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Article Presentation
Dr.Mohamamd Mataro Hingorjo
PGY2, Family Medicine AKU Karachi
The Physician’s Role in Managing Acute
Stress Disorder
MICHAEL G. KAVAN, PhD; GARY N. ELSASSER, PharmD; and
EUGENE J. BARO...
Case
• A young male Student, comes to your Clinic
with the complaints of
• Generalized boy ache
• Fatigue
• Indigestion, l...
On Examination
• Looks anxious, hyper alert to surroundings
• Vitally Stable
• Systemic examination in Normal limits
Spot ...
Acute Stress Disorder
• A psychiatric diagnosis that may occur in patients
after witnessing, hearing about, or being direc...
• Common experience.
• 50 to 90 percent of U.S. adults experience trauma during
their lives.
• ASD affects 14 to 33 percen...
Diagnostic Criteria
Essential features include
• Anxiety
• Re-experiencing the event
• Avoidance of stimuli that arouse re...
Risk Factors
 Avoidance behavior
 Below average IQ or
cognitive ability
 Excessive safety
behavior (e.g., taking
excess...
Management
• Patient’s refusing help may not be in denial,
but may see themselves more resilient or
expect good family sup...
NORMALIZING PATIENT RESPONSES
• Make patient understand the Normal body
response to a Stressful event.(it is not a mental
...
PSYCHOLOGICAL FIRST AID
A most appropriate evidence-informed
intervention that includes eight points.
Pscychological First Aid
Core action Tasks
Contact and
engagement
introducing self, inquiring about immediate needs, and a...
COGNITIVE BEHAVIOR
THERAPY
• Limited evidence exists for
providing direct psychological
intervention within the first
mont...
EMPIRICALLY SUPPORTED
INTERVENTION STRATEGIES FOR
ACUTE STRESS DISORDER
Principle Rationale • Intervention
Promoting a sense
of safety
Patients who maintain or
reestablish a sense of safety
have...
Principle Rationale Intervention
Promoting a sense
of self-efficacy and
collective efficacy
Patients feel better when they...
• A short intervention provided
immediately after trauma.
• It is typically delivered in a group
setting two to 10 days af...
PHARMACOLOGIC MANAGEMENT
• Insufficient evidence
• Indicated for those who cannot
participate in CBT
• Short term therapy ...
MONITORING AND REFERRAL
• Close Monitoring
• Patients with prolonged reactions causing
distress or affecting interpersonal...
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Role of family physcinan in a stress disorder

DR,M,Mataro Hingorjo
Aga Khan university Karachi Sindh Pakistan

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Role of family physcinan in a stress disorder

  1. 1. Article Presentation Dr.Mohamamd Mataro Hingorjo PGY2, Family Medicine AKU Karachi
  2. 2. The Physician’s Role in Managing Acute Stress Disorder MICHAEL G. KAVAN, PhD; GARY N. ELSASSER, PharmD; and EUGENE J. BARONE, MD Creighton University School of Medicine, Omaha, Nebraska American Family Physician www.aafp.org/afp Volume 86, Number 7 October 1, 2012
  3. 3. Case • A young male Student, comes to your Clinic with the complaints of • Generalized boy ache • Fatigue • Indigestion, lack of appetite • Decreased sleep & loss of concentration For past one week……
  4. 4. On Examination • Looks anxious, hyper alert to surroundings • Vitally Stable • Systemic examination in Normal limits Spot Diagnosis?
  5. 5. Acute Stress Disorder • A psychiatric diagnosis that may occur in patients after witnessing, hearing about, or being directly exposed to a traumatic event • Sensation of – Intense fear – Helplessness – Anxiety / depression – Fatigue – Headaches – Rheumatic symptoms
  6. 6. • Common experience. • 50 to 90 percent of U.S. adults experience trauma during their lives. • ASD affects 14 to 33 percent of persons exposed to severe trauma. – Robbery – Life-threatening circumstances – Physical or psychological assault or captivity – Persons who witnessed another being injured or killed – Motor vehicle crashes/Accidents – Terrorist Attacks/ Natural Disasters – Rescue workers • If not managed carefully may lead to PTSD
  7. 7. Diagnostic Criteria Essential features include • Anxiety • Re-experiencing the event • Avoidance of stimuli that arouse recollections of the event • Symptoms must be present for a minimum of two days, but not longer than four weeks • Symptoms of ASD typically peak in initial phase then gradually decrease over time • ASD specifically includes dissociative symptoms such as detachment, reduced awareness of surroundings, de- realization, de-personalization, and dissociative amnesia. • Persisting symptoms may lead to PTSD
  8. 8. Risk Factors  Avoidance behavior  Below average IQ or cognitive ability  Excessive safety behavior (e.g., taking excessive precautions, excessively avoiding trauma reminders)  Family history of anxiety or mood disorders  Female sex  Severity of trauma  Greater distress at time of event  Greater perceived threat to life  Greater symptom severity at one to two weeks after trauma  High level of hostility  History of sexual or physical abuse in childhood  Less social support after trauma  Prior psychological problems  Mental defeat  Negative self-appraisals  Newness of trauma memories  Per traumatic dissociative  Symptoms during assault  Per traumatic emotional responses
  9. 9. Management • Patient’s refusing help may not be in denial, but may see themselves more resilient or expect good family support • Physicians should support patients who want to talk about their experience, but not push those who prefer not to • Risk factors for PTSD should also be assessed • Physicians should evaluate dangerous behaviors of patients to harm oneself or others
  10. 10. NORMALIZING PATIENT RESPONSES • Make patient understand the Normal body response to a Stressful event.(it is not a mental illness) • Education on coping with acute responses in the form of counseling, handouts, or referral to a psychologist or psychiatrist.
  11. 11. PSYCHOLOGICAL FIRST AID A most appropriate evidence-informed intervention that includes eight points.
  12. 12. Pscychological First Aid Core action Tasks Contact and engagement introducing self, inquiring about immediate needs, and assuring confidentiality Safety and comfort Enhance immediate and ongoing safety while providing physical and emotional comfort Stabilization Calm, stabilize, and orient emotionally overwhelmed patients, and discuss the role of medication Information gathering: current needs and concerns Obtain information on nature and severity of experiences, concerns about post trauma circumstances, separation from loved ones, physical or mental health problems, losses, extreme feelings of guilt or shame, thoughts about harming self or others, social support, prior alcohol or drug use, and prior exposure to trauma Practical assistance Offer practical assistance, identify immediate needs, clarify needs, discuss an action plan, and address needs Connection with social support Enhance access to and use of primary support persons and local community resources Information on coping Provide basic information about stress reactions; review common psychological reactions to traumatic experiences and losses; discuss physical and emotional reactions; provide basic information on coping strategies, simple relaxation techniques, and management of anger and other emotions; assist with sleep problems; and address alcohol and substance use Connection with collaborative services Provide direct links to additional services, refer as appropriate, and promote continuity in helping relationships
  13. 13. COGNITIVE BEHAVIOR THERAPY • Limited evidence exists for providing direct psychological intervention within the first month after trauma • The use of cognitive behavior therapy (CBT) has been supported in situations where the threat has subsided and stability has started returning. • CBT alone or in combination with hypnosis is more effective • Effects are generally maintained over three years.
  14. 14. EMPIRICALLY SUPPORTED INTERVENTION STRATEGIES FOR ACUTE STRESS DISORDER
  15. 15. Principle Rationale • Intervention Promoting a sense of safety Patients who maintain or reestablish a sense of safety have a decreased risk of posttraumatic stress disorder; physicians are encouraged to take measures in which patients are brought to a safe place and assured safety. • Limit conversations about rumors and horror stories (often termed the “pressure cooker” effect) • Provide information about well-being of nears and dears of patient if possible • Limiting exposure to news media stories Promoting a sense of calm Some anxiety is normal, but it becomes problematic when it interferes with sleep, eating, hydration, decision making, and conducting normal tasks • Physicians may encourage therapeutic grounding (i.e., patients are no longer in a threatening situation), deep breathing, muscle relaxation, yoga, mindfulness, cognitive behavior strategies, and normalization of the stress reaction
  16. 16. Principle Rationale Intervention Promoting a sense of self-efficacy and collective efficacy Patients feel better when they can overcome threats and solve their own problems • Physicians may remind patients of their pre-trauma sense of self-efficacy (i.e., their ability to overcome adversity), support community efforts to mourn, attend religious activities, and collaborate on projects for the betterment of the community Promoting connectedness Connection allows patients to obtain essential information and to gain social support and a sense of community • Patients should be counseled about services and support- seeking connections with others especially loved ones as quickly as possible • Physicians should provide formal support if informal support is unavailable Instilling hope Maintaining a reasonable degree of hope helps to combat the shattered worldview, foreshortened future, and catastrophizing that may occur after trauma • Cognitive behavior therapy addresses patients’ exaggerated sense of personal responsibility for events, corrects catastrophizing, normalizes patient reactions, stresses that most persons recover spontaneously, and prevents
  17. 17. • A short intervention provided immediately after trauma. • It is typically delivered in a group setting two to 10 days after a traumatic event and is meant to mitigate emotional distress by allowing patients to share emotions about the event, providing education and tips on coping, and attempting to normalize patients' reactions to trauma. • Due to certain methodological limitations most studies have suggested no effect of such therapy, and it may impede the natural recovery. PSYCHOLOGICAL DEBRIEFING
  18. 18. PHARMACOLOGIC MANAGEMENT • Insufficient evidence • Indicated for those who cannot participate in CBT • Short term therapy < 6 weeks may benefit in relieving specific symptoms like pain/insomnia etc • Tofranil an fluoxetine has limited evidence except in children • Atypical Antipsychotics like resperidone is good for symptomatic improvement in acute disease • Propanolol has been shown to decrease the risk of PTSD and fear associated with re-exposure but it doesn't reduce the risk ASD
  19. 19. MONITORING AND REFERRAL • Close Monitoring • Patients with prolonged reactions causing distress or affecting interpersonal relationships and daily functioning should be referred. • Close Follow up with Trauma Victims is Necessary.

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