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Acute Stress Disorder

By

John W. Barnhill

, MD, Weill Cornell Medical College and New York Presbyterian Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
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Acute stress disorder is a brief period of intrusive recollections occurring within 4 weeks of witnessing or experiencing an overwhelming traumatic event.

In acute stress disorder, people have been through a traumatic event, experiencing it directly (eg, as a serious injury or the threat of death) or indirectly (eg, witnessing events happening to others, learning of events that occurred to close family members or friends). People have recurring recollections of the trauma, avoid stimuli that remind them of the trauma, and have increased arousal. Symptoms begin within 4 weeks of the traumatic event and last a minimum of 3 days but, unlike posttraumatic stress disorder, last no more than 1 month. People with this disorder may experience dissociative symptoms.

Diagnosis

  • Clinical criteria

Diagnosis is based on criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); these criteria include intrusion symptoms, negative mood, and dissociative, avoidance, and arousal symptoms.

To meet the criteria for diagnosis, patients must have been exposed directly or indirectly to a traumatic event, and ≥ 9 of the following must be present for a period of 3 days up to 1 month:

  • Recurrent, involuntary, and intrusive distressing memories of the event

  • Recurrent distressing dreams of the event

  • Dissociative reactions (eg, flashbacks) in which patients feel as if the traumatic event is recurring

  • Intense psychologic or physiologic distress when reminded of the event (eg, by entering a similar location, by sounds similar to those heard during the event)

  • Persistent inability to experience positive emotions (eg, happiness, satisfaction, loving feelings)

  • An altered sense of reality (eg, feeling in a daze, time slowing, altered perceptions)

  • Inability to remember an important part of the traumatic event

  • Efforts to avoid distressing memories, thoughts, or feelings associated with the event

  • Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) associated with the event

  • Sleep disturbance

  • Irritability or angry outbursts

  • Hypervigilance

  • Difficulty concentrating

  • Exaggerated startle response

In addition, manifestations must cause significant distress or significantly impair social or occupational functioning and not be attributable to the physiologic effects of a substance-related or another medical disorder.

Treatment

  • Self-care
  • Debriefing or supportive interviewing by professionals

  • Medication 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 in people who were involved in or witnessed a traumatic event, some experts recommend systematic debriefing to help guide the process. Other experts have expressed concern about widespread debriefing, especially since some studies show that debriefing may be quite distressing for some patients and may impede natural recovery.

Drugs to assist sleep may help, but other drugs are generally not indicated.

Self-care

Self-care is crucial during and after a crisis or trauma. Self-care can be divided into 3 components:

  • Personal safety

  • Physical health

  • Mindfulness

Personal safety is fundamental. After a single traumatic episode, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek the guidance of experts on how they and their loved ones can be as safe as possible.

Physical health can be put at risk during and after traumatic experiences. As much as possible, the at-risk person should try to maintain a healthy schedule of eating, sleeping, and exercise. Drugs that sedate and intoxicate (eg, alcohol) should be used sparingly, if at all.

A mindful approach to self-care aims to reduce the stress, boredom, anger, sadness, and isolation that traumatized people normally experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, for example, get up, shower, get dressed, go outside and take a walk, prepare and eat regular meals.

Community involvement can be crucial, even if maintenance of human connection is difficult during a crisis.

It is useful to practice familiar hobbies as well as activities that sound fun and distracting: draw a picture, watch a movie, cook.

Stretching and exercise are terrific, but it can be equally helpful to sit still and count one's own breaths or listen carefully for surrounding sounds. People can become preoccupied with the trauma or crisis, and so it is useful to choose to think of other things: read a novel or get engaged with a puzzle. Unpleasant emotions may typically feel "frozen" during and after a trauma, and it can be a relief to find activities that shift the feeling state: laugh, watch a fun movie, do something silly, draw with crayons.

Under stress, people can become short-tempered, even with people they care about. Spontaneous kindness can be a win/win solution for everyone: sending a nice note, making someone cookies, and offering up a smile may not only be a nice surprise for the recipient, but such actions can reduce the hopelessness and passivity that tend to be part of the sender's experience of trauma.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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