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.
- Barton KA, Blanchard EB, Hickling EJ. Antecedents and consequences of acute stress disorder among motor vehicle accident victims. Behav Res Ther. 1996;34(10):805-13. [PMID:8952123]
- 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.
- 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.
- Bryant, R. A. (2017). Acute stress disorder and posttraumatic stress disorder. (pp. 161-184). Washington, DC, US: American Psychological Association. doi:10.1037/0000019010
- Bryant RA, Harvey AG. Acute stress disorder: a critical review of diagnostic issues. Clin Psychol Rev. 1997;17(7):757-73. [PMID:9397336]
- Bryant RA, Mastrodomenico J, Felmingham KL, et al. Treatment of acute stress disorder: a randomized controlled trial. Arch Gen Psychiatry. 2008;65(6):659-67. [PMID:18519824]
- Bryant RA, Creamer M, O'Donnell M, et al. Acute and Chronic Posttraumatic Stress Symptoms in the Emergence of Posttraumatic Stress Disorder: A Network Analysis. JAMA Psychiatry. 2017;74(2):135-142. [PMID:28002832]
- Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319-45. [PMID:10761279]
- Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry. 1996;57(9):390-4. [PMID:9746445]
- Gradus JL. Prevalence and prognosis of stress disorders: a review of the epidemiologic literature. Clin Epidemiol. 2017;9:251-260. [PMID:28496365]
- Guthrie RM, Bryant RA. Auditory startle response in firefighters before and after trauma exposure. Am J Psychiatry. 2005;162(2):283-90. [PMID:15677592]
- Howlett JR, Stein MB. Prevention of Trauma and Stressor-Related Disorders: A Review. Neuropsychopharmacology. 2016;41(1):357-69. [PMID:26315508]
- Kornør H, Winje D, Ekeberg Ø, 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. 2008;8:81. [PMID:18801204]
- Nestadt, P.S., Speed, T.J., Keefe, F. J. and Dimsdale, J. E. (2017). “Stress and psychiatry”. In Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Edited by: Sadock, B. J., Sadock, V. A., and Ruiz P.: Philadelphia, PA: Lippincott
- Ozer EJ, Best SR, Lipsey TL, et al. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73. [PMID:12555794]
- Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety. 2009;26(12):1086-109. [PMID:19957280]
- Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 Suppl):3-31. [PMID:15617511]
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