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

• 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)

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.
  • 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.