Acute Stress disorder


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Acute Stress disorder

SYMPTOMS

Acute stress disorder is most often diagnosed when an individual has been exposed to a traumatic event in which both of the following were present: The person 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

The person's response involved intense fear, helplessness, or horror

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

  • 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")
  • Derealization
  • Depersonalization
  • Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
  • The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

Acute stress disorder is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, people). The person experiencing acute stress disorder also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

For acute stress disorder 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 acute stress disorder 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 can not be better explained by a a Brief Psychotic Disorder.

Criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Acute stress disorder is characterized by panic reactions, mental confusion, dissociation, severe insomnia, suspiciousness, and being unable to manage even basic self care, work, and relationship activities. Relatively few survivors of single traumas have this more severe reaction, except when the trauma is a lasting catastrophe that exposes them to death, destruction, or loss of home and community. Treatment includes immediate support, removal from the scene of the trauma, use of medication for immediate relief of grief, anxiety, and insomnia, and brief supportive psychotherapy provided in the context of crisis intervention.


DISTINGUISHING ACUTE TRAUMA FROM PTSD

Discussion with professionals who work with both the acute and the long-term aftermath of trauma has led me to conclude that aside from physical injury due to trauma, acute traumatic reactions may be indistinguishable from PTSD in the body and behavior of the victim. The same disorientation, fear, and indications of ANS activations - elevations in heart rate, blood pressure, respiration, shaking, etc. - may be present.

In the aftermath of a disaster, for example, most of those suffering from acute trauma will be easy to spot. Those who have been injured will be obvious. Among the uninjured there will also be many who look stunned, appear pale and faint, or be shaking. Some of those who appear to be suffering from trauma may not even be the actual victims of the disaster, but witnesses or rescuers who may be deeply affected by what they have or are seeing. Some may not be immediately identifiable, they may be highly active - looking for others or after others, organizing help and rescue. A percentage of these may, in the next days or weeks, develop symptoms of trauma.

Months or years later, the vast majority of the survivors, witnesses and rescuers will no longer be suffering psychologically from the after effects of the event. However, a minority will be suffering to an extreme degree, their lives decreased in quality, and a diagnosis of PTSD will be appropriate.

While symptoms of acute trauma and PTSD may not differ very much, response to these must differ significantly. Response to acute trauma may include emergency medical intervention for treatment of injuries and/or medical shock. On the psychological side reassurance and comfort will be the key. Often talking about what happened will be important for the survivor in the immediate aftermath of the event. Telling and re-telling the story to caring individuals may help prevent dissociation, and aid in integrating the experience. Providing physical support - holding, an arm around the shoulders, a comforting hand - may be appropriate, especially if the survivor is hysterical or shaking violently. The victim may be cold and in need of blankets and warm beverages. The victim may need to be reminded that the event is passed and they have survived it, "You're safe now." The more complete and appropriate the response to acute trauma, the greater the chance of preventing subsequent PTSD.

Later, working with those who do develop PTSD may resemble some of the aspects of response to acute trauma. Certainly a reassuring and comforting attitude on the part of the psychotherapist is important. But when the trauma is long past, simple comfort and reassurance will not be enough. The victim of PTSD will feel unable to contain his traumatic experience(s), will have become afraid of his body, and will have lost the sense of what was then and what is now. It is these three areas - containment, positive body awareness, dual time awareness - that must first be strengthened, before addressing the memory of a traumatic event can be done productively.

Containment of out-of-control emotions and thinking processes will help restore a feeling of control over the psychological self. Positive body-awareness will help restore a sense of the body and its sensations as friend, not foe. Dual time awareness will help to separate that the trauma occurred in the past even though it feels as if it is occurring now (Rothschild 1996, Rothschild 1997).

    CONCLUSION

Identification of a portion of those suffering from PTSD will be straightforward. But others may be difficult to spot owing to complicated life or defensive systems. Evaluation of the state of the ANS will assist in diagnosis and in setting treatment objectives where appropriate.


Possible books to learn more about PTSD.

Brett, EA, "The Classification of Posttraumatic Stress Disorder," in van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.), TRAUMATIC STRESS: THE EFFECTS OF OVERWHELMING EXPERIENCE ON MIND, BODY AND SOCIETY, Guilford Press 1996.

Diamond, MC, Scheibel, AB, & Elson, LM, THE HUMAN BRAIN COLORING BOOK, Harper Perenial 1985.

Elliott, Diana M, "Traumatic Events: Prevalence and Delayed Recall in the General Population," Journal of Consulting and Clinical Psychology, 65, 811-820, 1997.

Figley, Charles R., Ph.D., TRAUMA AND ITS WAKE, Volume I: The Study and Treatment of Post-Traumatic Stress Disorder, Brunner/Mazel, 1985.

Gallup, Gordon G., Jr., and Maser, Jack D., "Tonic Immobility: Evolutionary Underpinnings of Human Catalepsy and Catatonia", in Seligman, Martin E. P., and Masser, Jack D., PSYCHOPATHOLOGY: EXPERIMENTAL MODELS, San Francisco: W.H. Freeman and Company, 1977.

Herman, Judith L., MD, TRAUMA AND RECOVERY, Basic Books, 1992.

J˙rgensen, Steen, Cand. Psych., "Bodynamic Analytic Work with Shock/Post-Traumatic Stress", Energy and Character, Vol. 23, No. 2, September 1992.

Kluka, RA, Schlenger, WE, Fairbank, JA, Hough, RL, Jordan, BK, Marmar, CR,, & Weiss, DS, TRAUMA AND THE VIETNAM WAR GENERATION: REPORT OF FINDINGS FROM THE NATIONAL VIETNAM VETERANS READJUSTMENT STUDY, New York: Brunner/Mazel 1990.

Levine, Peter, Ph.D., WAKING THE TIGER : HEALING TRAUMA : THE INNATE CAPACITY TO TRANSFORM OVERWHELMING EXPERIENCES, 1997

Loewenstein, Richard, J., M.D., "Dissociation, Development and the Psychobiology of Trauma", Journal of the American Academy of Psychoanalysis, 21(4), 1993.

Marmar, CR, Weiss, DS, Schlenger, WE, Fairbank, JA, Jorday, K, Kulka, RA, & Hough, RL, "Peritraumatic Dissociation and Posttraumatic Stress in Male Vietnam Theater Veterans," American Journal of Psychiatry , 151, 1994.

Nadel, L & Jacobs, WJ, "The role of the Hippocampus in PTSD, panic, and phobia." In N. Kato (Ed.), HIPPOCAMPUS: Functions and clinical relevance. Amsterdam: Elsevier Science B.V. 1996.

Ornstein, Robert & Thompson, Richard, THE AMAZING BRAIN, Houghton Mifflin, USA, 1986

Puglisi-Allegra, Stephan, and Oliverio, Alberto, PSYCHOBIOLOGY OF STRESS, Kluwer Academic Publishers, 1990.

Selye, Hans, M.D., THE STRESS OF LIFE, McGraw-Hill Book Co., 1984.

van der Kolk, Bessel A, M.D., and Fisher, Rita E., Ed.M., "The Biologic Basis of Posttraumatic Stress", Primary Care, Vol. 20, No. 2, 1993. van der Kolk, Bessel, M.D. (1996a), "The Body Keeps the Score: Memory and the Evolving Psychobiology of Post-traumatic Stress", Harvard Psychiatric Review, Vol., 1, 1994.

van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.) TRAUMATIC STRESS: THE EFFECTS OF OVERWHELMING EXPERIENCE ON MIND, BODY AND SOCIETY Guilford Press 1996.


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