A 42-year-old man comes to the office accompanied by his wife for evaluation of mood changes. The patient's wife states that he has been restless and irritable since returning from a work trip. While staying in a hotel 2 weeks ago, the patient was unable to leave his room on the 8th floor after an earthquake caused debris to block the door. He had no cell phone or internet access during this time and remained in his room for 8 hours before the arrival of first responders. His wife says he refuses to talk about the earthquake and has started sleeping in the living room to have access to multiple exit routes "in case something happens." The patient has been working from home since he returned and is scheduled to leave for another work trip next week. He says, "I keep waking up from nightmares, but I'm sure I'll get over this on my own. I don't feel the need to talk about what happened because I know that getting back to my usual routine will help take my mind off of it." On mental status examination, the patient is cooperative and provides brief responses to questions. Although he states that his mood is "okay," he appears withdrawn. Which of the following is the most appropriate initial step in management of this patient?

Question

A 42-year-old man comes to the office accompanied by his wife for evaluation of mood changes.  The patient's wife states that he has been restless and irritable since returning from a work trip.  While staying in a hotel 2 weeks ago, the patient was unable to leave his room on the 8th floor after an earthquake caused debris to block the door.  He had no cell phone or internet access during this time and remained in his room for 8 hours before the arrival of first responders.  His wife says he refuses to talk about the earthquake and has started sleeping in the living room to have access to multiple exit routes "in case something happens."  The patient has been working from home since he returned and is scheduled to leave for another work trip next week.  He says, "I keep waking up from nightmares, but I'm sure I'll get over this on my own.  I don't feel the need to talk about what happened because I know that getting back to my usual routine will help take my mind off of it."  On mental status examination, the patient is cooperative and provides brief responses to questions.  Although he states that his mood is "okay," he appears withdrawn.  Which of the following is the most appropriate initial step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7ec_f43a_bc81_e135f79fa209_MD0003_00 This patient's presentation is suggestive of acute stress disorder (ASD), given his 2-week history of mood changes, nightmares, and hypervigilance following exposure to a traumatic event. In addition to experiencing arousal and intrusive symptoms, patients may experience dissociation and avoidance (eg, avoidance of reminders and talking about the trauma). Although ASD will remit in some individuals without intervention, treatment designed to alleviate symptoms and prevent development of posttraumatic stress disorder (PTSD) (diagnosed when symptoms persist for ≥4 weeks) can also be beneficial. Trauma-focused cognitive-behavioral therapy (CBT), not medication, is the first-line treatment. However, referring for individual therapy a patient who is not ready to engage in treatment is premature and unlikely to be well received. This patient is not seeking therapy and prefers not to talk about the trauma at this point (Choice E). The best initial approach is to provide education on common physical and emotional responses to trauma (eg, avoidance, hypervigilance) and the course of ASD. Normalizing the stress response, while explaining that symptoms may remit but can also cause persistent distress and impairment, would be helpful. Recommendations for further treatment can be provided at follow-up if necessary. (Choice A) This patient's preference not to talk at this time should be respected. Discussing the trauma in detail, which is typically conducted as part of trauma-focused CBT, could be undertaken when the patient is ready. (Choice B) This patient prefers to continue working. Encouraging him to take a temporary leave from work would likely reinforce the patient's avoidance, potentially worsening the course of ASD. (Choice C) Although some patients with ASD have spontaneous resolution of symptoms, others may develop PTSD and more persistent disability. This patient should be educated about the range of symptoms in ASD and what to do if his symptoms persist. (Choice D) Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine are used to treat PTSD when CBT is unavailable or if the patient prefers medication. There is a lack of evidence for the use of SSRIs in ASD. Educational objective: The initial approach to patients with acute stress disorder is to educate them on the range of reactions to trauma. Trauma-focused cognitive-behavioral therapy can be beneficial for patients with severe and persistent symptoms. References: Immediate and early behavioral interventions for the prevention of acute and posttraumatic stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21941180) The current evidence for acute stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/30315408)

A 42-Year-Old Man Comes to the Office Accompanied by His