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Stress disorders include acute stress disorder and posttraumatic stress disorder.
Acute Stress Disorder
Acute stress disorder is a brief period of intrusive recollections occurring within 4 wk of witnessing or experiencing an overwhelming traumatic event.
In acute stress disorder, people have been through a traumatic event, have recurring recollections of the trauma, avoid stimuli that remind them of the trauma, and have increased arousal. Symptoms begin within 4 wk of the traumatic event and last a minimum of 2 days but, unlike posttraumatic stress disorder, last no more than 4 wk. People with this disorder may experience dissociative symptoms.
Diagnosis
Diagnosis is based on criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR—see Table 5: Anxiety Disorders: Diagnosis of Acute Stress Disorder ); these criteria include dissociative symptoms.
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Table 5
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| Diagnosis of Acute Stress Disorder |
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With exclusion of other causes, affirmative answers to the following questions confirm the diagnosis:
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Has the patient experienced or witnessed an overwhelming traumatic event?
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Did the patient respond to the event with intense fear, helplessness, or horror?
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Is the patient experiencing ≥ 3 dissociative symptoms:
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Feeling numb, detached from other people, or emotionally unresponsive
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Being less aware of surroundings (eg, feeling in a daze)
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Feeling unreal or detached from self (depersonalization)
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Feeling that the external world is strange or unreal (derealization)
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Being unable to remember significant parts of the event (dissociative amnesia)
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Does the patient constantly relive the event?
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Does the patient avoid people, places, objects, or thoughts associated with the event?
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Does the patient have symptoms of increasing anxiety, such as the following:
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Have symptoms caused substantial distress or interfered with functioning?
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Did symptoms start within 4 wk of the event?
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Have symptoms lasted ≥ 2 days and ≤ 4 wk?
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Treatment
Many people recover once they are removed from the traumatic situation, shown understanding and empathy, and given an opportunity to describe the event and their reaction to it. To prevent or minimize this disorder, some experts recommend systematic debriefing to assist people who were involved in or witnessed a traumatic event as they process what has happened and reflect on its effect. In one approach to debriefing, the event is referred to as the critical incident and the debriefing is referred to as critical incident stress debriefing (CISD). Other experts have expressed concern and some studies show that CISD may be not be as helpful as supportive, empathic interviewing, may be quite distressful for some patients, and may even impede natural recovery.
Drugs to assist sleep may help, but other drugs are generally not indicated.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is recurring, intrusive recollections of an overwhelming traumatic event. The pathophysiology of the disorder is incompletely understood. Symptoms also include avoidance of stimuli associated with the traumatic event, nightmares, and flashbacks. Diagnosis is based on history. Treatment consists of exposure therapy and drug therapy.
When terrible things happen, many people are lastingly affected; in some, the effects are so persistent and severe that they are debilitating and constitute a disorder. Generally, events likely to evoke PTSD are those that invoke feelings of fear, helplessness, or horror. These events might include experiencing serious injury or the threat of death or witnessing others being seriously injured, threatened with death, or actually dying. Combat, sexual assault, and natural or man-made disasters are common causes of PTSD.
Lifetime prevalence approaches 8%, with a 12-mo prevalence of about 5%.
Symptoms and Signs
Most commonly, patients have frequent, unwanted memories replaying the triggering event. Nightmares of the event are common. Much rarer are transient waking dissociative states in which events are relived as if happening (flashback), sometimes causing patients to react as if in the original situation (eg, loud noises such as fireworks might trigger a flashback of being in combat, which in turn might cause patients to seek shelter or prostrate themselves on the ground for protection).
Patients avoid stimuli associated with the trauma and often feel emotionally numb and disinterested in daily activities. Sometimes the onset of symptoms is delayed, occurring many months or even years after the traumatic event. PTSD is considered chronic if present > 3 mo. Depression, other anxiety disorders, and substance abuse are common among patients with chronic PTSD.
In addition to trauma-specific anxiety, patients may experience guilt because of their actions during the event or because they survived when others did not.
Diagnosis
Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR—see Table 6: Anxiety Disorders: Diagnosis of Posttraumatic Stress Disorder).
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Table 6
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| Diagnosis of Posttraumatic Stress Disorder |
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With exclusion of other causes, affirmative answers to the following questions confirm the diagnosis:
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Has the patient experienced or witnessed an overwhelming traumatic event?
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Was the patient's response one of intense fear, helplessness, or horror?
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Does the patient constantly relive the event in any of the following ways?
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Having recurrent, intrusive disturbing memories
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Having recurrent disturbing dreams (eg, nightmares)
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Acting or feeling as if the event were happening again (eg, in hallucinations or flashbacks)
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Feeling intense psychologic or physiologic distress when reminded of the event (eg, by its anniversary or sounds similar to those heard during the event)
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Does the patient persistently avoid stimuli associated with the event, as evidenced by ≥ 3 of the following?
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Avoiding thoughts, feelings, or conversations associated with the event
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Avoiding activities, places, or people that trigger memories of the event
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Being unable to remember significant parts of the event (dissociative amnesia)
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Feeling detached or estranged from other people
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Having limited emotional response (restricted affect)
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Viewing the future as foreshortened (eg, not expecting to have a career or to marry)
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Is the patient experiencing ≥ 2 of the following symptoms of increased arousal (not present before the event)?
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Have symptoms lasted > 1 mo?
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Have symptoms caused substantial distress or interfered with functioning?
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Treatment
If untreated, chronic PTSD often diminishes in severity without disappearing, but some people remain severely impaired. The primary form of psychotherapy used, exposure therapy, involves exposure to situations that the person avoids because they may trigger recollections of the trauma. Repeated exposure in fantasy to the traumatic experience itself usually lessens distress after some initial increase in discomfort. EMDR is a form of exposure therapy that involves following a moving finger while doing exposure in fantasy.Stopping certain ritual behaviors, such as excessive washing to feel clean after a sexual assault, also helps.
Drug therapy, particularly with SSRIs (see Mood Disorders: Selective serotonin reuptake inhibitors (SSRIs)), is effective. Prazosin appears helpful in reducing nightmares. Mood stabalizers and atypical antipsychotics are sometimes prescribed but support for their use is scant.
Because the anxiety is often intense, supportive psychotherapy plays an important role. Therapists must be openly empathic and sympathetic, recognizing and acknowledging patients' mental pain and the reality of the traumatic events. Therapists must also encourage patients to face the memories through desensitizing exposure and learning techniques to control anxiety. For survivor guilt, psychotherapy aimed at helping patients understand and modify their self-critical and punitive attitudes may be helpful.
Last full review/revision July 2012 by John H. Greist, MD
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