A 48-year-old man comes to the office due to insomnia. The patient was attacked and robbed at gunpoint 3 weeks ago, during which he was kicked in the abdomen and chest and sustained a fractured rib that is healing without complication. He is no longer in pain but describes difficulty falling asleep, frequent nightmares, and multiple nighttime awakenings since the incident. The patient says, "I just need to get some rest so I can function the next day at work." He describes irritability and difficulty concentrating. He is unable to remember details of the attack and has avoided walking alone at night. Although his friends have offered support, the patient has no interest in seeing them and feels emotionally distant from his family. He is seen yearly for hypertension and familial hypercholesterolemia. He has no psychiatric history.
On mental status examination, the patient is anxious and tense and startles easily. Physical examination is unremarkable.
Which of the following is the most appropriate management for this patient?

Question

A 48-year-old man comes to the office due to insomnia.  The patient was attacked and robbed at gunpoint 3 weeks ago, during which he was kicked in the abdomen and chest and sustained a fractured rib that is healing without complication.  He is no longer in pain but describes difficulty falling asleep, frequent nightmares, and multiple nighttime awakenings since the incident.  The patient says, "I just need to get some rest so I can function the next day at work."  He describes irritability and difficulty concentrating.  He is unable to remember details of the attack and has avoided walking alone at night.  Although his friends have offered support, the patient has no interest in seeing them and feels emotionally distant from his family.  He is seen yearly for hypertension and familial hypercholesterolemia.  He has no psychiatric history.
On mental status examination, the patient is anxious and tense and startles easily.  Physical examination is unremarkable.
Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

11ec193a_98be_7969_853d_05a8d09ecf8e_MD0002_00 This patient's abrupt onset of insomnia, nightmares, amnesia, impaired concentration, and emotional detachment following a traumatic incident 3 weeks ago is consistent with acute stress disorder (ASD). ASD develops within 4 weeks of a traumatic event. Patients typically have some form of intrusive re-experience (eg, distressing memories, nightmares, flashbacks) and avoid reminders of the event. Arousal symptoms, such as sleep disturbance, irritability, impaired concentration, hypervigilance, and an exaggerated startle response, are common. Although this patient is focused on his sleep disturbance, the physician should educate him about the range of responses to trauma. Early recognition and intervention are important as patients with ASD are at higher risk for subsequent post-traumatic stress disorder (PTSD), which can become chronic and disabling if left untreated. First-line treatment of ASD consists of trauma-focused cognitive-behavioral therapy (CBT), which has been shown to reduce the likelihood of subsequent development of PTSD. (Choice A) Discussing the accident in detail (a form of exposure) is an important component of trauma-focused CBT. However, this should be undertaken in a psychotherapeutic setting where the therapist can assist the patient in processing the emotions related to recalling the trauma in a safe and gradual manner. (Choice B) CBT, not antidepressants, is the first-line treatment for ASD. Patients who subsequently develop PTSD may be treated with selective serotonin reuptake inhibitors as an adjunct to psychotherapy. (Choice C) Although short-term benzodiazepine treatment may be prescribed immediately following the traumatic event for intense anxiety and sleep disturbance, prolonged use is not recommended and carries risks of dependence and addiction. (Choice D) It is inappropriate to reassure the patient that his symptoms will likely improve over time, as a substantial proportion of patients with ASD will subsequently develop PTSD. The patient should receive regular follow-up to monitor his symptoms. Educational objective: Acute stress disorder (ASD) develops within 4 weeks of a traumatic event and is characterized by intrusive re-experiencing of the traumatic event, hyperarousal, and avoidance behaviors. Cognitive-behavioral therapy is the first-line treatment for ASD and decreases the risk of development of post-traumatic stress disorder. __________ References: The physician's role in managing acute stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23062092) The course, prediction, and treatment of acute and posttraumatic stress in trauma patients: A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28520689)

A 48-Year-Old Man Comes to the Office Due to Insomnia