The physician's role in managing acute stress disorder.

Acute stress disorder is a psychiatric diagnosis that may occur in patients within four weeks of a traumatic event. Features include anxiety, intense fear or helplessness, dissociative symptoms, reexperiencing the event, and avoidance behaviors. Persons with this disorder are at increased risk of developing posttraumatic stress disorder. Other risk factors for posttraumatic stress disorder include current or family history of anxiety or mood disorders, a history of sexual or physical abuse, lower cognitive ability, engaging in excessive safety behaviors, and greater symptom severity one to two weeks after the trauma. Common reactions to trauma include physical, mental, and emotional symptoms. Persistent psychological distress that is severe enough to interfere with psychological or social functioning may warrant further evaluation and intervention. Patients experiencing acute stress disorder may benefit from psychological first aid, which includes ensuring the patient's safety; providing information about the event, stress reactions, and how to cope; offering practical assistance; and helping the patient to connect with social support and other services. Cognitive behavior therapy is effective in reducing symptoms and decreasing the future incidence of posttraumatic stress disorder. Critical Incident Stress Debriefing aims to mitigate emotional distress through sharing emotions about the traumatic event, providing education and tips on coping, and attempting to normalize reactions to trauma. However, this method may actually impede natural recovery by overwhelming victims. There is insufficient evidence to recommend the routine use of drugs in the treatment of acute stress disorder. Short-term pharmacologic intervention may be beneficial in relieving specific associated symptoms, such as pain, insomnia, and depression.

Substance use and dependence education in predoctoral dental curricula: results of a survey of U.S. and Canadian dental schools.

The purpose of this study was to obtain information about education in substance use and dependence that appears in the predoctoral curricula of U.S. and Canadian dental schools. Sixty-eight deans were sent a twenty-item survey requesting information about when in the curriculum these subjects were taught, what instructional methods were used, and whether behavior change instruction was included to address these issues in clinical interactions. The survey had an 81 percent response rate. The topics of alcohol use and dependence, tobacco use and dependence, and prescription drug misuse and abuse were reported in over 90 percent (N=55) of responding schools' predoctoral curricula. The topic of other substance use and dependence was reported in only 72.7 percent (N=40) of these schools. The primary instructional method reported was the use of lecture. Less frequently used methods included small-group instruction, instruction in school-based clinic, community-based extramural settings, and independent study. As future health professionals, dental students are an important source for patients concerning substance use, abuse, and treatment. Our investigation confirmed that alcohol, tobacco, and prescription drug abuse is addressed widely in predoctoral dental curricula, but other substance use and dependence are less frequently addressed.

Generalized anxiety disorder: practical assessment and management.

Generalized anxiety disorder is common among patients in primary care. Affected patients experience excessive chronic anxiety and worry about events and activities, such as their health, family, work, and finances. The anxiety and worry are difficult to control and often lead to physiologic symptoms, including fatigue, muscle tension, restlessness, and other somatic complaints. Other psychiatric problems (e.g., depression) and nonpsychiatric factors (e.g., endocrine disorders, medication adverse effects, withdrawal) must be considered in patients with possible generalized anxiety disorder. Cognitive behavior therapy and the first-line pharmacologic agents, selective serotonin reuptake inhibitors, are effective treatments. However, evidence suggests that the effects of cognitive behavior therapy may be more durable. Although complementary and alternative medicine therapies have been used, their effectiveness has not been proven in generalized anxiety disorder. Selection of the most appropriate treatment should be based on patient preference, treatment success history, and other factors that could affect adherence and subsequent effectiveness.

A practical guide to crisis management.

Family physicians often treat patients who are experiencing psychological or medical crises. Any event perceived as overwhelming by the patient may trigger a crisis reaction consisting of psychological and physiological symptoms. Physicians are encouraged to assist patients who are experiencing a crisis by: (1) providing reassurance and support; (2) evaluating the nature of the problem and determining the patient's mental, psychiatric, suicidal or homicidal, and medical statuses; (3) ensuring the safety of the patient and others; (4) assisting the patient in developing an action plan that minimizes distress, and obtaining patient commitment to the plan; and (5) following up with the patient and other relevant persons to ensure follow-through, assess progress, and provide additional assistance and support. Medication or referral for psychiatric or psychological counseling may be necessary for patients with continuing problems.

Depression and congestive heart failure.

The prevalence rates of depression in congestive heart failure patients range from 24%-42%. Depression is a graded, independent risk factor for readmission to the hospital, functional decline, and mortality in patients with congestive heart failure. Physicians can assess depression by using the SIG E CAPS + mood mnemonic, or any of a number of easily administered and scored self-report inventories. Cognitive-behavior therapy is the preferred psychological treatment. Cognitive-behavior therapy emphasizes the reciprocal interactions among physiology, environmental events, thoughts, and behaviors, and how these may be altered to produce changes in mood and behavior. Pharmacologically, the selective serotonin reuptake inhibitors are recommended, whereas the tricyclic antidepressants are not recommended for depression in congestive heart failure patients. The combination of a selective serotonin reuptake inhibitor with cognitive-behavior therapy is often the most effective treatment.