Acute Stress Disorder

Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Treatment is based on CBT. Pharmacological treatment is used as an adjunct to treat symptoms of insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia or anxiety.

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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. Symptoms last more than 3 days but less than 1 month after inciting event.

Epidemiology

Prevalence:

  • 5%–20% depending on: 
    • Time period after traumatic event
    • Nature of event 
  • Higher rates after interpersonal traumatic events (e.g., assault, rape, mass 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 can result in acute stress.
  • Cognitive process model: Extremely negative and unrealistic assessment of traumatic event 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/derealization (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 disturbance 
      • Irritable behavior and angry outbursts 
      • Hypervigilance
      • Problems with concentration
      • Exaggerated startle response
  • Symptoms significantly impair the quality of a patient’s life.
  • Substance abuse 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 or agitation.
  • 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. Symptoms involve re-experiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, poor memory, 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, 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 and pharmacological adjuncts (serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs)).
  • 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 lasting 1+ day and < 1 month. Usually has sudden onset and is often stress related. Presence of psychotic symptoms, such as delusions or hallucinations, distinguishes this diagnosis from acute stress disorder. As well, there is a full return to baseline functioning after an episode of brief psychotic disorder. Treatment involves 2nd-generation antipsychotics and psychotherapy. 

References

  1. Sadock BJ, Sadock VA, Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 11, Trauma and stressor-related disorders, pages 437-446. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Harvey AG, Bryant RA. (1998). The relationship between acute stress disorder and posttraumatic stress disorder Posttraumatic Stress Disorder 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): a prospective evaluation of motor vehicle accident survivors. J Consult Clin Psychol. https://pubmed.ncbi.nlm.nih.gov/9642889/ 
  3. Bryant, R. (2019). Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. UpToDate. Retrieved May 10, 2021, from https://www.uptodate.com/contents/acute-stress-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis

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