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UWorld Library/ Psychiatry

Acute Stress Disorder

Introduction

Acute stress disorder (ASD) is a severe anxiety response to a life-threatening event that is characterized by reexperiencing trauma, dissociation, negative mood, avoidance, and hyperarousal.  ASD symptoms typically start immediately after a traumatic event; they must last at least 3 days and up to 1 month for diagnosis.  Treatment of ASD may decrease the likelihood of progression to posttraumatic stress disorder (PTSD), which can occur if symptoms persist for more than 1 month after a trauma event.

Epidemiology and risk factors

The prevalence of ASD within 1 month of trauma exposure varies depending on the nature of the event.  About 10%-20% of individuals develop ASD in response to an event that does not involve interpersonal assault (eg, motor vehicle collision, severe burn injury), and about 20%-50% of individuals develop ASD after being exposed to an interpersonal trauma (eg, mass shooting, rape). ASD is more common in female patients, which may be partly related to a higher likelihood of exposure to interpersonal trauma.

Risk factors that may increase the likelihood of developing ASD after trauma exposure include:


  • Severity of trauma
  • Close proximity to trauma (eg, self vs relative/witness)
  • Previous trauma exposures
  • History of a psychiatric condition prior to trauma
  • Avoidant style of coping with stress (eg, denial, substance use)

Clinical presentation

Patients with ASD present in many different ways, and for some, symptom onset may be delayed.  Most patients reexperience the trauma in some way (eg, trauma-related nightmares, intrusive memories of the event) and have a high level of reactivity to trauma cues (eg, panic attacks, startle response). Somatic symptoms (eg, sleep disturbances, headaches, heart palpitations) are common.

Patients may be reluctant to describe the traumatic event due to discomfort caused by memories of the trauma.  Dissociative symptoms can also occur, resulting in patients being unable to recall aspects of the trauma or associated feelings.  Some patients may experience excessive guilt associated with the trauma (eg, feeling responsible for the event or for not preventing the event, feeling weak for experiencing symptoms).

Diagnosis

For a diagnosis of ASD, the following criteria must be met:

Exposure to actual or threatened death, serious injury, or sexual violation in at least 1 of the following ways:


  • Having direct experience of a traumatic event (eg, sexual violence, earthquake)
  • Witnessing, in-person, the event as it occurred to others (eg, witnessing domestic violence or a fatal vehicle collision)
  • Learning that the event occurred to a close family member or friend
  • Experiencing repeated or extreme exposure to details of a traumatic event (eg, pathologist repeatedly performing autopsies on severely injured bodies)

Presence of ≥9 of the following symptoms, lasting at least 3 days and up to 1 month after exposure to trauma:


  • Intrusion symptoms
    • Recurrent, involuntary, and intrusive distressing memories of the trauma
    • Recurrent distressing dreams that relate to the trauma through content or affect (ie, frightening dreams not involving the trauma)
    • Dissociative reactions that are experienced as if the trauma is recurring (eg, flashbacks)
    • Intense emotional distress or physiological reaction in response to trauma cues (eg, storm clouds causing fear in child who experienced a tornado)
  • Negative mood
    • Persistent inability to experience positive emotions (eg, unable to feel happiness or excitement)
  • Dissociative symptoms
    • An altered sense of reality about the current environment (derealization) (eg, sensation that time is slowed) or self (depersonalization) (eg, out-of-body experience)
    • Inability to remember important aspects of the traumatic event (dissociative amnesia)
  • Avoidance symptoms
    • Efforts to avoid distressing memories, thoughts, or feelings related to the traumatic event (eg, excessive alcohol use)
    • Efforts to avoid cues that cause distressing memories, thoughts, or feelings (eg, not going out at night after being robbed)
  • Arousal symptoms
    • Sleep disturbance
    • Concentration difficulties
    • Irritability and angry outbursts (may involve physical or verbal aggression toward people or objects)
    • Hypervigilance
    • Exaggerated startle response

Differential diagnosis

  • PTSD:  This condition is also characterized by an impairing stress response resulting from actual/threatened death or injury; however, the duration of PTSD symptoms must be greater than 1 month.
  • Adjustment disorder:  This disorder also consists of an acute response to a stressor; however, the stressor can be of any severity (eg, moving, divorce) and is not typically associated with intrusive distressing memories or avoidance behaviors.

Management

Evaluating a patient who recently experienced a trauma requires patience, validation, and empathy.  General principles to consider during an evaluation include:


  • Gauge the patient's interest in talking about the traumatic experience
  • Follow the patient's lead and allow sharing of the narrative of what occurred
  • Avoid pushing for details or asking a series of closed-ended questions
  • Normalize the stress response
  • Provide psychoeducation on physical and emotional responses to trauma
  • Arrange regular follow-up appointments to monitor symptoms and provide support
  • Encourage contact with family, friends, and other social supports

Treatment goals for ASD include symptom reduction and decreasing the likelihood of progression to PTSD.  Trauma-focused cognitive-behavioral therapy (CBT) is a first-line intervention for ASD, and pharmacotherapy with benzodiazepines is reserved for specific cases as an adjunct to psychotherapy.


  • Trauma-focused CBT:  A first-line treatment for ASD, CBT consists of increasing coping skills, identifying and reframing cognitive distortions (eg, the world is unsafe), and exposing patients to trauma cues in a controlled manner.
  • Benzodiazepines:  These drugs may be appropriate for intense anxiety, agitation, or sleep disturbances; the lowest effective dose for a maximum of 4 weeks is recommended to prevent harm and not impede recovery (ie, develop tolerance and inhibit processing trauma during therapy).

ASD is associated with an elevated suicide risk and warrants screening for suicidal ideation, assessment of risk factors, and safety planning.

Prognosis

With appropriate intervention, ASD symptoms may remit and not progress to PTSD; however, 40%-80% of patients diagnosed with ASD progress to PTSD.

Summary

Acute stress disorder (ASD

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develops in response to life-threatening trauma and is characterized by intrusive experiences, arousal, dissociative symptoms, avoidance of traumatic reminders, and negative mood.  ASD symptoms typically start immediately after a traumatic event and must last at least 3 days and up to 1 month for diagnosis.  First-line treatment includes trauma-focused cognitive-behavioral therapy, which reduces ASD symptoms and decreases the probability of developing posttraumatic stress disorder.