Adult Disorders of Trauma and Stressors PDF

Adult Disorders of Trauma and Stressors Prof P M Joubert Department of Psychiatry  In this lecture Adjustment disorder Bereavement Prolonged grief disorder Next lecture: posttraumatic stress disorder  Adjustment Disorder There is an identifiable stressor Marked...

Adult Disorders of Trauma and Stressors Prof P M Joubert Department of Psychiatry  In this lecture Adjustment disorder Bereavement Prolonged grief disorder Next lecture: posttraumatic stress disorder  Adjustment Disorder There is an identifiable stressor Marked/disproportional emotional and/or behavioural symptoms.  Adjustment Disorder No other mental disorder explains the symptoms: – Does not meet criteria for another mental disorder – Not an exacerbation of existing mental disorder Not normal bereavement Starts within 3 months of stressor. Continues no longer than 6 months.  No other mental disorder First look for other medical conditions, medication, or substances that explain better Mental disorders especially: – Mood disorders – Depressive disorders – Anxiety disorders – Personality disorders – Acute or posttraumatic stress disorder  Adjustment Disorder Specifiers – With depressed mood – With anxiety – With mixed anxiety and depressed mood – With disturbance of conduct – With mixed disturbance of emotions and conduct – Unspecified  Adjustment Disorder Management – Necessary physical and mental work-up – Special investigations as indicated  Adjustment Disorder Management – Mostly psychosocial Management Crisis intervention Mobilise social support (family, friends…) Psychotherapy Social work Sometimes OT – Sometimes biological Example: brief course of a hypnotic or sedative  Bereavement Bereavement is not a mental disorder. The importance of bereavement lies in recognising it for what it is.  Bereavement Bereavement is a response to the death of a significant other (Sometimes loss of a significant object, relationship, and other losses are included But, here it will be about loss through death)  Bereavement Variety of symptoms, often culturally determined, for which there are no set criteria. Examples: – Intense sadness / crying/ bewilderment – Rumination – Insomnia – Poor appetite / weight loss – Difficulty concentrating – Other  Bereavement Symptoms associated with grief comes in waves that decrease over time Symptoms triggered by reminders of the loss.  Bereavement Duration is variable. Usually self-limiting. Disruptive symptoms usually subside within 2 months. Some symptoms of grief may persist months to years.  Bereavement Management: – Usually medical/psychological management is not needed for normal bereavement  Prolonged Grief Disorder In a nutshell: At least 12 months after the death of a loved one there has been disruptive persistent grief related symptoms that are disruptive.  Prolonged Grief Disorder At least 12 months since death of a loved one – (for children and adolescents: 6 months) At least 1 month of persistent grief response with nearly daily symptoms with at least one of: – Intense yearning or longing for the deceased – A preoccupation with thoughts or memories of the deceased  Prolonged Grief Disorder In addition at least 3 of the following, ongoing, clinically significant symptoms for most days: Identity disruption Marked sense of disbelief that the loved one died Avoidance of reminders that the person died Intense emotional pain about the person’s death Difficulty with reintegrating one’s relationships and activities because of the death Emotional numbness due to the death Thinking life is meaningless since the death Intense loneliness due to the death  Prolonged Grief Disorder The usual generic exclusion criteria.  Prolonged Grief Disorder Management: – Ensure that symptoms are not better explained by another mental disorder (e.g. major depressive disorder, posttraumatic stress disorder) or medical illness – Mostly psychosocial management: Clinical psychology (CBT recommended) Social work  Posttraumatic Stress Disorder Prof P M Joubert Department of Psychiatry  In this lecture Posttraumatic Stress Disorder Management Next lecture: Acute stress disorder  Posttraumatic Stress Disorder – A traumatic event threatening life or limb: – Experienced – Witnessed – Learned about close other…violent/accidental – Repeated, extreme exposure of first responders  Posttraumatic Stress Disorder My succinct description: – There is a traumatic event threatening life or limb that triggers intrusion symptoms regarding the traumatic event together with a combination of avoidance, cognitive, mood, arousal and reactivity symptoms for more than a month  Posttraumatic Stress Disorder The intrusion symptoms about the traumatic event: – Recurrent, involuntary, intrusive memories – Nightmares about the traumatic event – Dissociative reactions – Intense / prolonged psychological distress on exposure to reminders – Marked physiological reactions to exposure to reminders  Posttraumatic Stress Disorder Posttraumatic Stress Disorder: – Persistent avoidance of reminders of trauma; – Negative changes in cognition and mood – Marked changes in arousal and reactivity – (each group must be represented)  Posttraumatic Stress Disorder Persistent avoidance of reminders of trauma : – Internal reminders of traumatic event or events closely associated to it (distressing memories, thoughts, feelings) – Avoids external reminders of traumatic event or events closely associated to it (people, places, activities etc)  Posttraumatic Stress Disorder Negative changes in cognition and mood: – Dissociative amnesia – Persistent negative beliefs/expectations of self – Persistent distorted thoughts about the cause/consequences of the event – Persistent negative emotional state – Markedly reduced interest/participation – Feeling detached or estranged from others – Persistent inability to experience positive emotions  Posttraumatic Stress Disorder Marked changes in arousal and reactivity: – Irritable – Reckless or self-destructive – Hypervigilance – Exaggerated startle – Concentration problems – Sleep disturbance  Posttraumatic Stress Disorder Posttraumatic Stress Disorder: – There is impaired functioning or significant distress – Not better accounted for by another mental disorder, medical condition, or substances  Posttraumatic Stress Disorder Specifiers: Specifiers are used to make a homogenous syndrome more specific to specific individuals. In posttraumatic stress disorder they are: – With dissociative symptoms Specifically either or both of depersonalisation and derealisation – With delayed expression 6 months or more to meet full criteria  Posttraumatic Stress Disorder: Management Risk assessment: harm to self or others: low. – Outpatient treatment  Posttraumatic Stress Disorder: Management Risk assessment: harm to self or others Outpatient treatment at own responsibility Psychoeducation: – Diagnosis and course. – What to do: mobilise support, don’t avoid, stay away from substances. – Medication: side-effects, time to effect, duration. – CBT – (eye movement desensitisation and reprocessing therapy “EMDR”).  Posttraumatic Stress Disorder: Management Biological: – An SSRI Psychological: – Refer for CBT, EMDR  Posttraumatic Stress Disorder: Management Whom to involve: – Friends and family for support and exposure Whom to refer to: – Psychiatrist, psychologist, social worker (often multidisciplinary)  Posttraumatic Stress Disorder: Management When to follow up: – 1 week: check on side-effects and progress – If fine, 4 weekly until at psychiatrist etc – If problems, 1 week  Adult Disorders of Trauma and Stressors Prof P M Joubert Department of Psychiatry  In this lecture Acute stress disorder Management Other specified trauma- and related disorder Unspecified trauma- and related disorder Next lecture: Somatic symptom and related disorders Let’s first remind ourselves about posttraumatic stress disorder  Posttraumatic Stress Disorder My succinct description: – There is a traumatic event threatening life or limb that triggers intrusion symptoms regarding the traumatic event together with a combination of avoidance, cognitive, mood, arousal and reactivity symptoms for more than a month  Acute Stress Disorder My succinct description: – There is a traumatic event threatening life or limb that triggers a variety of symptoms of: Intrusions about the traumatic event, avoidance, cognition, mood, arousal and dissociation, for more than 3 days but less than a month  Acute Stress Disorder Broad outline: – Traumatic event threatening life or limb – Presence of nine or more from any of the following categories: Intrusion symptoms) Negative mood Dissociative Symptoms Avoidance Increased arousal – Typically begin immediately; last minimum three days; maximum 1 month – Significant distress or impairment – Not due to substances, a medical condition, brief psychotic disorder, exacerbation of another Axis I or II disorder  Acute Stress Disorder – A traumatic event threatening life or limb: – Same as for posttraumatic stress disorder  Acute Stress Disorder The intrusion symptoms about the traumatic event: – Recurrent, involuntary, intrusive memories – Nightmares about the traumatic event – Dissociative reactions – Intense or prolonged psychological distress or marked physiological reactivity on exposure to reminders  Acute Stress Disorder Negative mood: – Persistent inability to experience positive emotions  Acute Stress Disorder Dissociative symptoms: – Derealization or depersonalization – Dissociative amnesia  Acute Stress Disorder Avoidance symptoms: – Internal reminders of traumatic event or events closely associated to it (distressing memories, thoughts, feelings) – Avoids external reminders of traumatic event or events closely associated to it (people, places, activities etc)  Acute Stress Disorder Arousal symptoms: – Sleep problems – Irritable – Hypervigilance – Concentration difficulties – Exaggerated startle  Acute Stress Disorder: Management Risk assessment. Where to treat. Sometimes hospital / shelter.  Acute Stress Disorder: Management How to treat. – Medication: little role. Sometimes brief prescription for hypnotics Examples: zopiclone, zolpidem, short acting benzodiazepines hypnotic – Avoid sedatives and benzodiazepines as sedatives  Acute Stress Disorder: Management Psychoeducation – Make sure there is enough time – Explain the condition: Traumatic event disrupts the mind Such symptoms are common after trauma Nearly always resolve Patient can do much to help him/herself  Acute Stress Disorder: Management Psychoeducation – Advise against avoidance – Advise against alcohol , sedatives etc – Encourage tolerable confrontation of traumatic event: By discussion in rooms Encourage discussion with confidents Encourage confrontation with trauma (scene etc) Continue with confrontation of traumatic event until not markedly distressing anymore  Acute Stress Disorder: Management Whom to involve: – Family, confidents, friends etc Follow-up regularly. Watch for complications. Refer if needed. Other Specified Trauma- and Stressor- Related Disorders Provision for 2 “variants” of the classic adjustment disorders: – Adjustment-like disorder with delayed onset of symptoms that occur more than 3 months after the stressor – Adjustment-like disorder with prolonged duration of more than 6 months without prolonged duration of stressor – Persistent complex bereavement  Unspecified Trauma- and Stressor- Related Disorders Chooses not to specify why criteria are not met. Insufficient information.