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 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 (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:

  • 1st-line treatment is trauma-focused CBT.
  • Trauma-focused CBT may reduce risk of 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: 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 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 medications.
  • 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 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 (SSRIs)).
  • 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: 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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