Acute stress disorder

Acute stress disorder is a psychiatric diagnosis that may occur in patients within four weeks of a traumatic event after witnessing, hearing about, or being directly exposed to a traumatic event, such as motor vehicle crashes, acts of violence (e.g., military combat, sexual assault, robbery), work-related injuries, natural or man-made disasters, or sudden and unexpected bad news (e.g., diagnosis of life-threatening illness, death of a loved one). Patients with acute stress disorder respond with intense fear, helplessness, or horror, and may report anxiety, depression, fatigue, headaches, and gastrointestinal and rheumatic symptoms ¹. Essential features of acute stress disorder include anxiety, dissociative symptoms, reexperiencing the event, and avoidance of stimuli that arouse recollections of the event ². Symptoms must be present for a minimum of two days, but not longer than four weeks; patients with persistent symptoms should be assessed for post-traumatic stress disorder (PTSD). Symptoms of acute stress disorder typically peak in the days or weeks after a patient is exposed to trauma, then gradually decrease over time.11 acute stress disorder and PTSD (post-traumatic stress disorder) share many core symptoms, but acute stress disorder includes dissociative symptoms such as detachment, reduced awareness of surroundings, derealization, depersonalization, and dissociative amnesia ³.

Acute stress disorder is characterized by the development of severe anxiety, dissociation, and other symptoms that occurs from 3 days to 1 month following exposure to an extreme traumatic stressor or events (e.g., witnessing a death or serious accident) ⁴. Traumatic events that are experienced directly include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual violence, physical attack, active combat, mugging, childhood physical and/or sexual violence, being kidnapped, being taken hostage, terrorist attack, torture), natural or human made disasters (e.g., earthquake, hurricane, airplane crash), and severe accident (e.g., severe motor vehicle, industrial accident). For children, sexually traumatic events may include inappropriate sexual experiences without violence or injury. A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking during surgery, anaphylactic shock). Stressful events that do not possess the severe and traumatic components of events encompassed by Criterion A may lead to an adjustment disorder but not to acute stress disorder (see below under diagnostic criteria).

As a response to the traumatic event, the individual develops dissociative symptoms (eg, depersonalization, derealization, fugue, and amnesia). Individuals with acute stress disorder have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities and frequently feel guilty about pursuing usual life tasks. Often, this involves feeling afraid or on edge, flashbacks or nightmares, difficulty sleeping, or other symptoms. Acute stress disorder has the same symptoms as post-traumatic stress disorder (PTSD), except that it is diagnosed within a month of trauma exposure, and has a greater focus on dissociative symptoms ⁵. If your loved one has symptoms that last longer than a month and make it hard to go about daily routines, go to work or school, or handle important tasks, he or she could have post-traumatic stress disorder (PTSD).

Acute stress disorder may progress to PTSD (post-traumatic stress disorder) after 1 month, but it may also be a transient condition that resolves within 1 month of exposure to traumatic event(s) and does not lead to PTSD ⁴. In about 50% of people who eventually develop PTSD, the initial presenting condition was acute stress disorder. Symptoms of acute stress disorder may worsen over the initial month can occur, often as a consequence of ongoing stressors or additional traumatic events.

Whether your loved one has acute stress disorder or PTSD (post-traumatic stress disorder), assessment and counseling (psychotherapy) by a professional can make a critical difference in recovery. Encourage him or her to talk to a doctor or a trained mental health professional.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the frequency with which acute stress disorder develops in individuals exposed to traumatic events depends on both the nature of the event and the context in which it is assessed ⁴. Within and outside the United States, acute stress disorder tends to occur at the following rates:

• 20-50% of cases follow interpersonal traumatic events (eg, assault, rape, and witnessing a mass shooting)
• 13-21% of motor vehicle accidents
• 14% of mild traumatic brain injuries
• 19% of assaults
• 10% of severe burns
• 6-12% of industrial accidents

Acute stress disorder causes

Factors increasing the risk of acute stress disorder and post-traumatic stress disorder (PTSD) in someone suffering a sufficient precipitating event include the following:

• Loss of a loved one in the event
• Significant injury from the event
• Witnessing of horrendous images
• Dissociation at the time of the traumatic event
• Development of serious depressive symptoms within 1 week that last for 1 month or longer
• Numbness, depersonalization, a sense of reliving the trauma, and motor restlessness after the event
• Preexisting psychiatric problems
• Previous trauma
• Loss of home or community
• Extended exposure to danger
• Toxic exposure
• Absent social supports, or social supports who were also traumatized and thus are incapable of adequate emotional availability.

It has been estimated that 50 to 90 percent of U.S. adults experience trauma during their lives ⁶. Many victims of trauma recover on their own; others do not. acute stress disorder affects 14 to 33 percent of persons exposed to severe trauma ³. Acute stress disorder has been reported in 25 percent of persons who have experienced robbery, life-threatening circumstances, or physical or psychological assault or captivity, and in persons who witnessed another being injured or killed ⁷. In addition, 21 percent of adults involved in motor vehicle crashes ⁸ and 62 percent of Hurricane Katrina evacuees at an emergency shelter met criteria for acute stress disorder ⁹. Acute stress disorder has also been reported in 19.4 percent of children and adolescents involved in assaults or motor vehicle crashes ¹⁰ and in 14.6 percent of disaster workers after the September 11, 2001, terrorist attacks ¹¹.

Seven to 28 percent of trauma victims experience acute stress disorder and subsyndromal acute stress disorder (typically not including the dissociative criteria) ¹². Although persons who meet criteria for acute stress disorder are at increased risk of posttraumatic stress disorder (PTSD), most of those who eventually develop PTSD do not meet all of the criteria for acute stress disorder. Therefore, the value of acute stress disorder in predicting PTSD has been questioned ¹².

Acute stress disorder symptoms

A person with acute stress disorder may experience difficulty concentrating, feel detached from their body, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia).

In addition, at least one symptom from each of the symptom clusters required for posttraumatic stress disorder (PTSD) is present. First, the traumatic event is persistently re-experienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress when exposed to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided. Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness).

Specific symptoms of acute stress disorder:

Acute stress disorder is most often diagnosed when an individual has been exposed to a traumatic event in which both of the following were present:

• The person experienced, witnessed, or was confronted with (e.g., can include learning of) an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
• Though not required, the person’s response is likely to involve intense fear, helplessness, or horror.

Either during or following the distressing event, the individual has 3 or more of the following dissociative symptoms:

• A subjective sense of numbing, detachment, or absence of emotional responsiveness
• A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
• Derealization
• Depersonalization
• Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress when exposed to reminders of the traumatic event.

Acute stress disorder is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, people). The person experiencing acute stress disorder also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

For acute stress disorder to be diagnosed, the problems noted above must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The disturbance in an acute stress disorder must last for a minimum of 3 days and a maximum of 4 weeks, and must occur within 4 weeks of the traumatic event. Symptoms also can not be the result of substance use or abuse (e.g., alcohol, drugs, medications), caused by or an exacerbation of a general or preexisting medical condition, and can not be better explained by a a brief psychotic disorder.

Acute stress disorder diagnosis

Acute stress disorder DSM 5 diagnostic criteria ⁴

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend.
   • Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
   • Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

• 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
• 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
• 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood

• 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Dissociative symptoms

• 6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
• 7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance symptoms

• 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal symptoms

• 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
• 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
• 12. Hypervigilance.
• 13. Problems with concentration.
• 14. Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

• Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Acute stress disorder treatment

Managing stress

Everyone encounters stressful situations at times, and learning about managing stress can involve different strategies.

It may not be possible to remove the stress from your life; however, managing your stress may help you to get things done. Below are some ideas for managing stress:

• Be aware – monitor your levels of stress and ask whether they are helpful or getting you down.
• Take stock – think about things in your life or pressures you place on yourself that may be increasing your stress.
• Take charge – deal with unhelpful sources of stress before they build up and become a bigger problem.
• Make choices – look at areas in your life where you could manage your situation better or change the way you respond.

Some examples of good ways to deal with stress:

• Take some deep breaths.
• Talk to someone you trust.
• Create a stress diary, note down when you feel stressed and why.
• Have a health check with your doctor.
• Exercise.
• Eat a healthy, balanced diet.
• Try to avoid smoking, alcohol and caffeine.
• Make time for things you enjoy.

These are ways to help you bounce back and become more resilient to stress.

Recognizing the signs and symptoms of stress will help you figure out ways of coping and save you from adopting unhealthy methods such as drinking or smoking.

You can talk to your doctor about ways to help you bounce back and become more resilient to stress.

Identify the sources of stress in your life

Stress management starts with identifying the sources of stress in your life. This isn’t as straightforward as it sounds.

The first step is to identify your triggers, or what makes you feel stressed. Notice the warning signs that you are becoming stressed; these may include muscle tension, being irritable or tired.

Until you accept responsibility for the role you play in creating or maintaining it, your stress level will remain outside your control.

Changing the stressor

Some stressors can be changed while others may be beyond your control. For example if work is causing your stress you may be able to make changes to your work hours or job duties.

Postpone major life changes such as moving house if you are already stressed.

Practice the 4 A’s (avoid, alter, adapt, or accept) of stress management:

• Avoid unnecessary stress: It’s not healthy to avoid a stressful situation that needs to be addressed, but you may be surprised by the number of stressors in your life that you can eliminate.
• Alter the situation: If you can’t avoid a stressful situation, try to alter it. Often, this involves changing the way you communicate and operate in your daily life.
• Adapt to the stressor: If you can’t change the stressor, change yourself. You can adapt to stressful situations and regain your sense of control by changing your expectations and attitude.
• Accept the things you can’t change: Some sources of stress are unavoidable. You can’t prevent or change stressors such as the death of a loved one, a serious illness, or a national recession. In such cases, the best way to cope with stress is to accept things as they are. Acceptance may be difficult, but in the long run, it’s easier than railing against a situation you can’t change.

Exercising

Regular exercise can relieve tension, relax the mind and reduce anxiety.

When you’re stressed, the last thing you probably feel like doing is getting up and exercising. But physical activity is a huge stress reliever—and you don’t have to be an athlete or spend hours in a gym to experience the benefits. Exercise releases endorphins that make you feel good, and it can also serve as a valuable distraction from your daily worries.

While just about any form of physical activity can help burn away tension and stress, rhythmic activities are especially effective. Good choices include walking, running, swimming, dancing, cycling, tai chi, and aerobics. But whatever you choose, make sure it’s something you enjoy so you’re more likely to stick with it.

While you’re exercising, make a conscious effort to pay attention to your body and the physical (and sometimes emotional) sensations you experience as you’re moving. Focus on coordinating your breathing with your movements, for example, or notice how the air or sunlight feels on your skin. Adding this mindfulness element will help you break out of the cycle of negative thoughts that often accompanies overwhelming stress.

While you’ll get the most benefit from regularly exercising for 30 minutes or more, it’s okay to build up your fitness level gradually. Even very small activities can add up over the course of a day. The first step is to get yourself up and moving. Here are some easy ways to incorporate exercise into your daily schedule:

• Put on some music and dance around
• Take your dog for a walk
• Walk or cycle to the grocery store
• Use the stairs at home or work rather than an elevator
• Park your car in the farthest spot in the lot and walk the rest of the way
• Pair up with an exercise partner and encourage each other as you work out
• Play ping-pong or an activity-based video game with your kids

Relaxing

Deep breathing exercises, muscle relaxation exercises, yoga and meditation are some techniques that can relax the body and reduce stress.

Spending time with family for friends

Being with people you find uplifting, resolving personal conflicts, and talking about your feelings can help.

There is nothing more calming than spending quality time with another human being who makes you feel safe and understood. In fact, face-to-face interaction triggers a cascade of hormones that counteracts the body’s defensive “fight-or-flight” response. It’s nature’s natural stress reliever (as an added bonus, it also helps stave off depression and anxiety). So make it a point to connect regularly—and in person—with family and friends.

Keep in mind that the people you talk to don’t have to be able to fix your stress. They simply need to be good listeners. And try not to let worries about looking weak or being a burden keep you from opening up. The people who care about you will be flattered by your trust. It will only strengthen your bond.

Of course, it’s not always realistic to have a pal close by to lean on when you feel overwhelmed by stress, but by building and maintaining a network of close friends you can improve your resiliency to life’s stressors.

Looking after your health

In addition to regular exercise, there are other healthy lifestyle choices that can increase your resistance to stress.

• Eat a healthy diet. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day.
• Reduce caffeine and sugar. The temporary “highs” caffeine and sugar provide often end in with a crash in mood and energy. By reducing the amount of coffee, soft drinks, chocolate, and sugar snacks in your diet, you’ll feel more relaxed and you’ll sleep better.
• Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or drugs may provide an easy escape from stress, but the relief is only temporary. Don’t avoid or mask the issue at hand; deal with problems head on and with a clear mind.
• Get enough sleep. Adequate sleep fuels your mind, as well as your body. Feeling tired will increase your stress because it may cause you to think irrationally.

Do things you enjoy

If you feel unable to manage your stress alone or with support from loved ones, seek help from a counselor or health professional.

• Set aside leisure time. Include rest and relaxation in your daily schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.
• Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.
• Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways.
• Take up a relaxation practice. Relaxation techniques such as yoga, meditation, and deep breathing activate the body’s relaxation response, a state of restfulness that is the opposite of the fight or flight or mobilization stress response. As you learn and practice these techniques, your stress levels will decrease and your mind and body will become calm and centered.

Psychological and Behavioral Interventions

Debriefing

Critical incident stress debriefing is one of the most commonly considered interventions after a traumatic event ¹³. Classically, critical incident stress debriefing is carried out in 7 stages, as follows:

1. Introduction (purpose of the session)
2. Description of the traumatic event
3. Appraisal of the event
4. Exploration of the participants’ emotional reactions during and after the event
5. Discussion of the normal nature of symptoms after traumatic events
6. Discussion of ways of dealing with further consequences of the event
7. Discussion of the session and formulation of practical conclusions

It should be kept in mind that research efforts have not shown critical stress debriefing to be effective in preventing PTSD, depression, or anxiety. In some cases, if performed poorly, debriefing can even harm survivors by increasing arousal and overwhelming their defenses. Operational debriefing, which focuses on normalizing emotional response, informing patients of services available to them, and providing general support, is safer.

In engaging in a 1- to 2-session intervention after a traumatic event, there are several guidelines that should be followed to help avoid harm and maximize the chance of benefit, as follows:

• Provide trained individuals to perform the intervention
• Avoid ventilating feelings at high levels; this can lead to contagion and flooding rather than calming and improved ability to cope with feelings
• Do not pressure individuals to talk about things they do not want to talk about; respect their defenses, including denial

Critical tasks to cover include the following:

• Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation
• Discussion of ways to improve coping skills, including getting adequate rest, recreation, food, and fluids
• Avoidance of excessive exposure to media coverage of the traumatic incident
• Discussion of common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe
• Explanation of the signs and symptoms indicating that the survivor should get professional help

Cognitive-behavioral therapy

Whereas 70% of those receiving supportive therapy or no therapy after a traumatic event develop PTSD, only about 10-20% of those who receive cognitive-behavioral therapy (CBT) shortly after such an event develop PTSD ¹⁴. Moreover, patients who receive CBT with or without hypnosis report less reexperiencing and fewer avoidance symptoms than patients who receive supportive counseling. Individuals are aided by the following:

• Seeing that people are concerned about them
• Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)
• Being reminded to take care of concrete needs (eg, food, fluids, and rest)
• Cognitive restructuring (changing destructive schema to more constructive ones [see the Table below])
• Learning relaxation techniques
• Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo
• Desensitization to painful memories via repeated controlled exposures and systematic desensitization

Current data suggest that if the resources are available, a course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and may have to be addressed.

Brief school intervention

A brief school intervention lasts 1-2 hours and uses 4 therapists per class. A teacher is present, and parents are informed. The intervention includes the following steps:

• Introduce the therapists, and ask students to guess why they have come to the classroom
• Explain that therapists have come to talk about the disaster, and encourage students to share what they know for 10-30 minutes; validate correct information, and be calm
• Have children draw while therapists circulate, and ask students to tell them about their drawings
• Reassure students that their symptoms are normal and will ease; that people have different symptoms; that disasters are rare; and that teachers, parents, and counselors are available to help them
• Having students do a second drawing in which they depict a future and a positive state of the world is very important; the first picture is likely to focus on the trauma, their loss, and its effect on them; ideally, the second picture should show healing and restoration of normal life
• Thank the students and the teachers, and redirect their attention to learning.

Medications

The use of medications to decrease arousal and insomnia may have a long-term impact.

Beta blockers (as well as alpha-adrenergic agents) may limit hyperarousal both initially and over the longer term ¹⁵. For extreme agitation, aggression, psychosis, or dissociation, an atypical neuroleptic or mood stabilizer may be needed.

Diphenhydramine and other medications may be helpful for improving sleep. Benzodiazepines, by limiting hyperarousal and fostering sleep, can be helpful in the initial stages; however, continuous administration may interfere with grieving and readaptation, because these agents can interfere with learning ¹⁶. Longer-acting agents are particularly beneficial when medication is administered at the emergency site and follow-up treatment is in short supply.

Selective serotonin reuptake inhibitors (SSRIs) can be helpful in dealing with the core symptoms (including anxiety, depression, withdrawal, and avoidance) and can play a central role in longer-term treatment. Current research indicates that SSRIs prazosin and propranolol may be helpful in the treatment of PTSD. Benzodiazepines are often used but present significant risks especially to the elderly, individuals with co-morbid substance abuse histories, and traumatic brain injury.

Comorbid conditions such as attention deficit hyperactivity disorder (ADHD) should be targeted. Reduction in even 1 disabling symptom (eg, insomnia or hyperarousal) may have a powerful positive impact on the individual’s ability to re-compensate.

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