stress disorder is long term survivors.

II STUDIES AND LITERATURE RELATED TO THE EFFECTS OF PSYCHO EDUCATION ON POST TRAUMATIC STRESS DISORDER

Bethany (2007) stated that psycho education about the persistent effects of trauma help survivors to better understand their stress responses and knowledge of coping strategies which provides a sense of control over these responses. Trauma education for providers can minimizes negative counter transference and prevent vicarious traumatization. Advanced practice nurses may provide psychological and behavioural disturbances related to severe and persistent abuse or trauma, especially early in life. It provides a cognitive framework for their experience and helps minimize adverse responses. For persons with persistant symptomatology, education about physiological basis for psychological phenomena such as mood instability, flash backs, memory problems and depression allows them to see these symptoms and not as personal failings. Psycho education also need to address immediate needs for safety and self care. Oflaz, Halipoglu and Aydin (2006) conducted a quasi experimental study to examine the effectiveness of psycho education intervention on post traumatic stress disorder and coping styles of trauma survivors. 51 survivors of motor vehicle accidents who met diagnostic criteria for PTSD. Comparison groups were made up as psycho education only and medication only. Six semi structured psycho education session were conducted. Clinician Administered PTSD scale, Hamilton depression scale and coping strategies scale were used for me measurements. The result showed, that there was significant difference between ‘psycho education only' group and ‘medication only' group. Avoidance as a copying strategy had significant positive correlations with Post traumatic stress disorder. Kim et al; (2005) conducted randomized controlled trial at University of California Medical Center, USA to evaluate the effectiveness of psycho educational programme in reducing post traumatic stress disorder among patients following motor vehicle accidents. The study was done in seven out patients with post traumatic stress disorder. Following randomization, into psycho education group, patients completed the Clinician Assisted PTSD scale prior to and at the completion of intervention.The scores increased significantly is psycho education group (21%) when compared to standard care group 0.5% thus the results curtained up that there was significant difference between psycho education group and standard care group of patients. Pratt et al; 2005 conducted study for the evaluation of PTSD psycho educational program for trauma patients. 70 inpatient participants who met criteria for Post traumatic stress disorder attended three sessions of psycho educational programme using group format of video and discussion. The participants completed a knowledge of Post traumatic stress disorder questionnaire before and after the education programme. Participants, demonstrated significant increase in knowledge about trauma and Post traumatic stress disorder and reported high levels of satisfaction with the program. Findings supported the use of this intervention as a first step in increasing knowledge about Post traumatic stress disorder and stimulating motivation to seek future treatment. According to Gromisch (2010) treatment for Post traumatic stress disorder may include psycho therapy,medication or a combination of the two treatments. Another types of treatment that can be done along with psycho therapy is psycho education and trauma victims can often receive more information about their particular type of trauma through psycho education.Psycho education explores psychological responses to trauma, future symptoms. It needs to be individualized for that trauma victim. While information as the commonness of interpersonal violence may reduce the clients sense of being the only one who has be victimized, it may also reinforce the clients over estimation of the amount of danger in the interpersonal environment leading to increased fear and avoidance of others. Wessley et al;(2008) noted that psycho education covers the provision of information can occur following trauma exposure immediately which covers the provision of information about nature of stress, post traumatic and other symptoms and what to do about them. The aim of providing psycho education was to ameliorate the effects of exposure to extreme situations. Krupnick and Green (2008) quoted that psycho education for Post traumatic stress disorder is explaining to individuals or groups what common reactions have been found among those who have been exposed to traumatic stress. It includes a delineation of the symptoms of Post traumatic stress disorder, description of common reactions that occur, in addition to symptoms it might include indications of when to seek professional help. Hoslbuk (2004) conducted a study to explore the use of psycho education in the treatment of post traumatic stress disorder with military personnel.80 military personnel were selected who met the criteria for Post traumatic stress disorder as per DSM IV. Results from exploring the meaning and understanding of psycho education. The effectiveness in the treatment of Post traumatic stress disorder revealed subjective results due to time frame and situation of use with the treatment technique. Douglas and Yeomans (2008) conducted a study to examine the effect of psycho education on the nature and severity of traumatic stress symptoms in a Burundian sample.They used an experimental design to examine the influence of PTSD psycho education. Participants were randomized to three condition : A reconciliation workshop with psycho education, without psycho education and a waitlist control. Results showed that participants in the psycho education condition experienced a reduction of Post traumatic stress disorder symptoms and relative to other conditions. There was no differential effect by condition on more general symptoms of anxiety, depression and somatization symptoms. Secondary hypothesis predicting relationships at baseline between prior to exposure to trauma models developed in industrial societies and nature of severity of Post traumatic stress disorder symptoms were not supported. Gould, Greenberg and Hetherton(2007) conducted a study for the evaluation of PTSD psycho educational programme : stigma and military psycho educational management strategy based on peer group risk assessment developed by UK Royal Navy was used. Psycho education seeks to modify attitudes about Post traumatic stress disorder, and help seeking and trains military personnel to identify at risk individuals and refer them for early intervention. The quasi experimental study found that psycho education significantly improved attitudes about Post traumatic stress disorder, stress and copying. Blanchard et al; (2007) conducted randomized controlled trial comparing cognitive behavioural therapy with psychotherapy and waitlist control condition. 78 trauma survivors who were atleast 6 months past their motor vehicle accident completed treatment.Of this sample 81%(n=63) met diagnostic criteria for PTSD. Individuals receiving cognitive behavioural therapy including (muscle relaxation, exposure therapy, psycho education,desentization) showed significantly greater reduction than those in the waist list condition of those with diagnosable criteria at post treatment, compared to 48% of those treated by- supportive therapy and 24% of individuals in the waist list condition.

III.STUDIES RELATED TO EFFECT OF PROGRESSIVE MUSCLE RELAXATION THERAPY ON POST TRAUMATIC STRESS DISORDER:

Emery et al;(2006) conducted a randomized clinical trial to evaluate the effectiveness of progressive muscle relaxation training on post, traumatic stress after motor vehicle accident. In the study 55 trauma survivors were selected who met PTSD diagnostic criteria. Participants were then randomly assigned to 25 minutes progressive muscle relaxation condition.Following the brief intervention, participants completed self report questionnaire. Result indicated a significant time, with participants in the progressive muscle relaxation condition experiencing a significant decrease in post traumatic stress while participants is the no –treatment condition experienced no change is post traumatic stress disorder. Result supported the efficacy of progressive muscle relaxation in reducing post traumatic stress disorder and provide further evidence of the utility of behavioural stress management strategies. Blythe and Erdahl (2006) in a single case study found the effectiveness of progressive muscle relaxation intervention in reducing post traumatic stress disorder. Brown, Sterling and Hanley (2006) conducted randomised controlled trial of progressive muscle relaxation training is management of post traumatic stress disorder. Training in relaxation technique was provided to 69 patients among earthquake survivors for a period of six weeks. Level of post traumatic stress was measured by detailed assessment of Post traumatic stress disorder. Results showed that there was significant reduction in post traumatic stress symptoms (p=<0.001) Hayes (2007) conducted a comparative study in Sydney to compare the effectiveness of progressive muscle relaxation and guided imagery on post traumatic stress and quality of life. In this study 56 people following a natural calamity who were experiencing anxiety and post traumatic stress disorder symptoms, were to one of four treatment conditions:(i)Progressive muscle relaxation training,(ii)Guided imagery training(iii)Both of these treatments (iv)Control groups. Subjects were tested before and after learning muscle relaxation and guided imagery techniques for anxiety, post traumatic stress and quality of life using the hospital Anxiety and Depression scale and Brief Interview for Post traumatic Disorder (BIPD). There was no significant improvement for anxiety, however significant positive changes occurred for post traumatic stress disorder and quality of life in the third group. Fecteau and Nicki (2008) reported the first controlled treatment trial with motor vehicle accident survivors diagnosed with Post traumatic stress disorder. Treatment included three individual cognitive behavioural therapy (CBT) sessions involving psycho education, progressive muscle relaxation and cognitive interventions, individuals who received treatment showed significant improvement on clinician and self reported Post traumatic stress disorder symptoms. Four of 10 individuals who received CBT were free of Post traumatic stress disorder diagnoses after treatment. Thus even with relative short individual format treatment of six weeks CBT appeared effective for reducing the symptoms of motor vehicle accident related Post traumatic stress disorder. Blanchard, et al (2008) completed randomized controlled trial comparing cognitive behavioural therapy with supportive psychotherapy, both concluded in an individual treatment format and a wait list control condition. 78 survivors who were at least 6 months past their motor vehicle accident completed treatment. Of thin sample 81% (n=63) met diagnostic criteria for PTSD and the remainder had severely symptomatic subsyndromal forms of the disorder. CBT included 12 sessions of muscle relaxation, training, exposure therapy, psycho education, cognitive restructuring and desensitisation. Individuals received cognitive behavioural therapy showed significantly greater reduction in clinician rated Post traumatic stress disorder severity relative to those in the supportive psychotherapy condition than those in waitlist control condition. Hinkling, Sison and Vanderploeg (2009) investigated the use of bio-feed back and relaxation training as a treatment of post traumatic stress disorder. Subjects received between 8 and 14 sessions of training overall as well as concurrent individual and group therapy. Measures used to assess treatment outcome include pre and post Multidimensional Health Focus of Control scores as well as electromyographic and subjective measures of tension with each session. Additionally an overall post treatment clinical rating of change and 1-2 years follow up data were obtained for each subject. Improvements were demonstrated for each subject, an evidenced by a decrease is overall Multidimensional Health Focus Control scores, lowered EMG and subjective tension rating for all participants. Results suggest that use of relaxation training and biofeedback was a particularly useful component within a comprehensive treatment program for Post traumatic stress disorder. Parendeh et al;(2010) had conducted a clinical trial quasi experimental study to evaluate the effect of progressive muscle relaxation training on quality of life among Post traumatic stress disorder veterans' wives.28 war veteran's wives in Tehran city were selected and divided into interventional and control groups randomly. Educational program was performed for intervention group at 3 sessions, each lasted 2 hours during a week. The quality of life in both groups was determined before 6 weeks and 12 weeks after training, by SF36 questionnaire. The results revealed significant difference between quality of life mean score before and after in intervention group (P<0.001),and showed promoting their life quality.

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