Acute Stress Disorder
- 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
- 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)
- 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.
- PTSD (if symptoms persist for longer than 1 month)
- Adjustment disorder (encompassing more diverse forms of distress responses, whereas ASD is limited to fear/anxiety responses)
- Traumatic brain injury (can occur concurrently)
- Effects of analgesic medication or substance abuse
- Other psychiatric illnesses (mood disorder, panic disorder, dissociative disorder, OCD, psychotic disorder, personality disorder)
- 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.
- 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).
- 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.
- This is an important point to emphasize with patients, who otherwise may be further distressed by the notion that they are fated to suffer an extended course.
WHEN TO REFER
- Seek psychiatric care, particularly in cases of continued distress or potential for self-harm.
- ASD can progress to PTSD if symptoms do not resolve within 1 month of exposure.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Publishing.
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