Download Base Course Conditions Specifically Related to Extreme Stressors

Field test version – 1.00 April 2014
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Base Course
Conditions Specifically
Related to Stress
(STR)
Contents (Conditions specifically related to stress)
A.
B.
C.
Introduction 10 min
Learning objectives (including video) 20 min
Key actions
1. Establish communication and build trust 5 min
2. Conduct assessment 60 min
3. Plan and start management 95 min
4. Link with other services and supports 10 min
5. Follow up 5 min
•
Total time: 3 hours 25 min
mhGAP-IG base course - field test version 1.00 – April 2014
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Introduction
• Extreme stressors are events that are potentially traumatic and/or
involve severe loss.
• What extreme stressors have your patients faced? Which ones
are common?
• After exposure, most people will experience distress but will
not develop a condition that needs clinical management.
mhGAP-IG base course - field test version 1.00 – April 2014
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Two types of conditions
following exposure to extreme stressors
1. Problems and disorders that are more likely to occur after
extreme stressors but that also occur without such
exposure, such as:
–
–
–
–
–
–
depressive disorder (DEP)
psychosis (PSY)
behavioural disorders (BEH)
alcohol use and drug disorder (ALC, DRU)
self-harm/suicide (SUI)
0ther significant emotional or medically unexplained
complaints (OTH).
mhGAP-IG base course - field test version 1.00 – April 2014
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Two types of conditions
following exposure to extreme stressors
2. Problems and disorders that require exposure to extreme
stressors:
– significant symptoms of acute stress
– post-traumatic stress disorder (PTSD)
– grief and prolonged grief disorder
•The assessment and management of these are covered in this
module.
•Remember that these often occur in combination with other
mhGAP conditions.
mhGAP-IG base course - field test version 1.00 – April 2014
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Symptoms of acute stress
(within one month of the event)
• After recent exposure to extreme stressors, reactions are
diverse.
• We use the term symptoms of acute stress (within one
month of the traumatic event) to cover a wide range of
symptoms such as:
• feeling tearful, frightened, angry or guilty
• jumpiness or difficulty sleeping, nightmares or continually
replaying the event in one’s mind
• physical reactions (eg hyperventilation)
• These symptoms can indicate mental disorder, but often are
transient and not part of a disorder. If they impair functioning
or if people seek help for them, then they are significant
symptoms of acute stress.
mhGAP-IG base course - field test version 1.00 – April 2014
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The experience of acute stress and grief
• The experience of acute stress and grief usually does not
involve mental disorders
• However, if the experience persist and if functioning
remains/becomes impaired, then this may lead to mental
disorder, such as
– Depression (at least 2 months after the bereavement)
– Post-traumatic stress disorder (at least 1 month after
potentially traumatic event)
– Prolonged grief disorder (at least 6 months after the
bereavement)
– Alcohol and drug use disorders amongst other disorders
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Learning objectives
To be able to:
1.Recognize and distinguish specific conditions that arise in
response to extreme stress and loss
2.offer psychological first aid and other basic support in people
with a range of symptoms of acute stress after a recent
traumatic event
3.identify people with PTSD and offer basic clinical management
4.provide basic support to people who are grieving, and identify
and refer people with prolonged grief
5.routinely consider a range of mhGAP disorders beyond PTSD in
people exposed to extreme stress.
mhGAP-IG base course - field test version 1.00 – April 2014
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Video (Waleed)
Play video on assessment of assessment and management of a
person who experienced a robbery
mhGAP-IG base course - field test version 1.00 – April 2014
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Establish communication and build trust
• Start by listening – be patient and calm
– People may be disoriented and have difficulty taking in
important information.
– Allow people to communicate problems in their own
words without interruption.
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To talk or not to talk about the events
• People may avoid communicating about traumatic events
because
– Talking about it may trigger re-experiencing symptoms.
– Or they simply do not wish to do
• Never pressure the person to talk about the issue
• It is not necessary for every person to talk to recover
• Some people wish to talk about the issue, and if so it is
important to make time to listen
– Discuss the experience at the pace with which the person
is comfortable.
– Ensure confidentiality
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Grief and depression are not the same but they may
present similarly
mhGAP-IG
base course
testtest version – OCT
mhGAP-IG
Standard
course- -field
Pilot
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1.00 – April
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Common presentation for symptoms of acute stress
(within one month of a potentially traumatic event)
• Symptoms of acute stress vary greatly and involve being
severely distressed after a recent potentially traumatic event,
as shown by:
– sleep problems
– behavioural changes (e.g. crying spells, social isolation)
– physical sensations (e.g. aches, pains and numbness),
– extreme emotions (e.g., extreme sadness, anxiety, anger,
despair) or being in a daze
mhGAP-IG base course - field test version 1.00 – April 2014
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Common presentation for PTSD
(at least one month after a potentially traumatic event)
• Sleep problems, fatigue
• Irritability; persistent anxious or depressed mood
• Multiple somatic symptoms with no clear physical cause (e.g.
aches and pains, palpitations)
• Difficulties in carrying out usual work, school, domestic or
social activities
mhGAP-IG base course - field test version 1.00 – April 2014
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Process of assessment
Does the presentation
suggest a priority condition?
NO
End assessment
Go to relevant module(s)
Conduct assessment according to the module
Identify the condition and treatment
Develop a management plan
mhGAP-IG base course - field test version 1.00 – April 2014
If the person is presenting
with multiple possible
conditions, all must be
assessed.
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Assessment
• There are 5 sections to the assessment
1. Significant symptoms of acute stress
2. PTSD
3. Grief
4. Prolonged grief disorder
5. Concurrent conditions
mhGAP-IG base course - field test version 1.00 – April 2014
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Read the text in the module
Posttraumatic stress disorder (PTSD)
• Involves three clusters of traumatic stress symptoms
1. Re-experiencing symptoms
2. Avoidance symptoms
3. Symptoms related to a sense of heightened current
threat
• In PTSD,
1. event more than 1 month ago,
2. at least one symptom from all 3 clusters, AND
3. symptoms cause difficulties in day-to-day functioning.
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Re-experiencing symptoms
• These are repeated and unwanted recollections of the traumatic
event.
• 3 types of re-experiencing symptoms:
– intrusive memory
• unwanted, usually vivid, and causes intense fear or horror).
– flashback
• the person believes and acts for a moment as though they are
back at the time of the event, living through it again.
– Frightening dreams
mhGAP-IG base course - field test version 1.00 – April 2014
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Avoidance symptoms
• Avoiding situations, activities, thoughts or memories that remind
of the event.
– a person may not want to drive after a road accident
– a rape survivor may spend most of her time trying to avoid
thinking of the rape.
– the person may wish not to talk about the event with the
health-care provider
• Paradox: trying very hard not to think of something makes one
think more it.
• Exercise (plenum): try not to think of a white elephant for 1
minute.
mhGAP-IG base course - field test version 1.00 – April 2014
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Symptoms related to a sense of heightened current
threat
• Affected persons may feel constantly in danger,
• 2 types of symptoms related to a sense of heightened current
threat
– Hypervigilance: exaggerated concern and alertness to
danger
• Eg the person is much more watchful in public than
others, unnecessarily selecting “safer” places to sit.
– Exaggerated startle response: being easily startled or
jumpy - reacting with excessive fear to unexpected sudden
movements or loud noises.
• Eg person reacts much more strongly than others and
takes considerable time to calm down.
mhGAP-IG base course - field test version 1.00 – April 2014
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Features associated with PTSD
• All ages
– Anxiety, depression, anger
– Numbing, insomnia
– Medically unexplained complaints
• In adolescents and adults
– Alcohol and drug use problems
• In adolescents
– Risk-taking behaviour.
• In children
– Regressive behaviours, such as bedwetting, clinging and
temper tantrums.
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Show where the PTSD assessment can be found in
the module
Read the text in the module
(grief, prolonged grief, concurrent conditions)
Role Play 1: Assessment
• A patient comes to see you about trouble sleeping.
• The patient had a terrible car accident in which the s/he was
involved 2 years ago.
• Assess the patient for a possible mental disorder specifically
related to an extreme stressor.
• Use the handout for this exercise.
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1.
2.
3.
4.
5.
Establish communication and build trust
Conduct assessment
Plan and start management
Link with other services and supports
Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Management options
• The management is split into 5 sections
1. Significant symptoms of acute stress
2. PTSD
3. Grief
4. Prolonged grief disorder
5. Concurrent conditions
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Management of acute stress symptoms
STR 3.1: Psychological first aid
• A humane, supportive, common-sense response to a fellow
human being who is suffering and who may need support.
• All health workers should be able to provide psychological first
aid.
mhGAP-IG base course - field test version 1.00 – April 2014
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STR 3.1: Psychological first aid
• Key actions:
– listen to the person without pressuring them to talk.
– provide practical care and support without asking intrusive
questions.
– assess needs and concerns.
– help the person to address immediate, basic physical
needs (e.g. shelter for the night).
– help connect to services, family, social supports and
accurate information.
– As far as possible, protect people from further harm.
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STR 3.2: Addressing current psychosocial stressors
• Extreme stressors may be ongoing (eg domestic abuse,
refugee camp life).
• Ask about current psychosocial stressors and try to use
problem-solving techniques for major psychosocial stressors
or relationship difficulties,
• Assess and manage any situation of abuse (e.g. domestic
violence) and neglect (e.g. of children or older people).
• As appropriate, ask for and involve supportive family
members
mhGAP-IG base course - field test version 1.00 – April 2014
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Problem solving in 6 steps
Identify and
define the
problem
Analyse the
problem
Evaluate the
solution
Identify
possible
solutions
Implement
the
solution
Select and
plan the
solution
mhGAP-IG base course - field test version 1.00 – April 2014
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STR 3.3: Stress management
• The health care provider may have time to train people in
breathing exercises, progressive muscle relaxation, and
cultural equivalents.
• Breathing exercises
• Progressive muscle relaxation
mhGAP-IG base course - field test version 1.00 – April 2014
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Exercise: Stress management
• Let's relax . . .
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STR 3.4: Strengthening of positive coping methods
and social supports
• Encourage seeking support of trusted family members, friends or
people in the community.
• Build on people's strengths and abilities.
– Ask what is going well?
– What coping methods worked in the past?
• Encourage resumption of social activities and normal routines if
possible
– school attendance, family gatherings, outings with friends,
visiting neighbours, social activities at work sites, sports,
community activities.
• Explain that use of alcohol and drugs does not help recovery and
can lead to new problems.
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STR 3.5.1: Insomnia as a symptom of acute stress
(within 1 month of the event )
• Apply general management strategies for symptoms of acute stress.
In addition:
– Rule out or manage external causes (e.g., noise) and physical
causes (e.g. physical pain).
– Ask for the person’s explanation of why insomnia may be present.
– In adolescents and adults, consider relaxation techniques (see STR
3.3) and advice about sleep hygiene (regular bed times, avoiding
coffee and alcohol).
– Explain insomnia is a common problem after extreme stressors.
• If the problem persists one month, re-assess for and treat any
concurrent mental or physical disorder.
mhGAP-IG base course - field test version 1.00 – April 2014
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STR 3.5.1 - In exceptional cases only:
pharmacological management of insomnia
• In exceptional cases: When psychologically oriented
interventions are not feasible, short-term treatment (3-7 days)
with benzodiazepines (e.g., diazepam 2-5 mg/day) may be
considered for insomnia that severely interferes with daily
functioning.
• Precautions:
– Risk of dependence. Only prescribe benzodiazepines for
insomnia for a very short time in exceptional cases.
– In the elderly, use lower doses (e.g., half of adult doses).
– Do not prescribe benzodiazepines for insomnia during
pregnancy and breastfeeding or in children and adolescents
.
mhGAP-IG base course - field test version 1.00 – April 2014
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STR 3.5.2: Bed-wetting
as a symptom of acute stress in children
• Apply general management strategies for symptoms of acute
stress.
• In addition:
– Obtain history of bedwetting. Rule out and manage possible
physical causes.
– Manage carers’ mental disorders and psychosocial stressors.
– Explain to never punish the child for bedwetting. It worsens
the symptoms.
– Consider training parents in the use of simple behavioral
interventions
• rewarding avoidance of excessive fluid intake before sleep,
• rewarding toileting before sleep.
• Rewards can be extra play time, stars on a chart, etc.
• If the problem persists after one month, re-assess for and treat
any concurrent mental or physical disorder.
mhGAP-IG base course - field test version 1.00 – April 2014
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Management of PTSD
Management of PTSD
• Management options as they appear in mhGAP STR module
– STR 3.2 Assess for and address current stressors
– STR 3.6 Psycho-education for PTSD
– STR 3.3 Stress management
– INT Referral for CBT or EMDR
– DEP 3 Anti-depressants
– STR 3.4 Strengthen coping and social supports.
• Which of these have we covered already under the
management of symptoms of acute stress?
mhGAP-IG base course - field test version 1.00 – April 2014
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3.6 Psycho-education for PTSD
Group work (read & answer)
• Get into small groups
• Read section 3.6 on psycho-education (10 minutes)
• Provided there is time, discuss the following 3 questions
1. Is there anything in the text you do not understand?
2. Is there anything in the text you do not agree with?
3. How does psychoeducation for PTSD differ from
psychoeducation for symptoms of acute stress?
mhGAP-IG base course - field test version 1.00 – April 2014
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INT referral for CBT or EMDR
• Cognitive-behavioural therapy (CBT) and eye movement
desensitization and reprocessing (EMDR) are 2
psychotherapeutic techniques that have good evidence for
PTSD.
• Other therapies (whether psychotherapeutic or
pharmacological) do not have such evidence basis for PTSD.
• Refer for CBT or EMDR, if competent (trained and supervised)
CBT or EMDR therapists are available. Are they available here?
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DEP 3 anti-depressants
• Research shows that antidepressants in most people with
PTSD only have a small effect (they tend to work on average a
bit better than placebo).
• In adults, only consider antidepressants when CBT, EMDR, or
stress management prove ineffective or are unavailable.
• In children and adolescents, NEVER offer antidepressants to
manage PTSD.
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Management of grief
Management of prolonged grief disorder
Management of concurrent conditions
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Role play 2: Psychoeducation for PTSD
• This role play involves the case of the person who had a car
accident (see role play 1).
• Continue the role play with a focus on psychoeducation for
PTSD.
• Use the handout for this exercise.
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1.
2.
3.
4.
5.
Establish communication and build trust
Conduct assessment
Plan and start management
Link with other services and supports
Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Link with other services and supports
• What services might be available for someone suffering from
a condition specifically related to stress in your community
• Ensure that your patients have access to these services and
that they are followed up appropriately.
• With which resources would you possibly link to help a rape
survivor for:
– Protection?
– Social support?
– Legal support?
– Psychological support?
mhGAP-IG base course - field test version 1.00 – April 2014
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Contents (Conditions related to stress)
A.
B.
C.
Introduction
Learning objectives
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
mhGAP-IG base course - field test version 1.00 – April 2014
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Frequency of follow up
• For symptoms of acute stress (i.e within 1 month of event)
– Follow up after 1 month in case person is not improving.
– At follow up, assess for a range of conditions, incl. PTSD.
• For PTSD
– Follow after 2-4 weeks to see whether management is
working.
– Long-term follow up at regular intervals may be necessary.
• For grief
– Follow-up 6 month after loss to assess for prolonged grief
disorder.
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What to do at follow up
• Monitor improvement by asking the person and family.
• Ask about and possibly address ongoing psychosocial
stressors.
• Monitor adherence, response and side-effects of medications,
if prescribed.
• Check once again for concurrent conditions (eg DEP, ALC) that
may have developed
• Provide more psychoeducation (STR 3.6).
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Key messages
• Symptoms of acute stress are common and, when
substantial, need basic non-pharmacological support from
PHC providers.
• The management of PTSD in PHC involves addressing
psychosocial stressors, psycho-education, stress management,
and if available referral for CBT/EMDR.
• Anti-depressants are second-line line treatment for PTSD.
• People who are grieving need basic non-pharmacological
support from PHC providers.
• If grief is both disabling and prolonged, consult with a
specialist.
• Consider diverse conditions beyond PTSD in people exposed
to extreme stressors.
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