Globally anxiety disorders rank high Lifetime prevalence 7%, ⁰1 healthcare 2-3x higher SASH ( South Africa,2009)

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1 Dr JJ Benson-Martin August 2011

2 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%

3 Content Pathological anxiety What is trauma Syndromes Screening What to do

4 Anxiety is normal Associated with cognitions and physical reactions Spectrum of anxiety disorders: DSM-IV Pathological anxiety associated with trauma

5 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?

6 < 1 Aftermath Acute Stress Disorder 1-3 Acute PTSD >3 Chronic PTSD Wax &wane >6 Delayed PTSD Subclinical PTSD

7 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& wanereactivation) Co-morbidities

8 Presentation Sleep difficulties Symptoms of feeling low Often inconsolable Sustained physical tension Irritability Chronic pain (vague, peristent) or somatisation Substance-abuse

9 Screening Ask if experienced trauma Establish timeline Ask directly about symptoms Be Empathic Provide education

10 Immediate Aftermath Ensure safety & basic needs Appropriate care for injuries Basic listening skills without force Convey compassion Mobilize support

11 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

12 Acute Trauma Provide education Only minority will develop PTSD Risk factors (to be discussed later)

13 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)

14 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 mthprobable PTSD

15 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

16 PTSD Symptoms: Triad Re-experience Traumatic event Avoidance Arousal

17 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

18 Symptoms Re-experiencing Intrusive thoughts Nightmares Emotional numbing Difficulty experiencing positive emotion Increased arousal Sleep difficulties Exaggerated startle response Impair functioning

19 Screen co-morbid Depression Panic disorder Somatisation Suicidality Substance-Abuse

20 Now what? Psycho educate effects of trauma & treatability Empathic listening Enquire/establish support network

21 Trauma-focused psychotherapy Reduce severity symptoms Prevent co-morbidity Improve adaptive functioning Promote developmental progression Enlist support Integrate the experience Ensure safety

22 Evidence-based Psychotherapy Refer psychology/psychiatrist Trauma focused CBT Stress inoculation training (SIT) Desensitization & re-processing therapy Exposure therapy NNT=12 Support groups-sadag

23 Pharma-When Therapy alone not relieving Co-morbidities Symptoms interfere with therapy Not routinely in children/adolescents

24 Pharmacology No benzodiazepines in long term (no evidence for effectiveness) Paroxetine 20-60mg/d Sertraline 200mg/d, Fluoxetine 20-60mg/d SNRIs: venlafaxine mg/d all NNT=4,5

25 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

26 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 1 st 3 months

27 When to stop treatment? No robust studies on this 9-12 months after symptom remission

28 Care for the Carer Harness support & supervision Recognise burn-out

29 When to refer Patient not improving Co-morbidity multiple Legal pitfalls- PTSD & disability applications

30 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

31 Where to refer- Cape Town NGO- support eg SADAG Clinical psychologist CBT Psychiatric Services- Community Clinics Local Clinic- Intern psychologists J2- Groote Schuur