Detecting Psychological Stress: The Alkhathami 5-Step Approach
- 1. Consultant of Family, Community Medicine and Medical Education, Director of the Postgraduate Family Medicine Programme and Supervisor of the Primary and Community Mental Health programme, Eastern Province, Saudi Arabia
CITATION
AlKhathami AD (2024) Detecting Psychological Stress: The Alkhathami 5-Step Approach. J Sleep Med Disord 8(4): 1142.
INTRODUCTION
Psychological stress is a pervasive factor that contributes significantly to both physical and mental health conditions. Within healthcare clinics, identifying stress in patients who may not present with obvious psychological complaints poses a unique challenge. The AlKhathami 5-Step Approach is an innovative, structured model designed to detect, assess, and manage psychological stress within primary care settings, aligning with the WHO’s objectives of mental health integration (mhGAP 2013- 2030). This approach equips healthcare providers with the tools necessary to uncover underlying psychological stress, improve diagnostic accuracy, and facilitate timely intervention [1].
INTRODUCTION TO PSYCHOLOGICAL STRESS DETECTION
Stress is often manifested through physical symptoms or unexplained medical complaints, making it difficult for healthcare providers to recognize the root psychological causes without a structured assessment framework [2]. By implementing the AlKhathami 5-Step Approach, healthcare providers can systematically identify and respond to signs of stress, improving patient outcomes and helping to reduce healthcare utilization rates linked to unrecognized psychological conditions [3].
THE ALKHATHAMI 5-STEP APPROACH TO STRESS DETECTION
The AlKhathami 5-Step Approach facilitates psychological stress identification through a series of guided interactions, enabling thehealthcareprovidertoassessstress comprehensively. The steps include suspecting psychological care needs, exploring hidden complaints and psychological stress, determining the level of care, conducting a diagnosis, and implementing a management plan. Each step contributes to a holistic understanding of the patient’s well-being and mental health, particularly as stress often intersects with other physical complaints.
STEP 1: SUSPECTING - ASSESS THE NEED FOR MENTAL HEALTHCARE
This foundational step prepares the healthcare provider to identify psychological stress in patients presenting with physical or unexplained symptoms. Stress can manifest in various forms, and this step includes assessing three primary indicators:
- Uncontrolled physical complaint or disease: That persist despite adequate medical management, suggesting a potential underlying psychological factor.
- Frequent visits to healthcare services: For psychological concerns without notable improvement, which may indicate a need for tailored psychological support.
- Chronic sleep disturbances: Such as insomnia or disrupted sleep patterns, which are common indicators of elevated stress levels [4,5].
By observing these indicators, providers can recognize patients likely in need of psychological intervention, even when the initial complaints appear solely physical.
STEP 2: SCREENING–EXPLORING HIDDEN PROBLEMS AND PSYCHOLOGICAL STRESS
In the second step, the AlKhathami Approach emphasizes thorough screening to uncover underlying psychological issues that may not be immediately evident. This step includes two tools.
ICE Technique for Identifying Hidden Problems and Delusions
The ICE (Ideas, Concerns, and Expectations) technique is used to reveal hidden problems, delusions, or misconceptions that a patient might not openly share. The healthcare provider uses open-ended questions, structured around the following aspects:
Ideas: Ask the patient about their thoughts on their symptoms or condition. This helps in identifying any underlying misconceptions or psychological issues:
- “What do you think might be causing your symptoms or affecting your ability to control this condition?” or
- “What do you believe could be the underlying reason for your physical complaints or the challenges in controlling your condition?”
Concerns: Explore any worries or fears the patient might have, which could indicate hidden stressors or delusions:
- “Is there anything about your health that worries you the most?”
- “Do you have concerns about how this condition might impact your life?”
Expectations: Inquire about the patient’s expectations for their treatment and recovery, helping to gauge their level of insight into their condition:
- “What do you hope this treatment will achieve?”
- “How do you think this issue should be addressed?”
By exploring these areas, the ICE technique provides insight into the patient’s mental state and can reveal psychological stress or delusional thinking that may not be immediately apparent. For patients presenting with delusions, an immediate referral to a psychiatrist is recommended, bypassing the remaining steps of the AlKhathami Approach. This ensures timely access to specialized mental health care, which is essential for effectively managing delusional symptoms.
Screening for Psychological Stress with Three Key Questions
This screening involves three questions addressing key areas affected by stress: sleep quality, concentration and performance in daily tasks, and social relationships. These questions help identify the severity and impact of stress on the patient’s life:
The Sleep Indicator: It can be assessed through two specific questions, helping the doctor gauge the level of psychological stress:
- Falling Asleep:
- “When you put your head on the pillow, do you fall asleep easily, or do you find it difficult to fall asleep?”
- Difficulty in falling asleep typically indicates mild stress.
- Interrupted Sleep:
- “Once you’re asleep, is your sleep interrupted, or do you wake up frequently during the night?”
- Interrupted or fragmented sleep often points to moderate to severe stress.
Concentration and Performance indicator: Assess the impact of stress on the patient’s daily performance and concentration:
- “Have you noticed any changes in your ability to focus or complete daily tasks?”
- Reports of declining performance or difficulty concentrating may reflect moderate to severe stress.
Social Relationships indicator: Explore the effect of stress on interpersonal interactions, especially noting irritability or withdrawal:
- “How have your relationships with others been lately? Have you noticed feeling more easily frustrated, quick to anger, or preferring to spend time alone?”
- Quick temper, easy anger, or isolation tendencies can indicate moderate to severe stress.
This step serves as an opportunity for the healthcare provider to build trust and rapport, enabling the patient to discuss sensitive issues openly. Uncovering these hidden complaints often reveals psychological stress that may be amplifying physical symptoms [6].
STEP 3: SCOPING - DETERMINING REFERRAL OR CONTINUED CARE
This step assesses whether the healthcare provider should continue managing the patient’s treatment or refer them to a mental health specialist. Typically, all psychological disorders warrant referral to specialists, with exceptions for depression and various types of anxiety, such as generalized anxiety disorder, phobias, panic attacks, and obsessive-compulsive symptoms. However, certain cases of depression or anxiety still require referral under specific conditions, such as:
Suicidal ideation.
- Mania or hypomania signs
- Postpartum depression.
- Children as patients.
- Presence of addiction.
- Difficulty in managing the condition effectively.
This referral decision ensures patients receive care tailored to their mental health needs, balancing management within primary care with specialized intervention for more severe cases [2].
STEP 4: DIAGNOSIS - IDENTIFYING DEPRESSION AND TYPES OF ANXIETY
In this step, the healthcare provider synthesizes findings from previous assessments to accurately identify any stress-related mental health conditions, focusing on both depression and various types of anxiety. Diagnosis is based on a symptom history of more than two weeks, with disorder severity determined by the psychological stress level identified in Step 2.
The Diagnostic Process May Reveal
- Depression - indicated by a persistently low mood or loss of interest in usual activities, assessed using the PHQ-2, a validated screening tool for depression [7].
- Anxiety - presenting as chronic tension or excessive worry, evaluated with the GAD-2, which is recognized for its effectiveness in screening for generalized anxiety disorder [8].
Other Anxiety types - presenting in various forms, including:
- Phobias - intense, irrational fears of specific objects or situations.
- Panic Attacks - sudden episodes of intense fear, often with physical symptoms like rapid heartbeat.
- Post-Traumatic Stress - anxiety and stress symptoms following traumatic events, manifesting as flashbacks or heightened arousal.
- Obsessions and Compulsions - repetitive, intrusive thoughts or actions.
- Combination of Depression and Anxiety - since stress frequently contributes to or intensifies symptoms of both conditions, making comorbid presentations common [8,9].
The healthcare provider should also rule out symptoms of mania or hypomania, as these may suggest a bipolar disorder rather than depression alone. If bipolar disorder is suspected, a referral to a psychiatrist is recommended to confirm the diagnosis and ensure appropriate treatment.
Step 4: Management - Applying a Comprehensive
Treatment Plan
The AlKhathami Approach concludes with a personalized treatment plan tailored to the patient’s specific diagnoses and stress level. This comprehensive management approach includes three key components:
1. Non-Pharmacological Therapy: This part includes six elements to enhance well-being:
- Regular walking to stimulate the production of “happiness hormones”.
- Avoiding arguments and negativity to maintain a positive mindset.
- Reducing self-blame by reminding the patient of their positive attributes, such as the ability to see and walk, to help sustain the body’s natural happiness hormones.
- Deep-breathing relaxation exercises to lower stress hormone levels.
- Narrative therapy (preferably in a follow-up visit) to help the patient resolve conflicts, make decisions, and improve interactions with others.
- Scheduled follow-up visits: Initial follow-up at 2 and 5 weeks, then monthly until remission. Then, bi-monthly visits continue for 9 months post-remission, with a gradual reduction in frequency, ultimately leading to a medication-free phase.
- Pharmacological Therapy (SSRIs): Selective Serotonin Reuptake Inhibitors (SSRIs) are recommended for moderate to severe cases. For mild cases, SSRIs are generally not prescribed but can be considered if non-pharmacological methods are insufficient.
- Nutritional Supplements: Vitamins and minerals, particularly magnesium and Vitamins B1, B6, B12, and D3, are included to support mental and physical health. A healthy, balanced diet is also encouraged.
This comprehensive approach, represented as a triangular structure, symbolizes the balance and synergy of its elements improve the patient’s overall well-being, and reduce the risk of physical health complications stemming from untreated stress.
CONCLUSION
The AlKhathami 5-Step Approach is an essential model for primary care settings, enabling early detection and effective management of psychological stress. This approach not only enhances the healthcare provider’s capacity to support mental well-being within a primary care context but also aligns with broader goals of accessible mental health integration. By identifying and treating stress-related issues early, the AlKhathami Approach contributes to a more comprehensive, patient-centered model of care, bridging the gap between mental health and primary care services.
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