Acute Stress Disorder

Overview

Definition

Acute stress disorder describes a set of behaviors expressed in reaction to being exposed to traumatic events, including near-death experiences, serious injury, or sexual assault Sexual Assault Sexual Abuse. Symptoms last more than 3 days but less than 1 month after inciting event.

Epidemiology

Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:

• 5%–20% depending on:
  • Time period after traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD)
  • Nature of event 
• Higher rates after interpersonal traumatic events (e.g., assault, rape, mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast shooting)  
• Women > men

Risk factors:

• Severity of trauma correlates with risk.
• Prior psychiatric history
• History of prior trauma

Pathogenesis

• Fear conditioning model: Fear experienced during event results in conditioning model, in which a reminder of the traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD) can result in acute stress.
• Cognitive process model: Extremely negative and unrealistic assessment of traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD) increases symptomatic responses, leading to acute stress.

Diagnosis

• Exposure to or witnessing life-threatening event
• Presence of > 9 of the following symptoms for 3 days to 1 month:
  • Intrusion symptoms:
    • Recurrent, involuntary, distressing memories of event
    • Recurrent distressing dreams 
    • Flashbacks
    • Exaggerated response to stimuli that resemble event
  • Negative mood:
    • Inability to experience positive emotions (happiness, love)
  • Dissociative symptoms:
    • Depersonalization Depersonalization State in which an individual perceives or experiences a sensation of unreality concerning the self or the environment; it is seen in disorders such as schizophrenia, affection disorders, organic mental disorders, and personality disorders. Depersonalization/Derealization Disorder/ derealization Derealization Derealization is a persistent subjective sense of detachment or unreality of the surrounding world often described by the patient as unreal, dreamlike, foggy, lifeless, or visually distorted reality. Depersonalization/Derealization Disorder (altered sensation of one’s surroundings)
    • Dissociative amnesia Dissociative amnesia Dissociative amnesia is a dissociative disorder characterized by temporary memory gaps in response to stressful events. Dissociative amnesia can be subclassified as generalized versus localized or continuous versus systematized. Dissociative Amnesia (can’t remember details about event)
  • Avoidance symptoms:
    • Avoidance of memories of event
    • Avoidance of external reminders (people, places, conversations)
  • Arousal symptoms:
    • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbance 
    • Irritable behavior and angry outbursts 
    • Hypervigilance
    • Problems with concentration
    • Exaggerated startle response
• Symptoms significantly impair the quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of a patient’s life.
• Substance use disorder or other medical causes must be excluded.

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:

• 1st-line treatment is trauma-focused CBT.
• Trauma-focused CBT may reduce risk of PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD) progression.

Pharmacotherapy:

• No FDA-approved medication therapy for acute stress disorder 
• Short-term benzodiazepine (< 4 weeks) is suggested if patient suffers from intense anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus.
• Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbances may benefit from medication treatment with short course of hypnotics (e.g., eszopiclone).

Differential Diagnosis

• PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD): set of behaviors lasting 1+ month expressed in reaction to being exposed to traumatic events, including near-death experience, serious injury, or sexual assault Sexual Assault Sexual Abuse. Symptoms involve re-experiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment, and concentration. Distinguishing feature between PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD) and acute stress disorder is the duration of symptoms. Treatment is similar to acute stress disorder, i.e., involving psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, but also making use of antidepressants and antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medications.
• Adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder: psychological response to identifiable stressor. Marked by emotional or behavioral symptoms that develop < 3 months from exposure and last < 6 months. Adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder differentiates itself from acute stress disorder by having a less defined set of symptoms and lack of reactive symptoms to trauma (e.g., intrusion, negative mood, dissociate symptoms, arousal symptoms). Treatment involves cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy and pharmacological adjuncts ( serotonin-norepinephrine reuptake inhibitors Serotonin-Norepinephrine Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants), selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)).
• Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder: presence of 1+ psychotic symptoms Psychotic symptoms Brief Psychotic Disorder lasting 1+ day and < 1 month. Usually has sudden onset and is often stress related. Presence of psychotic symptoms Psychotic symptoms Brief Psychotic Disorder, such as delusions or hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, distinguishes this diagnosis from acute stress disorder. As well, there is a full return to baseline functioning after an episode of brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder. Treatment involves 2nd-generation antipsychotics and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.