addressing crisis, trauma, and disasters in the FM setting

acute disruption in psychological homeostasis where usual coping mechanisms fail to manage stress or trauma.

define a crisis

Suicidal ideation or attempt, panic attack, acute psychosis, severe anxiety

presentation of psychiatric crisis in primary care

Ensure patient safety first; assess suicidal intent and means

primary clinical considerations for pt presenting with psychiatric crisis

Newly diagnosed life-threatening illness, acute grief, job loss, financial strain

typical presentation of a medical psychosocial crisis

Normalize distress, provide support and short-term counseling

management of a medical-psychosocial crisis

Stabilize medically; refer for detox or rehab

management of substance-related crisis

Trauma-related symptoms, hypervigilance, insomnia, irritability

-screen for acute stress disorder or PTSD

typical presentation of violence/disaster related exposure crisis

Major life transitions (pregnancy, retirement, empty nest)

-provide anticpatory guidance and community resources

examples of developmental/situational crises

~1 in 4 women and 1 in 9 men experience intimate partner violence (CDC)

prevalence of intimate partner violence

HITS screening tool

assesses intimate partner violence and asks how often your partner hurts you, insults you, threatens you, or screams at you. Score greater than 10 is considered positive

SAFE-T screening tool

Screening tool for suicidal ideation

suspected child or elder abuse

as a physician, you have mandatory reporting for

-exposure to trauma AND

-symptoms >1 month in ≥4 categories:

Intrusion: flashbacks, nightmares

Avoidance: of reminders, people, or places

Negative mood/cognition: guilt, detachment, loss of interest

Hyperarousal: irritability, insomnia, startle response

diagnostic criteria of PTSD according to DSM-5

Intrusion: flashbacks, nightmares

Avoidance: of reminders, people, or places

Negative mood/cognition: guilt, detachment, loss of interest

Hyperarousal: irritability, insomnia, startle response

what are the 4 categories of symptoms of PTSD (IANH)

trauma-focused CBT, EMDR, and SSRIs (sertraline, paroxetine

first line management of PTSD

4-6 weeks

average duration of acute crisis phase

acute crisis phase

Individual experiences intense disequilibrium; usual coping mechanisms fail; symptoms may include anxiety, insomnia, irritability, somatic complaints

adaptation/resolution phase

-follows acute phase

-Individual begins to integrate the event, develop new coping mechanisms, or adapt through growth or maladaptive behaviors

persist for more than 6 weeks

if symptoms of acute crisis phase persist for __________ or worsen, evaluate for adjustment disorder, MDD, PTSD, etc

adjustment disorder

an emotional disturbance caused by ongoing stressors within the range of common experience

may amplify hopelessness or impulsivitity

how do mood disorders (MDD, bipolar) impact current crisis

-Unstable relationships, emotional reactivity, difficulty with trust

how do personality disorders impact current crisis

Stress may exacerbate hallucinations or paranoia

how do psychotic disorders impact current crisis

1. Ensure safety (suicidality, violence, abuse, psychosis).

2. Stabilize emotions and function — help the patient regain control.

3. Mobilize supports and guide toward adaptive coping.

primary goals of approach to crisis in primary care office

Used in crisis assessment to visualize causal factors, supports, and stressors contributing to the crisis.

purpose of a timeline and ecological map (wheel and spoke model) in management of crisis

-Central circle = individual/patient.

-Outer spokes = key domains of influence (family, work, finances, health, social support, faith, etc.).

-Used to assess how each system interacts to create or buffer crisis.

define the features of an ecological map

1. Symptom-oriented treatment provides stability.

2. Problem-focused intervention facilitates long-term recovery and resilience.

optimal management of a crisis includes

anxiolytics (benzodiazapenes)

-Short-term use for acute anxiety, panic, agitation, or insomnia

SSRIs/SNRIs

-use: Depression, anxiety, PTSD; may be initiated during stabilization phase

-Onset 4-6 weeks; monitor for suicidal ideation in young adults

Monitor for EPS, QT prolongation

things to monitor in short term use of antipsychotics

for Severe agitation, acute psychosis, mania

common uses of antipsychotics in a crisis

lithium, valproate, carbamazepine

name the mood stabilizers

crisis intervention therapy

-Short-term (4-6 sessions); focuses on here-and-now stabilization and problem-solving

-Useful for situational crises (loss, assault, disaster)

identifies and restructure maladaptive thoughts

key element of CBT

Effective for trauma-related anxiety and depression

how is CBT effective in a crisis

trauma focused CBT

Combines CBT with exposure and relaxation

trauma focused CBT

First-line therapy for PTSD, especially in children/adolescents

Eye Movement Desensitization and Reprocessing (EMDR)

Desensitization to traumatic memories through guided bilateral eye stimulation

Supported for PTSD and trauma-related phobias

clinical uses of EMDR

psychodynamic/supportive therapy

Explores unconscious conflicts and defense mechanisms

-For complex trauma or chronic maladaptive coping

Particularly beneficial after shared trauma (e.g., disaster

group therapy is particularly helpful in this scenario

PTSD or chronic dysfunction.

Early, structured intervention and psychosocial support in wake of crisis can reduce progression to

Positive reframing, mindfulness, acceptance

-reduces distressing thoughts

define cognitive coping

Exercise, journaling, relaxation breathing

-restores self-control and agency

examples of behavioral coping

Seeking support, joining groups

examples of social coping

Step 1: Identify the specific problem (not general distress).

Step 2: Brainstorm possible solutions (even imperfect ones).

Step 3: Evaluate pros/cons and select the most feasible option.

Step 4: Implement the plan and review outcomes.

Step 5: Reinforce successes and adjust failures collaboratively.

steps for patients to take in adaptive problem solving