Dr JJ Benson-Martin

August 2011

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%

Content

Pathological anxiety

What is trauma

Syndromes

Screening

What to do

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

Acute Trauma

Provide education

Only minority will develop PTSD

Risk factors (to be discussed later)

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

PTSD Symptoms: Triad

Re-experience

Arousal Avoidance

Traumatic event

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

Screen co-morbid

Depression

Panic disorder

Somatisation

Suicidality

Substance-Abuse

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 stop treatment?

No robust studies on this…

9-12 months after symptom remission

Care for the Carer

Harness support & supervision

Recognise burn-out

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

Where to refer- Cape Town

NGO- support eg SADAG

Clinical psychologist –CBT

Psychiatric Services- Community Clinics

Local Clinic- Intern psychologists

J2- Groote Schuur