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Definition
Acute stress disorder develops within one month after an individual experiences or sees an event involving a threat or actual death, serious injury, or physical violation to the individual or others, and responded to this event with strong feelings of fear, helplessness or horror. The diagnosis was established to identify those individuals who would eventually develop post-traumatic stress disorder. As far back as World War I this condition was referred to as "shell shock," in which there are similarities between reactions of soldiers who suffered concussions caused by exploding bombs or shells and those who suffered blows to their central nervous systems. Civilians may also suffer from it. More recently, ASD was brought to light as it became clear that for a short period, people might exhibit PTSD-like symptoms immediately after a trauma.
Trauma has both a medical and a psychiatric definition. Medically, trauma refers to a serious or critical bodily injury, wound or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. Psychiatrically, trauma has assumed a different meaning and refers to an experience that is emotionally painful, distressful or shocking, which often results in lasting mental and physical effects.
Psychiatric trauma, or emotional harm, is essentially a normal response to an extreme event. It involves the creation of emotional memories about the distressful event that are stored deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk for emotional harm. Thus in a school shooting, for example, the student who is injured probably will be most severely affected emotionally; and the student who sees a classmate shot or killed is likely to be more emotionally affected than the student who was in another part of the school when the violence occurred. But even secondhand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster, even if only through graphic media reports, should be watched for signs of emotional distress.
Symptoms
For a diagnosis of acute stress disorder, symptoms must persist for a minimum of two days to up to four weeks within a month of the trauma.
A person may be described as having acute stress disorder if other mental disorders or medical conditions do not provide a better explanation for the person's symptoms. If symptoms persist after a month, the diagnosis becomes post-traumatic stress disorder.
Symptoms include:
- Lack of emotional responsiveness, a sense of numbing or detachment
- A reduced sense of surroundings
- A sense of not being real
- Depersonalization or a sense of being dissociated from self
- An inability to remember parts of the trauma, "dissociative amnesia"
- Increased state of anxiety and arousal such as a difficulty staying awake or falling asleep
- Trouble experiencing pleasure
- Repeatedly re-experiencing the event through recurring images and/or thoughts, dreams, illusions, flashbacks
- Purposeful avoidance of exposure to thoughts, emotions, conversations, places or people that remind them of the trauma
- Feelings of stress interfering with functioning; social and occupational skills are impaired affecting the patient's ability to function, pursue required tasks and seek treatment
Causes
When a fearful or threatening event is perceived, humans react innately to survive: They either are ready for battle or run away (hence the term "fight-or-flight response"). The nature of the acute stress response is all too familiar. Its hallmarks are an almost instantaneous surge in heart rate, blood pressure, sweating, breathing and metabolism, and a tensing of muscles. Enhanced cardiac output and accelerated metabolism are essential to mobilizing for fast action. This explanation is thought to be in part a cause for anxiety disorders. Yet over the past decade, the limitations of the acute stress response as a model for understanding anxiety have become more apparent. The first and most obvious limitation is that the acute stress response relates to arousal rather than anxiety. Anxiety differs from arousal in several ways: First, with anxiety, the concern about the stressor is out of proportion to the realistic threat. Second, anxiety is often associated with elaborate mental and behavioral activities designed to avoid the unpleasant symptoms of a full-blown anxiety or panic attack. Third, anxiety is usually longer lived than arousal. Fourth, anxiety can occur without exposure to an external stressor. Cognitive factors, especially the way people interpret or think about stressful events, play a critical role in the etiology of anxiety. A decisive factor is the individual's perception, which can intensify or dampen the response. One of the most salient negative cognitions in anxiety is the sense of uncontrollability. It is typified by a state of helplessness due to a perceived inability to predict, control or obtain desired results. These are among the factors considered as causes of anxiety disorders such as acute stress disorder.
Treatment
Cognitive behavioral therapy is the treatment that has met with the most success in combating ASD. It has two main components: First, it aims to change cognitions, patterns of thought surrounding the traumatic incident. Second, it tries to alter behaviors in anxiety-provoking situations.
Cognitive behavioral therapy not only ameliorates the symptoms of ASD, but also it seems to prevent people from developing post-traumatic stress disorder. The chance that a person diagnosed with acute stress disorder will develop PSTD is about 80 percent; the chance that they will develop PTSD after cognitive-behavioral therapy is only about 20 percent.
Psychological debriefing and anxiety management groups are two other types of therapy that have been examined for the treatment of ASD. Psychological debriefing involves an intense therapeutic invention immediately after the trauma, so that traumatized individuals can "talk it all out." In anxiety management groups, people share coping strategies and learn to combat stress together. However, both types of therapy have proven to be largely ineffectual for the treatment of ASD.
Sources:
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
- Anxiety and Its Disorders: The nature and treatment of anxiety and panic (Guilford Press)
- Journal of Consulting and Clinical Psychology
- American Journal of Psychiatry
- Journal of Anxiety Disorders
- Journal of Traumatic Stress
- Journal of Clinical Psychiatry
- War Psychiatry: Textbook of Military Medicine
- Journal of the American Academy of Child and Adolescent Psychiatry
- National Institute of Mental Health
- National Center for PTSD
- Department of Health & Human Services