Acute Stress Disorder

Clinical Features

• Acute stress disorder (ASD) typically presents with severe levels of re-experiencing and anxiety in response to reminders of the recent trauma
• Acute avoidance of any perceived threat or reminders of threat
  • Can generalise to reluctance to discuss experience with supports or during clinical assessment
• Patients may present with flat or blunted affect (i.e. emotional numbing)

EXAMPLE

A patient presented in treatment two weeks after being assaulted and robbed at his store. He reported that he was experiencing frequent nightmares of the assault, as well as terrifying dreams of being attacked in other situations. He reported daily intrusive memories of the experience (eg, vivid recollections of the assailant sliding a knife against his throat; strong perceptual memories that included smelling the assailant’s breath and feeling the scraping sensation of the knife against his skin. The patient reported intense distress to many reminders, including meeting strangers, people of the same ethnic appearance as the assailant, and even entering his own store. He suffered distressing memories every time he shaved because the sensation of the razor on his skin triggered clear memories of the assailant’s knife at his throat. This caused him to tremble with fear, causing him to cut himself while shaving further exacerbating his memories and fears. He became intensely fearful of all potential threats, and constantly scanned his surroundings for anything that may harm him. He always ensured he had his back to the wall so nobody could approach him from behind, and never entered situations which did not allow for ready escape.

Diagnostic Criteria

• 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) (eg, 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 recognisable content.
    3. Dissociative reactions (eg, 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 (eg, inability to experience happiness, satisfaction, or loving feelings).
  • Dissociative symptoms 6. An altered sense of the reality of one’s surroundings or oneself (eg, 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 (eg, 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 three days to one month after trauma exposure.
  • Note: Symptoms typically begin immediately after the trauma, but persistence for at least three days and up to a month is needed to meet disorder criteria.
  • Generally it is suggested that the diagnosis should be delayed until at least a weak after the event (to avoid misdiagnosing transient stress reaction)
• D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Symptoms of ASD should be present at a severe level to warrant diagnosis. As an example, many people will display some form of avoidance in the month after trauma; however, to meet the avoidance criterion for ASD, the patient needs to be engaging in effortful avoidance that reflects a pattern of actively not engaging with reminders of the event.
• E. The disturbance is not attributable to the physiological effects of a substance (eg, medication or alcohol) or another medical condition (eg, mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Differential Diagnosis

• Panic disorder
  • Characterised by panic attacks that are sudden in onset and lead to anxiety about future recurrence of the panic attack itself rather than re-experiencing of a preceding traumatic event
• Adjustment disorder
  • The response to the stressor does not meet symptomatic criteria for PTSD or if it is consistent, the stressor is not of the severity needed (e.g. breakup of relationship)

Management

• First line: trauma-focused cognitive behavioural therapy (TF-CBT)
  • Usually starting at least two weeks after trauma exposure
  • One month after after trauma exposure, the patient may qualify for PTSD diagnosis
• Adjunctive pharmacotherapy:
  • Usually SSRI (usually escitalopram)
  • If prominent arousal symptoms (e.g. sleep disturbance, irritable behaviour, hypervigilance or angry outbursts) ⇒ low dose benzodiazepine (try to limit duration to avoid dependence)