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Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

Three weeks after surviving an armed robbery at his workplace, a 35-year-old bank teller is brought to the psychiatry clinic by his husband. The patient was held at gunpoint for several minutes during the incident. Since that day, he reports experiencing intense, distressing flashbacks of the weapon being pointed at his face, which often cause him to wake up sweating in the middle of the night. He strongly refuses to return to the bank, avoids watching any media that might depict crime, and states that he feels completely detached from his family. His husband notes that the patient is constantly "on edge" and becomes easily startled by sudden, normal noises like a door closing. He has no significant past medical or psychiatric history and takes no medications. The patient requests a daily medication to suppress his memories and reduce his hyperarousal. Which of the following is the most appropriate next step in management?

  1. A
    Begin treatment with oral escitalopram
  2. B
    Prescribe a short course of alprazolam
  3. Recommend exposure-based cognitive-behavioral therapyCevap
  4. D
    Provide reassurance and schedule a follow-up in 4 weeks
  5. E
    Initiate nightly administration of prazosin

Cevap

The most appropriate management is to recommend exposure-based cognitive-behavioral therapy.
This patient's presentation of intrusive flashbacks, avoidance behaviors, emotional detachment, and hyperarousal following a life-threatening event that occurred exactly 3 weeks ago meets the diagnostic criteria for acute stress disorder (ASD). ASD is diagnosed when symptoms persist for 3 days to 1 month following a trauma. If symptoms persist beyond 1 month, the diagnosis changes to post-traumatic stress disorder (PTSD). The first-line, evidence-based treatment for ASD is trauma-focused cognitive-behavioral therapy (CBT), which typically incorporates exposure techniques. Early initiation of CBT is highly effective in reducing symptom severity and preventing the transition from ASD to PTSD. While the patient requests a medication, pharmacotherapy (such as SSRIs) is generally not recommended as the initial treatment for ASD.

Adım Adım Çözüm

1
Analyze the timeline of the patient's symptoms relative to the traumatic event.
The traumatic event occurred 3 weeks ago, and symptoms have been present within this initial 1-month window.
Differentiating acute stress disorder from post-traumatic stress disorder relies strictly on the duration of symptoms (less than vs. greater than 1 month).
2
Identify the symptom clusters present to confirm the diagnosis.
The patient exhibits intrusion (flashbacks, nightmares), avoidance (refusing to return to the bank), negative alterations in mood (feeling detached), and hyperarousal (easily startled).
Confirming these four clusters ensures the diagnostic criteria for a trauma-related disorder (specifically acute stress disorder) are met.
3
Determine the appropriate intervention for acute stress disorder.
For acute stress disorder, trauma-focused cognitive-behavioral therapy is the first-line treatment.
Unlike PTSD, where SSRIs are first-line pharmacotherapy, acute stress disorder is primarily managed with early psychotherapeutic intervention to reduce severity and prevent progression to PTSD.

Anahtar Kavram

The diagnosis of acute stress disorder is made when trauma-related symptoms last between 3 days and 1 month; the first-line management is trauma-focused cognitive-behavioral therapy rather than pharmacotherapy.
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Konular

Anxiety, OCD, and Trauma-Related Disorders

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