dr jj benson-martin august 2011
TRANSCRIPT
Epidemiology
Globally anxiety disorders rank high
Lifetime prevalence 7%,
⁰1 healthcare 2-3x higher
SASH ( South Africa,2009)
Lifetime prevalence anxiety disorders 15,8%
PTSD 2%
Anxiety is normal
Associated with cognitions and physical
reactions
Spectrum of anxiety disorders: DSM-IV
Pathological anxiety associated with
trauma
Trauma
Experienced or witnessed intense fear,
horror helplessness
Perceived threat to well-being/life
Self or others
Violence/acts of war
Accidents
Abuse
Birthing process?
Aftermath
Acute Stress Disorder
Acute PTSD
Chronic PTSD
Delayed PTSD Subclinical PTSD
< 1
1-3
>3
>6
Wax &wane
Time Line
Immediate aftermath of traumatic event
Acute stress reaction (< 1 month)
Acute PTSD (1-3 months)
Chronic PTSD (> 3 months)
Delayed PTSD (onset > 6 months after event)
Subclinical PTSD (wax& wane- reactivation)
Co-morbidities
Presentation
Sleep difficulties
Symptoms of feeling low
Often inconsolable
Sustained physical tension
Irritability
Chronic pain (vague, peristent) or
somatisation
Substance-abuse
Screening
Ask if experienced trauma
Establish timeline
Ask directly about symptoms
Be Empathic
Provide education
Immediate Aftermath
Ensure safety & basic needs
Appropriate care for injuries
Basic listening skills without force
Convey compassion
Mobilize support
Acute Trauma
Evidence suggest debriefing & benzos
avoided
Acute stress management vs acute
stress treatment
Hobfoll et al: 5 emperically supported
intervention strategies ie promoting
1) a sense of safety, 2) calming, 3) a
sense of self- and community
efficacy,4)connectedness, and 5) hope
Prevention of PTSD in acute
Trauma four Ps—
do not pathologize,
do not psychologize,
do not pharmacologize,
do not push for professional contact.
(Zohar 2009)
Acute Stress reaction
Resolves within 1 month
‘Watchful waiting’
Reassure
No drugs!
If sleep problems, hypnotic short term
F/U in 1 month with same clinician
If symptoms distressing or >1 mth- probable PTSD
Acute Stress Reaction/Disorder
Provide information
Psychological symptoms that MAY follow
When to seek help
Kinds of treatments available
Info to patient & carers
Aim:
○ normalize experience
○ Ensure help-seeking if necessary
Risk Factors
• Female
• nature of trauma
• lack of social support
• other stressors
• adverse circumstances post stress
• Genetics/family hx of mental illness
• unpredictability
• sexual victimization
Symptoms
Re-experiencing
Intrusive thoughts
Nightmares
Emotional numbing
Difficulty experiencing positive emotion
Increased arousal
Sleep difficulties
Exaggerated startle response
Impair functioning
Now what?
Psycho educate effects of trauma &
treatability
Empathic listening
Enquire/establish support network
Trauma-focused psychotherapy
Reduce severity symptoms
Prevent co-morbidity
Improve adaptive functioning
Promote developmental progression
Enlist support
Integrate the experience
Ensure safety
Evidence-based Psychotherapy
Refer psychology/psychiatrist
Trauma –focused CBT
Stress inoculation training (SIT)
Desensitization & re-processing therapy
Exposure therapy
NNT=12
Support groups-SADAG
Pharma-When
Therapy alone not relieving
Co-morbidities
Symptoms interfere with therapy
Not routinely in children/adolescents
Pharmacology
No benzodiazepines in long term (no
evidence for effectiveness)
Paroxetine 20-60mg/d
Sertraline 200mg/d,
Fluoxetine 20-60mg/d
SNRIs: venlafaxine 75-375mg/d
all NNT=4,5
Pharmacology
4-6 weeks after intro SSRI- partial
remitters need treatment specific
symptoms
Treat co-morbid anxiety symptoms
Typical trial 12 weeks (vs 6-8 wks
depression)
In no response- switch SSRI or another
Still struggling- refer
Vigilance
Start low, go slow
Inform re: side-effects especially early
Agitation, increased anxiety
Abrupt stopping not encouraged!
Paradoxical effects
Monitor suicide risk
High risk patients reviewed 1 week post initiation
Others 2 -4 weekly for 1st 3 months
When to refer
Patient not improving
Co-morbidity multiple
Legal pitfalls- PTSD & disability
applications
Summary
Ensure safety
Support
No ‘debriefing’
Mobilize support
Encourage discussion when ready with person they trust
Psychological & pharma when appropriate
Refer if all too much