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Acute Stress Disorder

Acute Stress Disorder (ASD) is characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stress-event (e.g., witnessing a death or serious accident).

As a response to the traumatic event, the person develops dissociative symptoms. Individuals with ASD 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.

An individual with ASD may experience difficulty concentrating, feel detached from their bodies, 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 is present:

1. 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 on exposure to reminders of the event).
2. Reminders of the trauma (e.g., places, individuals, activities) are avoided.
3. Hyper-arousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hyper-vigilance, an exaggerated startle response, and motor restlessness).

Specific Symptoms of ASD:

ASD is most often diagnosed when a person has been exposed to a traumatic event in which both of the following were present:

• The individual's response involved intense fear, helplessness, or horror
• The individual experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

Either while experiencing or after experiencing the distressing event, the individual has 3 or more of the following dissociative symptoms:

• Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
• Derealization
• Depersonalization
• 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")

The traumatic event is persistently re-experienced in at least one of the following ways:

• recurrent images, thoughts, dreams, illusions
• flashback episodes
• a sense of reliving the experience
• distress on exposure to reminders of the traumatic event.

ASD is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, individuals). The individual experiencing ASD also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper-vigilance, exaggerated startle response, motor restlessness).

For ASD 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 ASD must last for a minimum of 2 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 cannot be better explained by a Brief Psychotic Disorder.

Treatment of ASD

The person with acute stress disorder often will not seek treatment because his ability to mobilize and perform necessary tasks is affected. The severity of the disorder may be reduced if professional intervention is initiated soon after the trauma. Treatment for acute stress disorder usually includes a combination of antidepressant medications and short-term psychotherapy.

Initial Assessment—

The initial step in identifying people with acute stress disorder or post traumatic stress disorder involves screening for recent or remote trauma exposure, although the clinical approach may vary depending on the recency of the traumatic event. If eliciting vivid and detailed recollections of the traumatic event immediately after exposure enhances the patient's distress, the interview may be limited to gathering information that is essential to provide needed medical care. The first interventions in the aftermath of an acute trauma consist of stabilizing and supportive medical care and supportive psychiatric care and assessment. After large-scale catastrophes, initial psychiatric assessment includes differential diagnosis of physical and psychological effects of the traumatic event (e.g., anxiety resulting from hemodynamic compromise, hyperventilation, somatic expressions of psychological distress, fatigue) and identification of persons or groups who are at greatest risk for subsequent psychiatric disorders, including ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER. This identification may be accomplished through individual evaluation, group interviews, consultation, and use of surveillance instruments.

Diagnostic evaluation may be continued after the initial period has passed and a physically and psychologically safe environment has been established, the individual's medical condition has been stabilized, psychological reassurance has been provided, and, in disaster settings, necessary triage has been accomplished. It is important for this diagnostic assessment to include a complete psychiatric evaluation that specifically assesses for the symptoms of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, including dissociative, re-experiencing, avoidance/numbing, and hyper-arousal symptom clusters and their temporal sequence relative to the trauma (i.e., before versus after 1 month from the traumatic event). Other important components of the assessment process include functional assessment, determining the availability of basic care resources (e.g., safe housing, social support network, companion care, food, clothing), and identifying previous traumatic experiences and comorbid physical or psychiatric disorders, including depression and substance use disorders.

Psychiatric Management—

Psychiatric management for all individuals with ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER includes instituting interventions and activities to ensure physical and psychological safety, required medical care, and availability of needed resources for self-care and recovery. The patient's level of functioning and safety, including his or her risk for suicide and potential to harm others, is always important to evaluate during initial assessment and may determine the treatment setting. The goals of psychiatric management for individuals with ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER also include establishing a therapeutic alliance with the patient; providing ongoing assessment of safety and psychiatric status, including possible comorbid disorders and response to treatment; and increasing the individuals understanding of - and active adaptive coping with - psychosocial effects of exposure to the traumatic event, such as injury, job loss, or loss of loved ones. Additional goals of psychiatric management include providing education regarding ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, enhancing treatment adherence, evaluating and managing physical health and functional impairments, and coordinating care to include collaborating with other clinicians.

General Principles of Treatment Selection—

The goals of treatment for people with a diagnosis of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER include reducing the severity of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER symptoms, preventing or treating trauma-related comorbid conditions that may be present or emerge, improving adaptive functioning and restoring a psychological sense of safety and trust, limiting the generalization of the danger experienced as a result of the traumatic situation(s), and protecting against relapse.

Individuals assessed within hours or days after an acute trauma may present with overwhelming physiological and emotional symptoms (e.g., insomnia, agitation, emotional pain, dissociation). Limited clinical trial evidence is available in this area, as randomized designs are difficult to implement; however, clinical experience suggests that these acutely traumatized people may benefit from supportive psychotherapeutic and psycho-educational interventions. Pharmacotherapy may be the first-line intervention for acutely traumatized individuals whose degree of distress precludes new verbal learning or non-pharmacological treatment strategies. Research has not consistently identified patient- or trauma-specific factors that predict the development of ACUTE STRESS DISORDER or interventions that will alter the evolution of ACUTE STRESS DISORDER into POST TRAUMATIC STRESS DISORDER. However, early after a trauma, once the patient's safety and medical stabilization have been addressed, supportive psychotherapy, psycho-education, and assistance in obtaining resources such as food and shelter and locating family and friends are useful.

Effective treatments for the symptoms of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER encompass psychopharmacology, psychotherapy, and psycho-education and other supportive measures. Although studies using a combination of these approaches for ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER are not presently available, combination treatment is widely used and may offer advantages for some individuals. The psychotropic medications used in clinical practice and research for the treatment of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER were not specifically developed for these disorders but have been used in doses similar to those recommended or approved for other psychiatric illnesses.

For individuals with ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER, choice of treatment includes consideration of age and gender, presence of comorbid medical and psychiatric illnesses, and propensity for aggression or self-injurious behavior. Other factors that may influence treatment choice include the recency of the precipitating traumatic event; the severity and pattern of symptoms; the presence of particularly distressing target symptoms or symptom clusters; the development of interpersonal or family issues or occupational or work-related problems; preexisting developmental or psychological vulnerabilities, including prior trauma exposure; and the patient's preferences.

When the patient's symptoms do not respond to a plan of treatment, selection of subsequent interventions will depend on clinical judgment, as there are limited data to guide the clinician. It is important to systematically review factors that may contribute to treatment non-response, including the specifics of the initial treatment plan and its goals and rationale, the patient's perceptions of the effects of treatment, the patient's understanding of and adherence to the treatment plan, and the patient's reasons for non-adherence if non-adherence is a factor. Other factors that may need to be addressed in individuals who are not responding to treatment include problems in the therapeutic alliance; the presence of psychosocial or environmental difficulties; the effect of earlier life experiences such as childhood abuse or previous trauma exposures; and comorbid psychiatric disorders, including substance-related disorders and personality disorders.

Specific Treatment Strategies—

Psychopharmacology:

Although it has been hypothesized that pharmacological treatment soon after trauma exposure may prevent the development of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, existing evidence is limited and preliminary. Thus, no specific pharmacological interventions can be recommended as efficacious in preventing the development of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER in at-risk people.

For individuals with ACUTE STRESS DISORDER, there are few studies of pharmacological interventions. However, selective serotonin reuptake inhibitors (SSRIs) and other antidepressants represent reasonable clinical interventions that are supported by limited findings in ACUTE STRESS DISORDER as well as by findings of therapeutic benefits in individuals with POST TRAUMATIC STRESS DISORDER.

SSRIs are recommended as first-line medication treatment for POST TRAUMATIC STRESS DISORDER. In both male and female individuals, treatment with SSRIs has been associated with relief of core POST TRAUMATIC STRESS DISORDER symptoms in all three symptom clusters (re-experiencing, avoidance/numbing, hyper-arousal). Other antidepressants, including tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs), may also be beneficial in the treatment of POST TRAUMATIC STRESS DISORDER.

Benzodiazepines may be useful in reducing anxiety and improving sleep. Although their efficacy in treating the core symptoms of POST TRAUMATIC STRESS DISORDER has not been established, benzodiazepines are often used in trauma-exposed people and individuals with POST TRAUMATIC STRESS DISORDER. However, clinical observations include the possibility of dependence, increased incidence of POST TRAUMATIC STRESS DISORDER after early treatment with these medications, or worsening of POST TRAUMATIC STRESS DISORDER symptoms after withdrawal of these medications. Thus, benzodiazepines cannot be recommended as mono-therapy in POST TRAUMATIC STRESS DISORDER.

In addition to being indicated in individuals with comorbid psychotic disorders, second generation antipsychotic medications (e.g., olanzapine, quetiapine, risperidone) may be helpful in individual individuals with POST TRAUMATIC STRESS DISORDER. Anticonvulsant medications (e.g., divalproex, carbamazepine, topiramate, lamotrigine), alpha-2-adrenergic agonists, and beta-adrenergic blockers may also be helpful in treating specific symptom clusters in individual individuals.

Psychotherapeutic Interventions:

Some evidence is available about the effectiveness of psychotherapeutic intervention immediately after trauma in preventing development of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER. Studies of cognitive behavior therapy in motor vehicle and industrial accident survivors as well as in victims of rape and interpersonal violence suggest that cognitive behavior therapies may speed recovery and prevent POST TRAUMATIC STRESS DISORDER when therapy is given over a few sessions beginning 2-3 weeks after trauma exposure.

Early supportive interventions, psycho-education, and case management appear to be helpful in acutely traumatized people, because these approaches promote engagement in ongoing care and may facilitate entry into evidence-based psychotherapeutic and psychopharmacological treatments. Encouraging acutely traumatized persons to first rely on their inherent strengths, their existing support networks, and their own judgment may also reduce the need for further intervention. In populations of individuals who have experienced multiple recurrent traumas, there is little evidence to suggest that early supportive care delivered as a stand-alone treatment will result in lasting reductions in POST TRAUMATIC STRESS DISORDER symptoms. However, no evidence suggests that early supportive care is harmful. In contrast, psychological debriefings or single-session techniques are not recommended, as they may increase symptoms in some settings and appear to be ineffective in treating people with ACUTE STRESS DISORDER and in preventing POST TRAUMATIC STRESS DISORDER.

No controlled studies of psychodynamic psychotherapy, eye movement desensitization and reprocessing (EMDR), or hypnosis have been conducted that would establish data-based evidence of their efficacy as an early or preventive intervention for ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER.

For individuals with a diagnosis of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER, available evidence and clinical experience suggest that a number of psychotherapeutic interventions may be useful. Individuals with ACUTE STRESS DISORDER may be helped by cognitive behavior therapy and other exposure-based therapies. In addition, cognitive behavior therapy is an effective treatment for core symptoms of acute and chronic POST TRAUMATIC STRESS DISORDER. EMDR also appears to be effective; however, therapeutic benefit for the rapid eye movement component of this therapy has not been consistently demonstrated. Stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be indicated for treatment of POST TRAUMATIC STRESS DISORDER and POST TRAUMATIC STRESS DISORDER-associated symptoms such as anxiety and avoidance. The shared element of controlled exposure of some kind may be the critical intervention.

Psychodynamic psychotherapy may be useful in addressing developmental, interpersonal, or intrapersonal issues that relate to the nature, severity, symptoms, or treatment of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER and that may be of particular importance to social, occupational, and interpersonal functioning.

Case management, psycho-education, and other supportive interventions may be useful in facilitating entry into ongoing treatment, appear not to exacerbate POST TRAUMATIC STRESS DISORDER symptoms, and in some pilot investigations have been associated with POST TRAUMATIC STRESS DISORDER symptom reduction. Present-centered and trauma-focused group therapies may also reduce POST TRAUMATIC STRESS DISORDER symptom severity.

Facts and Tips about Acute Stress Disorder—

• ASD begins with contact with an extremely traumatic, horrifying, or terrifying event.
• ASD is a kind of diagnostic category which was started in 1994 to differ the reactions for trauma which are time dependent and reactions from post-traumatic stress disorder (PTSD).
• ASD is the immediate reaction to trauma and if not treated, it could develop into Post traumatic stress disorder (PTSD).
• Clonidine, propanolol, clonazepam and fluoxetine are some medications used to treat the individual symptoms.
• Cognitive behavioral therapy is the most successful treatment to combat ASD.
• Some dissociative symptoms of ASD include derealization, reduction in awareness of vicinity, psychic numbing, depersonalization and sometimes dissociative amnesia.

Useful Terms:

• Trauma- In the context of ASD, a disastrous or life-threatening event.
• Dissociation- A reaction to trauma in which the mind splits off certain aspects of the trauma from conscious awareness. Dissociation can affect the patient's memory, sense of reality, and sense of identity.
• Derealization- A dissociative symptom in which the external environment is perceived as unreal.
• Depersonalization- A dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving.

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