Crisis / Stress

Crisis

1. When a patient presents with acute emotional distress:
   1. Take the necessary time to assist the patient, even if they present unexpectedly
   2. Acknowledge their feelings and help them de-escalate
   3. Employ the therapeutic effect of conversation
2. As part of your management of a patient facing a crisis:
   1. Identify your patient’s personal resources for support (e.g., family, internal strength, friends) as part of your management of a patient facing a crisis.Use psychoactive medication rationally to assist patients in crisis.
   2. Offer appropriate community resources (e.g., counsellor) as part of your ongoing management of a patient with a crisis
   3. Negotiate a follow-up plan with the patient
   4. Be careful not to cross boundaries when treating a patient in crisis (e.g., lending money, providing appointments outside regular hours)
3. When a patient presents with emotional distress or declares themselves in crisis:
   1. Carefully assess the risk of harm to themselves or others
   2. Ask your patient if there are others needing help associated with the crisis
   3. Act accordingly
4. Use psychoactive medication rationally to assist patients in crisis.
5. Inquire about unhealthy coping methods (e.g., drugs, alcohol, eating, gambling, violence, sloth, promiscuity) in your patients facing crisis.
6. Prepare your practice environment for possible crises or disasters and include colleagues and staff in the planning for both medical and non-medical crises.
7. When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia):
   1. Be calm and methodical
   2. Assess the environment for needed and available resources (people, material)
   3. Ask for the help you need
   4. Take timely action as appropriate in the context of the situation (e.g., resuscitation in the waiting room of the clinic versus in the emergency department)
8. In all patients, to identify possible previous crises and avoid re-traumatization during medical encounters:
   1. Be attentive to triggers for re-traumatization
   2. Recognize different manifestations of emotional distress
   3. Address as appropriate

Stress

1. In a patient presenting with a symptom that could be attributed to stress (e.g., headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
2. In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
3. In patients not coping with stress, look for and diagnose, if present, mental illness (e.g., depression, anxiety disorder).
4. In patients not coping with the stress in their lives,
   1. Clarify and acknowledge the factors contributing to the stress,
   2. Explore their resources and possible solutions for improving the situation.
5. In patients experiencing stress, look for inappropriate coping mechanisms (e.g., drugs, alcohol, eating, violence).

General Overview

• Stress: Belief that demands being placed on us exceed our ability to cope
• Distress: Unable to adapt to stressors
• Coping: Behavioral response to reduce stress to maintain function
  • Emotion (social support)
  • Thoughts (distraction, mindfulness)
  • Behaviours (action)
• Not coping: Decline in function
  • Assess function:
    • Relationships, family, friends
    • School, work
    • Exercise, diet, sleep, driving
    • Sexual, psychological
  • Other affected (spouse, family, friends)
  • Identify maladaptive coping behaviors
    • Substance use (alcohol, drugs, smoking)
    • Violence
    • Gambling
  • Rule out psychiatric disorder (see anxiety, depression, eating disorders)

Management

• Reassure that it is safe to discuss concern
• Commend patient for seeking help
• Provide support, encouraging statements, active listening
• Validation of the problem/feelings
• Evaluate crisis severity
  • Psychiatric/medical status
  • Safety of patient and others (suicidality/homicidality)
  • Collateral
• Action plan
  • Reassure
  • Relaxation techniques (deep breathing)
  • Focus on coping mechanisms that were successful in past
  • Resources: Support system (friends/family) and Community resources
  • Consider short-term anxiolytics/hypnotics
  • Discourage inappropriate coping mechanisms (denial, withdrawal, harmful behaviours/substances)
• Follow-up

DSM-V Definitions

Acute Stress Reaction

• Exposure to actual or threatened death, serious injury, or sexual violation
• Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred
• Duration 3 days to 1 month after trauma exposure.
• Significant distress or functional impairment
• Management
  • Trauma-specific CBT (can be delayed if suicidal)
  • For severe anxiety or sleep disturbance, consider short-term clonazepam 0.25mg PO BID <2 weeks

PTSD

• Diagnosis
  • Traumatic event exposure (actual or threatened death, serious injury, or sexual violence)
  • Re-experience the event (intrusion symptoms)
  • Avoidance of stimuli
  • Unable to function or significant distress
  • Mood / 1 Month duration
  • Arousal and reactivity
• Management
  • Follow-up with IES-R scale
  • CBT (TF-CBT, EMDR, PE, stress management therapy)
  • Paroxetine, venlafaxine XR, fluoxetine, sertraline
  • For sleep disruption/nightmares, consider prazosin 1mg PO qHS (increase by 1mg every 3-7 days to max of 15mg PO qHS)

Adjustment Disorder

• Emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
• Significant impairment or marked distress
  • The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.
  • The symptoms do not represent normal bereavement.
  • Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.
• Specifiers: with depressed mood, with anxiety, with mixed anxiety and depressed mood