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Physical and Sexual Trauma
Victims of trauma may require urgent medical and psychiatric attention. Here, trauma is defined as “exposure to actual or threatened death, serious injury, or sexual violence,” as defined by criterion A for post-traumatic stress and acute stress disorders in Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). This chapter is a brief guide for the psychiatric consultant on how to provide psychiatric intervention in the hours after acute trauma. The goals of intervention are to assist emergent medical and forensic evaluation, reduce acute emotional distress, and minimize future psychiatric morbidity. As in previous editions of this book, consideration of the acute management of the victim of rape is here used to illustrate basic principles that can be applied to crisis intervention in general. Special considerations for other populations follow.
Background
Of every 100,000 persons age 12 or older in the United States, 1100 reported to be a victim of rape in 2014, and the majority of incidents of rape were undisclosed. One out of every 10 rape victims is male. Transgender and gender-nonconforming individuals are at higher risk for sexual assault. One in every six women will be a victim of completed or attempted rape at some time in her life.
Phone call
Questions
- 1.
What is the behavior of the patient?
Symptoms of dissociation and reexperiencing phenomena after trauma may be associated with behavioral agitation and disorganization, which can endanger patient safety and impede evaluation. Suicidal and homicidal comments and violent behavior may follow from feelings of intense fear, anger, shame, and guilt.
- 2.
What is the patient’s medical status?
Rape is a violent act, and victims require immediate medical evaluation. In addition to assessment of physical trauma, including possible head trauma, evidence of alcohol and drug intoxication or withdrawal should be pursued. Abnormal vital signs may be an unrecognized clue that alcohol or substance use is involved.
Orders
- 1.
Agitated patients may require pharmacologic intervention before the psychiatric consultant is able to arrive if the agitation poses acute risk to self or others. One dose of a benzodiazepine (e.g., lorazepam 1 to 2 mg or diazepam 5 to 10 mg orally or parenterally ) may be useful.
- 2.
Especially with patients who display poor behavioral control or express feelings of intense distress, including suicidal or homicidal comments, one-to-one observation is prudent until psychiatric evaluation is completed.
- 3.
Full routine laboratory tests, pregnancy test, and screens for sexually transmitted diseases and indicated radiologic studies should be ordered by the primary team; request urine and blood toxicologic screening, including screening for amnestic “date rape” agents like gamma-hydroxybutyrate (GHB), flunitrazepam (Rohypnol), and ketamine, if it has not been obtained.
Inform RN
“Will arrive in … minutes.”
Elevator thoughts
Acute responses to trauma are conceptualized by Osterman and Chemtob as the three “survival mode” functions. Functions of “fight,” “flight,” and “freeze” generate symptoms of anger, anxiety, and dissociation, respectively. The persistence of these functions and symptoms may contribute to the brief and chronic psychiatric symptomatologies of acute stress and post-traumatic stress disorders. Symptoms of reexperiencing the traumatic event (intrusive thoughts or images, dreams, reliving, distress or physiologic reactivity to external cues), avoidance (of thoughts, activities, memories, relationships, emotions, and expectation of a foreshortened future), hyperarousal (sleep difficulty, irritability, poor concentration, hypervigilance, exaggerated startle), and negative alterations in cognitions and mood (inability to remember totality of trauma, persistent distorted cognitions about cause or consequence of trauma, anhedonia, detachment, persistent negative emotional state) may emerge and persist from 2 to 4 weeks (meeting a diagnosis of acute stress disorder) or greater than 1 month (meeting a diagnosis of post-traumatic stress disorder). These symptoms may also contribute to emerging mood or other anxiety disorders.
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