Selective Past History

For an acute crisis, the patient's past history is relevant only as it can help explain and resolve the current crisis. Many patients, wanting to avoid the pain of the current crisis, may unconsciously lead the family physician "down the garden path" to chronic problems, avoiding the pain of the current issues. To avoid the past history trap, the physician must try to understand the dynamics of the current crisis and then look for similar events in the patient's past that can be used to understand more about the current situation. For example, a selective past history of suicide attempts and the circumstances surrounding those attempts may provide valuable clues to understanding a current suicidal crisis. This selective history can assist in developing an understanding of the "Why now?" of the current suicide attempt.

Table 45-1 Psychiatric Disorders Related to Trauma or Crisis


Diagnostic Criteria* and Symptom Picture


Adjustment disorder

Emotional, behavioral symptoms in response to identifiable stressor(s) Distress in excess of what would be expected from exposure to stressor Symptoms create marked distress or impairment in social or occupational functioning

Does not represent bereavement

Begins within 3 mo of onset of stressor Symptoms usually resolve within 6 mo of termination of stressor.

Acute stress disorder

Exposure to traumatic event that involved actual or threatened death or threat of serious injury to self or others

Response to threat—intense fear, helplessness, or horror

Marked avoidance of stimuli associated with the trauma (including thoughts, places, conversations)

Dissociative symptoms (e.g., numbing, detachment, feeling dazed, depersonalization, derealization, dissociative amnesia)

Trauma reexperienced through flashbacks, distressing recollections, dreams, sense of reliving, or psychological-physiologic reactions when exposed to cues that represent the trauma

Symptoms of increased arousal, exaggerated startle response, hypervigilance, motor restlessness, or anxiety

Clinically significant impairment in social or occupational functioning Not merely an exaggeration of existing psychiatric condition

Lasts minimum of 2 days and maximum of 4 wk+


Same as for acute stress disorder, with three possible time courses: acute, chronic, or delayed

Acute: 1-3 mo Chronic: >3 mo Delayed: >6 mo

Major depressive disorder

Must have depressed mood or loss of interest or pleasure In addition to above, 5 of following 9 symptoms present for at least 2 weeks: depressed mood most of day, anhedonia, weight loss or gain, insomnia or hypersomnia, agitation or motor retardation, fatigue, feelings of worthlessness or excessive guilt, poor or decreased concentration, and recurrent thoughts of suicide or death

Symptoms represent change from previous functioning Causes distress or social or occupational impairment

Onset common 6-12 mo after crisis or disaster

Symptoms present for most of day, nearly every day, for 2 wk

Substance use or abuse

Numbing substances (e.g., alcohol, heroin, marijuana) and sedative-hypnotic abuse usually preferred

Most common 6-12 mo after crisis

Dissociative disorders

Dissociative amnesia, dissociative fugue, dissociative identity disorder (formerly multiple personality disorder), depersonalization disorder

Disturbance consists of one or more episodes of inability to recall important personal information, usually of traumatic nature

Sequelae of enduring chronic trauma, abuse, or neglect

Generalized anxiety disorder

Persistent symptoms of excessive anxiety or worry for at least 6 mo

Also associated with restlessness, being easily fatigued, poor concentration, irritability, and sleep disturbances

Free-floating anxiety unrelated to specific person(s) or situation

Any time after trauma

Panic disorder (with or without agoraphobia)

Recurrent, unexpected panic attacks, defined as episodic periods of intense anxiety, often with physical symptoms (e.g., palpitations, tremors, chest discomfort) Symptoms develop abruptly, increase in intensity over 10 min Persistent concerns about having additional attacks

Anxiety, worry about implications or consequences of attack (e.g., heart attack, losing control)

Any time after trauma

Specific phobia, social phobia (social anxiety disorder)

Specific phobias: excessive or unreasonable fear of specific objects or situations (e.g., animals, heights, needles), which provokes immediate anxiety response Patient avoids feared situation or object.

Social phobias: fear of social or performance situations in which patient fears possible excessive scrutiny by others

Patient constantly worried about acting in humiliating or embarrassing way.

Any time after trauma

Modified from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC, APA, 2000. *DSM-IV-TR abridged criteria, 2000.

fMore than 4 weeks; see criteria for posttraumatic stress disorder (PTSD).



Table 45-1 Psychiatric Disorders Related to Trauma or Crisis—cont'd


Diagnostic Criteria* and Symptom Picture


Brief psychosis

Presence of one or more: hallucinations, delusions, disorganized speech, and disorganized or catatonic behavior

Eventual full return to premorbid level of functioning

At least 1 day to <1 mo

Somatization disorder

Unexplained physical symptoms (e.g., pain, gastrointestinal, sexual, neurologic) Symptoms begin before age 30 and occur over several years. Symptoms are not intentionally produced or feigned.

Any time after trauma

Conversion disorder

One or more symptoms affecting motor or sensory function suggest neurologic or general medical condition.

Initiation or exacerbation of symptoms often is preceded by conflicts or stressors. Symptoms are not intentionally produced or feigned.

Any time after trauma

Table 45-1 Psychiatric Disorders Related to Trauma or Crisis—cont'd

Additional events from the past history that might be helpful in understanding a suicide attempt include deaths, separations, severe medical illnesses, and a history of depression, alcoholism, or family suicide. Selective past history that could be relevant for understanding an acute violent crisis might be the timing and circumstances of past episodes of violence, childhood experiences of abuse or neglect, previous hospitalizations for violence, prior incarcerations, past legal problems, and past neurologic or medical illness.

When dealing with trauma victims, it is important to ask about past trauma, previous successful coping styles or adaptations, and cultural and religious beliefs, because this information can help promote recovery. The less severe the current traumatic event, the more critical are predisas-ter variables, such as neuroticism or history of a psychiatric illness.

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