Johns Hopkins Psychiatry Guide

Acute Stress Disorder

Katie W. Hsih, , Dean MacKinnon, M.D.

DEFINITION

  • Trauma- and stressor-related disorder with onset 3 days to 1 month after a traumatic event (direct exposure or indirectly experienced), characterized by intrusive memories, avoidance of associated stimuli, and changes in mood and arousal that impair daily functioning

EPIDEMIOLOGY

  • Prevalence: occurs in 20-50% of victims or witnesses of trauma involving interpersonal assault (e.g. rape, witnessing a shooting), < 20% following trauma without interpersonal assault (e.g. motor vehicle accidents, traumatic brain injury, severe burns)
  • Risk factors: prior trauma, prior mental disorder, female gender, high neuroticism, avoidant coping, hyperarousal (e.g. elevated startle response)
  • Symptoms can vary across culture (e.g. ataque de nervios among Latin Americans)

DIAGNOSIS

Clinical Presentation

  • Re-experiencing of the traumatic event through intrusive and distressing memories, nightmares, flashbacks
  • Avoidance of reminders of trauma, which can induce emotional numbing as well as heightened reactivity
  • Catastrophic thoughts about role in traumatic event, response to exposure, or likelihood of future harm
  • Inability to experience positive emotions, but frequent negative emotions (e.g. fear, sadness, anger, guilt, shame)
  • Other signs: hyperarousal, poor concentration, insomnia, irritability, impulsive behavior

Tests and Procedures

  • Acute stress disorder (ASD) is a clinical diagnosis based on history and physical without a diagnostic laboratory test.
  • Screen for exposure to traumatic event considering the nature of the event and the patient’s response.
  • Identify comorbidities; rule out other explanations for symptoms.
  • Structured measurements: Stanford Acute Stress Reaction Questionnaire, Acute Stress Disorder Interview, Acute Stress Disorder Scale (more useful for assessing severity).
  • Elevated ASD or PTSD scale scores suggest increased risk for lasting PTSD symptoms.

Differential Diagnosis

TREATMENT

General

  • Limited studies evaluating efficacy of treatment for ASD
  • Goals: reduce symptoms, improve functioning, rehabilitate sense of security, prevent PTSD
  • Consider early intervention with trauma-focused cognitive-behavioral therapy (CBT).

Pharmacotherapy

  • Antidepressants may reduce intrusion symptoms, avoidance, dissociation, hyperarousal, and comorbid psychiatric disorders.
  • Anticonvulsants may reduce intrusion symptoms.
  • Morphine for pain management during a critical illness or immediately following a physical trauma (including burns) may help prevent PTSD.
  • Stress-dose corticosteroids (e.g., hydrocortisone) may prevent PTSD in the context of critical illnesses like septic shock or during/following cardiac surgery.
  • Avoid acute use of benzodiazepines, which may paradoxically increase the risk for long-term PTSD symptoms.

Psychotherapy

  • Trauma-focused CBT
    • Patient education: normalize the stress response, increase the expectation of recovery
    • Exposure: in-imagination (reliving) and in vivo exposure to enable extinction learning; contraindicated with extreme avoidance/dissociation, suicidal risk, acute grief
    • Cognitive processing: reframe maladaptive appraisals about past trauma and future triggers
  • Address salient interpersonal issues such as changes in relationships, loss of trust, anger and aggression, as well as generalization of fears and threats.
  • Administer 2 weeks after exposure for 6 weekly individual sessions.
  • Time therapy with regard for other trauma-related events (e.g. pain, surgery, legal complications).

Other

  • If patient is in acute distress immediately after exposure, stabilize with supportive care until psychologically and physiologically safe.
    • Probing questions or inadvertent reminders of the traumatic event may exacerbate distress.
    • After stabilization, establish education, early intervention, and case management.
  • Encourage reliance on patient’s internal strengths and existing support structures.
  • Address concurrent issues such as depression, suicidality, self-harm, substance abuse.
  • 25-50% of ASD cases will resolve without formal intervention.

WHEN TO REFER

  • Seek psychiatric care, particularly in cases of continued distress or potential for self-harm.

FOLLOW UP

  • ASD can progress to if symptoms do not resolve within 1 month of exposure.

COMMENTS

  • ASD was introduced in the DSM-IV to identify patients at risk for PTSD; criteria were narrower (notably requiring dissociative symptoms to be present) and did not reliably predict PTSD.
  • There is still uncertainty regarding factors that predict ASD or interventions that prevent PTSD.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing.
  2. Barton KA, Blanchard EB, Hickling EJ: Antecedents and consequences of acute stress disorder among motor vehicle accident victims. Behav Res Ther 34:805, 1996  [PMID:8952123]
  3. Benedek MB, Friedman MJ, Zatzick DF, Ursano RJ. (2009). Guideline watch (March 2009): practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. American Psychiatric Association.
  4. Bryant RA, Harvey AG, Dang ST, Sackville T. (1998). Assessing acute stress disorder: psychometric properties of a structured clinical interview. Psychological Assessment 10(3), 215-220.
  5. Bryant RA. (2006). Acute stress disorder. Psychiatry 5(7), 238-239.
  6. Bryant RA, Harvey AG: Acute stress disorder: a critical review of diagnostic issues. Clin Psychol Rev 17:757, 1997  [PMID:9397336]
  7. Bryant RA et al: Treatment of acute stress disorder: a randomized controlled trial. Arch Gen Psychiatry 65:659, 2008  [PMID:18519824]
  8. Ehlers A, Clark DM: A cognitive model of posttraumatic stress disorder. Behav Res Ther 38:319, 2000  [PMID:10761279]
  9. Gelpin E et al: Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry 57:390, 1996  [PMID:9746445]
  10. Guthrie RM, Bryant RA: Auditory startle response in firefighters before and after trauma exposure. Am J Psychiatry 162:283, 2005  [PMID:15677592]
  11. Kornør H et al: Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: a systematic review and meta-analysis. BMC Psychiatry 8:, 2008  [PMID:18801204]
  12. Ozer EJ et al: Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull 129:52, 2003  [PMID:12555794]
  13. Ponniah K, Hollon SD: Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety 26:1086, 2009  [PMID:19957280]
  14. Ursano RJ et al: Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 161:3, 2004  [PMID:15617511]
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Last updated: October 17, 2014