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.He claims that when he closes his eyes, all he sees is an image of his wifebeing buried under rubble, and he hears the loud roar of the tornado.The patient says that since that time he has isolated himself from othersas much as possible so that he does not have to talk about what hap-pened.He has not slept well for several days, and when he hears a loudnoise, he thinks the tornado is coming back, which makes him veryanxious and jumpy.He has been unable to work and has not called anyof his insurance companies to tell them about the disaster.The patientstates that he has never been to a psychiatrist before and came todayonly because his friend insisted.¤' What is the most likely diagnosis for this patient?¤' What should be the next step in his treatment? 268 CASE FILES: PsychiatryANSWERS TO CASE 30:Acute Stress DisorderSummary: A 35-year-old man presents to a psychiatrist 1 week after livingthrough a tornado that killed his wife.Since that time he has been in adaze, and he describes feelings of numbness and derealization.He sees recur-rent intrusive images of the event and tries to avoid thinking about it.Hedoes not sleep well and becomes anxious when he hears a loud noise.Hisability to function has been impaired (he is not able to work or call his insurancecompanies).¤' Most likely diagnosis: Acute stress disorder.¤' Next step in treatment: The major initial approach is support, especiallyfacilitating and strengthening family and community support.Prior spiritualor religious affiliation, which can lend meaning to the event and loss, canbe very helpful to the individual.Educating the patient and family aboutexpected symptoms and a variety of coping techniques (such as relaxationtraining) can be very helpful.The use of sedatives or hypnotics in the shortterm can also be useful.ANALYSISObjectives1.Recognize acute stress disorder in a patient.2.Understand the recommended treatment approaches for patients with thisdisorder.ConsiderationsThis patient suffered an acute traumatic episode 1 week prior to his appear-ance at the psychiatrist s office.The response to the trauma has lasted morethan 2 days but less than 4 weeks.The patient experiences several dissocia-tive symptoms (feeling in a daze, derealization, numbing).He relives theevent over and over in his mind (seeing his wife killed and hearing the tor-nado).The patient avoids talking about the trauma to avoid arousing recol-lections of it.He has symptoms of anxiety (insomnia, anxiety when hearingloud noises) that prevent him from functioning well (not working, failing tocall his insurance companies to report the losses). CLINICAL CASES 269APPROACH TOAcute Stress DisorderDEFINITIONSDEREALIZATION: A perception that the environment is somehow differentor strange, although the individual cannot account for the changes.DISSOCIATIVE AMNESIA: Memory loss of some component of an event,which in the case of acute stress disorder, is usually traumatic.CLINICAL APPROACHAcute stress disorder (ASD) is a syndrome that develops shortly after an indi-vidual is exposed to a traumatic event.It is characterized by intense fear andfeelings of helplessness, as well as a number of dissociative symptoms.Thetraumatic events are usually frightening enough to cause strong reactions inanyone; examples are war (as a combatant, civilian survivor, or refugee),torture, political violence, terrorism, natural or accidental disasters, and sexualor physical assault.The fear response is activated via the hypothalamic-pituitary-adrenal axis and locus ceruleus/norepinephrine system, resulting ina cascade of further physiologic events.Acute stress disorder is defined asoccurring within the first 4 weeks after a traumatic event because researchindicates that in many individuals this syndrome can resolve without pro-gressing to posttraumatic stress disorder (PTSD).DIAGNOSTIC CRITERIAAcute stress disorder has the same criteria as the Diagnostic and StatisticalManual of Mental Disorders, Fourth edition, text revision (DSM-IV-TR) criteriafor PTSD, with the addition of one symptom cluster and a different timeframe.Acute stress disorder occurs within 4 weeks of the traumatic eventand lasts for a minimum of 2 days.The patient must also have at least threeof the following dissociative symptoms as a response to the traumatic event:1.A feeling of numbing, detachment, or lack of emotional responsiveness2.Decreased awareness of surroundings3.Derealization4.Dissociative amnesia 270 CASE FILES: PsychiatryDIFFERENTIAL DIAGNOSISAn individual involved in an accident or assault is likely to have suffered ahead injury, which can produce a postconcussion clinical picture resemblingthe dissociative symptoms of ASD.A patient can have an independent sub-stance abuse or dependence problem and drinks and uses street drugs to self-treat the symptoms of ASD, complicating the diagnosis.Cocaine intoxication canresemble the hypervigilance and hyperarousal of ASD.Other anxiety disor-ders such as panic disorder can resemble ASD; the occurrence of a traumaticevent and the reliving of it, along with avoidance symptoms, differentiate thedisorders.Dissociative disorders can resemble ASD because of the dissociativesymptoms associated with the latter.In order to make the correct diagnosis,the clinician must ask about the other symptom clusters present in ASD;patients with dissociative disorders do not have the trauma history or displaythe avoidance behavior of patients with ASD.Malingering should be in thedifferential diagnosis for patients pursuing financial gain as compensation fora traumatic event; this is especially true considering recent publicity about thedisorder.Experienced clinicians should be able to detect genuine symptoms ofhyperarousal and reexperiencing of an event in a patient with ASD.TREATMENTTreatment of a patient with ASD consists of supportive intervention; there isa wide range of possibilities based on the type of trauma, the patient s culture,and the presence or absence of a social network.The clinician should attemptto mobilize all active social supports, including family, religious groups, andthe community, to assist the individual.Education about the symptoms andcoping skills can be very helpful.Research on critical incident stress debrief-ing (CISD), in which the individual is encouraged to talk about and processthoughts about the event, is inconclusive regarding its effectiveness.Wheninsomnia and marked hypervigilance are problematic, hypnotics and anxi-olytics can be used on a short-term basis.There is emerging research that sug-gests that beta-blockers, such as propranolol, started directly following thetraumatic event, are effective in preventing the development of PTSD. CLINICAL CASES 271Comprehension Questions30.1 A 28-year-old male assembly-line worker comes in for treatment afterdeveloping symptoms a few days after a serious factory accident inwhich he was knocked unconscious by a machine.He was medicallycleared directly following the event but later developed nightmaresabout the accident [ Pobierz caÅ‚ość w formacie PDF ]
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.He claims that when he closes his eyes, all he sees is an image of his wifebeing buried under rubble, and he hears the loud roar of the tornado.The patient says that since that time he has isolated himself from othersas much as possible so that he does not have to talk about what hap-pened.He has not slept well for several days, and when he hears a loudnoise, he thinks the tornado is coming back, which makes him veryanxious and jumpy.He has been unable to work and has not called anyof his insurance companies to tell them about the disaster.The patientstates that he has never been to a psychiatrist before and came todayonly because his friend insisted.¤' What is the most likely diagnosis for this patient?¤' What should be the next step in his treatment? 268 CASE FILES: PsychiatryANSWERS TO CASE 30:Acute Stress DisorderSummary: A 35-year-old man presents to a psychiatrist 1 week after livingthrough a tornado that killed his wife.Since that time he has been in adaze, and he describes feelings of numbness and derealization.He sees recur-rent intrusive images of the event and tries to avoid thinking about it.Hedoes not sleep well and becomes anxious when he hears a loud noise.Hisability to function has been impaired (he is not able to work or call his insurancecompanies).¤' Most likely diagnosis: Acute stress disorder.¤' Next step in treatment: The major initial approach is support, especiallyfacilitating and strengthening family and community support.Prior spiritualor religious affiliation, which can lend meaning to the event and loss, canbe very helpful to the individual.Educating the patient and family aboutexpected symptoms and a variety of coping techniques (such as relaxationtraining) can be very helpful.The use of sedatives or hypnotics in the shortterm can also be useful.ANALYSISObjectives1.Recognize acute stress disorder in a patient.2.Understand the recommended treatment approaches for patients with thisdisorder.ConsiderationsThis patient suffered an acute traumatic episode 1 week prior to his appear-ance at the psychiatrist s office.The response to the trauma has lasted morethan 2 days but less than 4 weeks.The patient experiences several dissocia-tive symptoms (feeling in a daze, derealization, numbing).He relives theevent over and over in his mind (seeing his wife killed and hearing the tor-nado).The patient avoids talking about the trauma to avoid arousing recol-lections of it.He has symptoms of anxiety (insomnia, anxiety when hearingloud noises) that prevent him from functioning well (not working, failing tocall his insurance companies to report the losses). CLINICAL CASES 269APPROACH TOAcute Stress DisorderDEFINITIONSDEREALIZATION: A perception that the environment is somehow differentor strange, although the individual cannot account for the changes.DISSOCIATIVE AMNESIA: Memory loss of some component of an event,which in the case of acute stress disorder, is usually traumatic.CLINICAL APPROACHAcute stress disorder (ASD) is a syndrome that develops shortly after an indi-vidual is exposed to a traumatic event.It is characterized by intense fear andfeelings of helplessness, as well as a number of dissociative symptoms.Thetraumatic events are usually frightening enough to cause strong reactions inanyone; examples are war (as a combatant, civilian survivor, or refugee),torture, political violence, terrorism, natural or accidental disasters, and sexualor physical assault.The fear response is activated via the hypothalamic-pituitary-adrenal axis and locus ceruleus/norepinephrine system, resulting ina cascade of further physiologic events.Acute stress disorder is defined asoccurring within the first 4 weeks after a traumatic event because researchindicates that in many individuals this syndrome can resolve without pro-gressing to posttraumatic stress disorder (PTSD).DIAGNOSTIC CRITERIAAcute stress disorder has the same criteria as the Diagnostic and StatisticalManual of Mental Disorders, Fourth edition, text revision (DSM-IV-TR) criteriafor PTSD, with the addition of one symptom cluster and a different timeframe.Acute stress disorder occurs within 4 weeks of the traumatic eventand lasts for a minimum of 2 days.The patient must also have at least threeof the following dissociative symptoms as a response to the traumatic event:1.A feeling of numbing, detachment, or lack of emotional responsiveness2.Decreased awareness of surroundings3.Derealization4.Dissociative amnesia 270 CASE FILES: PsychiatryDIFFERENTIAL DIAGNOSISAn individual involved in an accident or assault is likely to have suffered ahead injury, which can produce a postconcussion clinical picture resemblingthe dissociative symptoms of ASD.A patient can have an independent sub-stance abuse or dependence problem and drinks and uses street drugs to self-treat the symptoms of ASD, complicating the diagnosis.Cocaine intoxication canresemble the hypervigilance and hyperarousal of ASD.Other anxiety disor-ders such as panic disorder can resemble ASD; the occurrence of a traumaticevent and the reliving of it, along with avoidance symptoms, differentiate thedisorders.Dissociative disorders can resemble ASD because of the dissociativesymptoms associated with the latter.In order to make the correct diagnosis,the clinician must ask about the other symptom clusters present in ASD;patients with dissociative disorders do not have the trauma history or displaythe avoidance behavior of patients with ASD.Malingering should be in thedifferential diagnosis for patients pursuing financial gain as compensation fora traumatic event; this is especially true considering recent publicity about thedisorder.Experienced clinicians should be able to detect genuine symptoms ofhyperarousal and reexperiencing of an event in a patient with ASD.TREATMENTTreatment of a patient with ASD consists of supportive intervention; there isa wide range of possibilities based on the type of trauma, the patient s culture,and the presence or absence of a social network.The clinician should attemptto mobilize all active social supports, including family, religious groups, andthe community, to assist the individual.Education about the symptoms andcoping skills can be very helpful.Research on critical incident stress debrief-ing (CISD), in which the individual is encouraged to talk about and processthoughts about the event, is inconclusive regarding its effectiveness.Wheninsomnia and marked hypervigilance are problematic, hypnotics and anxi-olytics can be used on a short-term basis.There is emerging research that sug-gests that beta-blockers, such as propranolol, started directly following thetraumatic event, are effective in preventing the development of PTSD. CLINICAL CASES 271Comprehension Questions30.1 A 28-year-old male assembly-line worker comes in for treatment afterdeveloping symptoms a few days after a serious factory accident inwhich he was knocked unconscious by a machine.He was medicallycleared directly following the event but later developed nightmaresabout the accident [ Pobierz caÅ‚ość w formacie PDF ]