Episode 133: Abuse, Violence, and Trauma Disorders

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 133. We’re moving into psych and behavior. Today, this evening, we have a lovely topic for you, including abuse, violence, and trauma disorders.

All right. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And what I’ve been doing here for the past 15 years is trying to help students to not just understand the material better, but understand themselves better, understand how they study, understand how they take tests, understand how they can present themselves in the best possible light for either lectures, test taking, clinical rotations, the PANCE, job interviews, all of the above. It all kind of ties together. So that’s a lot of what we cover here. If you’re interested in more, there’s of course the Instagram channel.

I don’t know what you call it. Instagram, the, my Instagram, I’m old. I’m sorry. You can find me on Instagram. It’s not that hard if you search. And of course the email list will be over to the website and you can find how to sign up for that and where I give tips and tricks almost daily. As far as all of this stuff goes.

The other thing where we really dial it in and move to help people accelerate their learning and improve their testing scores, whether that’s end of rotation exams, whether that’s medicine courses, especially for the PANCE or those people who have struggled to pass the PANCE, is with the 33 Days to Pass the PANCE program at physicianassistantexamreview.com/33. Don’t worry, I’ll get it together. Things will get better from here.

Okay, so this week we’re going to be covering, we’re going to be getting with psych and moving through abuse, violence, and trauma disorders.

So let’s start with, let’s just kind of get things moving here and start with our priming questions. Now that I know that I say this every episode, but if you’re new, the priming questions are designed for you to start thinking. So don’t just ignore them. Don’t pretend that you don’t know it so it’s okay. No, no, no. The idea is by thinking, you are creating almost like shelves or hooks to hang the information on as it comes. So it’s almost like previewing before a lecture.

You want to actually go through the material, read the headlines of what’s coming. Not that you’re going to learn it. Not that you’re going to know it, but it sort of lays down a little bit of a foundation, a little bit of a scaffolding that you can then attach the information to as it comes in. It’s been a, it’s a proven strategy to retain more. And a lot of what we do here is just things like that, like little tiny things that will make you go from like, you know, wondering why the person next to you is doing so much better in school and you’re struggling. And the answer is they just have one or two tricks that they don’t even know they’re doing. And this is one of them.

So the priming questions, I want you to really think about them, focus on them and try to come up with an answer. Even if you’re wrong, it’s the act of doing it that really makes the difference.

All right, so for number one, what eye finding is a classic red flag for child abuse? What eye finding is a classic red flag for child abuse? What specific type of fracture strongly suggests child abuse? What specific type of fracture strongly suggests child abuse? How long do symptoms of adjustment disorder typically last? How long do symptoms of adjustment disorder typically last? Name the recommended antibiotic regimen for empiric STI prophylaxis after sexual assault.

Name the recommended antibiotic regimen for empiric STI prophylaxis after sexual assault. Auditory hallucinations in someone grieving. Is this always pathological? Auditory hallucinations in someone grieving. Is this always pathological?

Okay. So this one is, you know, you’ve heard me cover some tough topics before, and so once in a while I get feedback that I am not taking them seriously enough. It’s hard because these are just on paper for me, right? Some of them are real, just like I talked about in the last episode. Some things are real for me, just like for you. Some diseases are very personal, really affect you, and some don’t. Some don’t affect you at all in any way whatsoever.

So as I go through these, please, I’m going to ask you for your forgiveness in advance, because I generally tend to take things lightly and look for the positive side of things. So these are some tough topics, but I’m certainly not going to be down because we’re covering tougher topics. I’m going to continue in the same fashion I normally do. So if that’s an issue for you, if one of these is a particular trigger for you, just, you know, skip this episode. No big deal. This isn’t a super complicated topic. I think you can probably handle it, but just so you have that up front.

We’re going to start with child abuse. Obviously, it’s a horrible, horrible topic, something that I find abhorrent and one of the most evil things that could possibly happen. But let’s go through it because we’re going to study it as it would being prepared for your PANCE and help your patients in the future. So this is physical, sexual, or emotional maltreatment or neglect of a child. This has a high prevalence across all socioeconomic classes. Really the key here is to be vigilant. Keep an eye out.

You’re going to be looking for this and have it in your head as a practitioner. Clinical presentation. So, this is where you should get little red flags that go up, right? Little things that you find weird. This is what’s nice about being in something like a family practice where you see the same people over and over and over because you can kind of build that feeling. So, in this case, clinical presentation would be things like unexplained or suspicious injuries. So one of those would be the spiral fractures.

That’s what we were talking about in our priming question. A spiral fracture would be a twisting. So if you take someone’s arm and you twist it until the bone breaks, that’s a pretty odd fracture to get. Like you don’t, kids don’t get that, right? You don’t get that from falling. It’s a very obvious pattern in the fracture, right? So that’s one that should immediately scream child abuse.

Another would be like a stocking glove pattern for a burn, right? So someone sticks their hand into a pot of boiling water, it’s going to burn in a stocking glove pattern, right? So it’s as if they put a glove on, that’s where the burn is. That is suspicious as though someone did that to them. It’s not like they picked up something that was hot. It’s not like they accidentally spilled something, right? So that’s a suspicious type of injury.

Retinal hemorrhages would be for shaken baby syndrome is how you might wind up with a retinal hemorrhage. A hyphema is a term you should definitely know. This is blood in the anterior chamber, and this is a blunt trauma wound to the eye. Doesn’t necessarily mean child abuse, but certainly should, again, be a cause for concern. You may also see in the way the child behaves. So anxiety, PTSD-type symptoms, depression, failure to thrive, and then as they get older, substance abuse, suicidal ideations, those kind of things. Lab studies and imaging, skeletal surveys like x-rays and things, head CT, MRI for suspected trauma, and so on.

Treatment and management. So this is mandatory reporting if you believe that this is a problem. Obviously, treating the injuries themselves, but really it’s a bigger multidisciplinary involvement. So social services, child protective services, all of these other things. So the injury is important, but obviously that becomes like the least important thing in this instance.

Okay, so the thing you want to focus on here would be that fracture pattern, the hyphema, the retinal hemorrhages, that kind of thing for the things that you’re going to want to study for your PANCE or for your medical exams on this.

Next, we have the other side of the spectrum. We have elder abuse. So this is abuse of elderly individuals, especially frail, isolated, or cognitively impaired people. Approximately 4% prevalence annually. I would guess that number is probably low. Clinical presentation, unexplained injuries. Again, so same as before, you might not get that spiral fracture, but you might.

You might get some kind of injury that’s a stocking glove burn, that kind of thing. Certainly possible, right? But more here is signs of neglect, right? Malnutrition, poor hygiene. You may find the patient to be emotionally withdrawn or fearful or concerned. Lab studies and imaging would be the same as before, right? There’s nothing really, unless there’s some type of specific injury.

Treatment and management, again, mandatory reporting, coordinating with social services, supportive care, all these things. One of the main issues here is also isolation of the person being abused. We want to be careful of that.

Next, we have what has been termed intimate partner violence or domestic violence. This is a pattern of violence or abuse between partners prevalent across demographics, heightened risk during pregnancy, interestingly. Clinical presentation. So these are all going to be kind of similar. Frequent healthcare visits with nonspecific complaints. So sort of vague wanting to reach out, but not really having something they want to share or a specific injury. And then you get injuries inconsistent with history or various healing stages.

So that’s another one I should have brought up for the other two abuses. Multiple injuries in various stages of healing that would demonstrate that multiple events have occurred, right? So if you fall down once, that’s one thing. But if you fall down once and then the next week you run into the doorknob and the next week you slip and fall and the next week it’s the stairs. And then, you know, this pattern is kind of nobody’s that clumsy, right? So that’s kind of what you’re looking out for. So injuries that have various healing stages and then injuries with inconsistent stories.

So things that either don’t add up or change with time. And then you also want to watch for the partner, is there any controlling or aggressive behavior during the visit? So if they won’t let you talk to the patient by themselves, if they are always answering for the individual, those sorts of things. Again, nothing there tells you because there’s also cultural issues and things, but there’s nothing there that tells you that there’s an actual problem, but all these things are going to get pieced together to make you concerned over time. So imaging and studies are going to be, you know, again, the same thing. Treatment and management, mandatory reporting, depending on what’s going on, safety planning and counseling, referral to community resources. One of the big keys for all of these is going to be interviewing the patient by themselves, right?

So always perform private interviews whenever possible. That’s always why you see in a lot of healthcare facilities, they have those flyers for either sex trafficking or domestic violence or in the bathrooms where the patients would be by themselves with a phone number they can call and things. So something to consider. So before we get on the trauma, just a little bit on physical and psychological abuse. Again always looking for fearful behavior, anxiety, unexplained somatic complaints, low self-esteem, depression, and then our treatments are going to be counseling, psychotherapy, safety planning, community resources, etc. Now the last one in this category is going to be sexual abuse. So clinical presentation here might be that, you know, the patient comes into the ED having had being sexually abused.

They may have general trauma. They may have STIs. Pregnancy is a concern. Lab studies and imaging, again, so sexual assault, forensic exam. There’s usually a kit available, I believe. STI and pregnancy screening. Treatment and management.

Mandatory reporting. So this has to be reported. If you have a case of sexual abuse, obviously the patient’s going to need some psychological counseling and support. Now I was looking into this, and maybe some of you can reach out and let me know if I’m wrong here, but what I found is that you may begin STI prophylaxis. So you may begin with ceftriaxone, IM single dose for gonorrhea, doxycycline for chlamydia, metronidazole for trichomonas. I don’t work in the ED. I don’t do this kind of thing.

I did look into it a little bit, and this is what I came across, although I wasn’t sure that you wouldn’t wait for symptoms or how exactly that would work. Something to consider. You might do a hep B vaccine if indicated, if you don’t know the status of the patient. Emergency contraception may be necessary.

All right, let’s move along to trauma and stress-related disorders. So we have two in this category, adjustment disorder and post-traumatic stress disorder. Number one is going to be adjustment disorder. So, this is emotional or behavioral response to identifiable stressors. So, this is things if that are like moving, like you have a teenager who moves to a new high school, right? You might wind up with an adjustment disorder. Emotional or behavioral response to identifiable stressor usually resolves within, or does resolve within six months.

The thing here is that it’s a disproportionate emotional distress causing temporary functional impairment. And that’s usually what we’re looking for here is it’s getting in the way of your daily life. It’s not just being upset. It’s not just having an issue. It’s having an issue so bad that you can’t, that the person can’t function on a normal level. Treatment is going to be supportive counseling, psychotherapy, and then perhaps short-term anxiety-focused meds. Oh, I missed one.

There’s three in this section. Slightly, on the same path, but a little bit different is bereavement. So normal versus complicated grief, this to me is how they’re going to ask it. It’s just a comparison. So normal grief is a gradual improvement. Sadness diminishes over time. You know, it comes and goes.

There can be good days and bad days, but over time, things get better with the normal grieving period. And usually that can be up to 12 months, maybe a little bit longer, depending that the symptoms are so bad that they interfere with your day. Complicated grief is persistent and lasts greater than 12 months. And this is real functional impairment. So that’s sort of the difference maker here. Clinical presentation, so intense sorrow, prolonged emotional distress. You can get hallucinations, both auditory and visual, with either of these, by the way.

If you’re getting them past 12 months, then we’re calling it complicated grief. But if you get them before 12 months, it can be very normal. Treatment is going to be counseling and psychotherapy in both cases, quite honestly. It makes sense. It’s a good idea. And then our last one for today is post-traumatic stress disorder, so PTSD. The clinical presentation here is intrusive memories, nightmares, avoidance behavior, hyperarousal that lasts greater than a month after the incident.

These are, you know, so this is generally someone who’s been in an extremely traumatic situation. So, this is soldiers coming back from war, seeing people die in front of them or around them. This is rape victims, where those thoughts come crashing back and interfere with their daily lives. You get these intrusive memories that seem so real. You get these these nightmares or night terrors. You get this hyper hyper arousal, which makes sense. So in order to diagnose this, you need obviously the exposure to the trauma plus the symptoms, right?

So you’re re-experiencing, you’re having that avoidance of situations that might be similar, or that might recreate it, you have that hyperarousal and it’ll last greater than one month. If it’s less than a month, at that point, you’re still calling it acute stress disorder, which we haven’t covered yet, but that’s all of these symptoms happening in less than one month. That is acute stress disorder. Post-traumatic stress disorder is this continues beyond that time period. And again, one of the keys here is a symptom caused significant distress or functional impairment. So again, the patient might be irritable. They have sleep disturbances.

They have those intrusive memories and flashbacks. They want to avoid anything that’s similar. So, they may have emotional numbness or detachment or reduced interest in activities as an effort to protect themselves. They may avoid memories, people or places that bring that memories back, that sort of thing. So, our first line treatment here is going to be trauma focused therapy. So, cognitive behavioral therapy with trauma exposure. There’s also something called eye movement desensitization and reprocessing.

So EMDR has some interesting things. I didn’t go that deep into it. You might want to, but I don’t think for the PANCE, it’s going to really be necessary. Medications, you could use SSRIs like sertraline or paroxetine for nightmares of that hyperarousal. You could use an alpha one blocker like prazosin, benzodiazepines for severe anxiety. Obviously there’s some risk associated with that, but something you could do. There’s some really interesting things coming down the way with psychedelics and treating things like PTSD.

Obviously, it’s a little ways out, but just some interesting stuff that’s coming certainly won’t be on your PANCE. So again, just to be real clear, how this is going to be, I think most people can wrap their head around what PTSD looks like. I think how it’s going to trip you up and what’s going to be asked is that less than one month thing is acute stress disorder. Greater than one month is PTSD.

Okay, that wraps up the content portion.

Now, we have a couple things left to do before we wrap up the episode. We’re going to cover our study tip, answer our priming questions, and then I introduced a new section for today because I’ve been playing with how to handle a couple things. I was doing the companion episodes, but I wasn’t loving it, quite honestly, but I like the idea. So, what we’re going to do today is we’re going to include some PANCE questions here at the end to change things around a little bit. But regardless, our study tip for today, let’s talk about something that’s really important that I noticed this weekend. And that’s the question of who are you bringing? Who are you bringing to the exam?

What version of you? Who’s coming to test day, to the biggest day that you’ve got? Whether that’s a major exam, whether that’s an end of rotation exam, whether that’s your end of curriculum exam, whether that’s your PANCE. Who’s coming with you? What version of you are you bringing? I watched my son over the last month or so, and he’s now 16, going into his junior year and looking at playing baseball in college. We went to a couple national tournaments this summer, and during one of them, he pitched really well at the first one, and then at the second one, he faced the number six team in the country, walked away with no runs, six strikeouts, I think he had one walk, maybe two hits, something like that.

Just unbelievable, phenomenal, hit 86 on the radar gun a couple times, which, for those of you who don’t know, for a 16 year old, that puts him in like the 97th percentile for fastball speed. Now the top kid’s at 97 or 99, so he’s not close to that, obviously, but still puts him way, way, way up on the list. And he just went from good to incredible during that game, and he was just absolutely energized. It was exciting to watch him play. You couldn’t wait to see him go out there, and he was facing some unbelievable talent, and you couldn’t wait to see what he was going to do with it. And he was, we were talking about how the kids who really have breakout days like that are riding the edge of excitement, but not over that edge into that panicky, weird zone where you’re just crazy. But you’re right on that edge.

You’re walking right up to it. You’re using all the energy of the day. You’re using all of the emotion in the crowd and the emotion from the dugouts. And you, and you’ve got all of it built into your body and you’re just absolutely full of life and you’re electric and you can see it on players when they play like that. Then two weeks later, we just got, we just went up to Boston for a different tournament, different team. It was high level, but not quite as high. And my son got the 8 AM start.

We had a long drive up the day before and the pouring rain was miserable. A four and a half hour drive took us eight and a half hours. And we went to bed at about 10 o’clock, got up at about 5:30 because it was still about a 40 minute ride over. He slept in the car on the way over and we got to warm ups a little bit late. And he was the starting pitcher and he never, ever had it. He did okay. He didn’t do well.

He walked the first two kids and there were some other issues, but he just never had it. And some of the other parents were like, no, he did okay. I was like, you don’t understand what I saw a couple weeks ago. I saw something unbelievable a few weeks ago. And this week, it just wasn’t the same. So even if he had muddled his way through it, it would have been okay. But there were just two different versions of him, right?

The one that was absolutely electric, absolutely engaged mentally and physically, and the one that physically showed up. But that was it. And you could see the difference. I could see it. Maybe nobody else knew because they don’t know him as well. And they thought he did okay. But absolutely not the same.

And the reason I’m telling this story is to drive it home to you. That there are different versions of you, right? So which one are you bringing on test day? Which one is, are you going to be ready? Are you leaning in? Are you excited? Are you ready to go?

Or are you, and are you right up to that line of being excited about your performance and using that energy? Or did you stay up too late? Did you sleep in? Are you so nervous you didn’t sleep at all? You have so much nervous energy that you can’t focus. You know, where is that line? How do you get up to it without going over it?

And it’s something we talked about after the game and a couple of days later on our drive home. And I said, you know, maybe for you, you got an AM game. It might be worth going for a mile or two run before the game. It seems a little crazy, but that way you get your energy up. You got everything functioning and flowing. You get out of your own head. You stop worrying about pitching and you pitch.

That’s why I talk to a lot of test takers. You stop worrying about taking tests and you take the test. So to me, physical activity is a great way to bridge that gap. There’s a whole host of ways and we go into it. I’ve gone into it before and I’ll go into it again in different areas. But for today, I just want to focus on that one point that you want to bring the best version of yourself for that activity. And there are ways to get you into the right mindset.

There are ways to get your energy into the right zone. But you have to be aware of yourself enough to know that you need to do that. But anyway, let’s talk about our priming questions and then we’ll hit it. Some, some PANCE questions to wrap us up for today.

Let’s get the answers to our priming questions. Well, what eye finding is a classic red flag for child abuse? So we talked about this. What eye finding is a classic red flag for child abuse? That’s going to be your hyphema. The blood in the anterior chamber is a blunt trauma to the eye until proven otherwise. As this child abuse until proven otherwise.

What specific type of fracture strongly suggests child abuse? What type of fracture strongly suggests child abuse? That’s the spiral fracture we talked about. How long do symptoms of adjustment disorder typically last? Adjustment disorder. That’s going to be six months. Name the recommended antibiotic regimen for empiric STI prophylaxis after sexual assault.

Name the recommended antibiotic regimen for empiric STI prophylaxis after sexual assault. It’s going to be ceftriaxone, doxycycline, and metronidazole. Auditory hallucinations and someone grieving. Is this always pathological? No, no, no. It can be very normal during regular bereavement. Auditory or visual hallucinations are very much within the normal range for bereavement.

All right, and then our last section for today, these PANCE questions.

Let’s just run through. I have two for you today, and let’s see how these go. Number one, a three-month-old infant presents with fussiness and lethargy. Physical exam reveals retinal hemorrhages and a bruise on the forehead. Which of the following is the most likely diagnosis? A, hemophilia. B, osteogenesis imperfecta.

C, shaken baby syndrome. D, normal bruising from accidental injury.

Now, osteogenesis imperfecta in the words most likely diagnosis, probably never, ever, ever going to go together, right? Is osteogenesis imperfecta possible? Of course it’s possible, but really, really unlikely. Hemophilia without any other issues or any other information, again, pretty unlikely. They’re going to give you something else to go along with that. Normal bruising from accidental injury, certainly possible. But when you have those retinal hemorrhages, there’s really only one way to go here, and that’s going to be shaken baby syndrome.

Retinal hemorrhages are a pretty bad sign. Number two, a 68-year-old woman brought by her caregiver presents with unexplained bruising, poor hygiene, and appears withdrawn. Which of the following actions is most appropriate? Which of the following actions is most appropriate? A, admit for psychiatric eval. B, immediately begin treatment with antidepressants. C, report suspicion to adult protective services.

D, refer the patient for cognitive behavioral therapy. And in this case, we’re going to go with the answer is C, report suspicion to adult protective services. Suspected elder abuse requires immediate mandatory reporting. That’s really all there is to it. So when you get to these professional practice questions, I think this might fall under that. I don’t even know. Your answer is going to be reported.

Even when you don’t want to, let someone else take a look if you have suspicions or you have concerns.

Okay, that brings us up to the end for today’s episode. Fun to get started with psych. This is the last one in this pass through the blueprint. I guess we’re going to be starting over from the beginning after we finish this. But psych’s going to be it. So pretty exciting to be on that road. Thank you guys so much for listening.

Thank you so much for participating. Look forward to hearing how you guys do on your exams. And don’t forget the next cohort for the 33 Days to Pass the PANCE program is going to be September 1st. So if your test is coming up anytime, November, December, January, that may be the cohort for you. physicianassistantexamreview.com/33. Take care. Have a great day.