History

Fact Explanation
History of Stressful/ traumatic event According to DSM-5 Criterion A, a person must have been exposed to one of several situations of extreme stress, prior to onset of symptoms for a diagnosis of Acute Stress Disorder (ASD) to be made. These situations include experiencing an event or events that involved a threat of death, actual or threatened serious injury, or actual or threatened physical or sexual violation of himself or herself, personally witnessing an event or events that involved the actual or threatened death, serious injury, or physical or sexual violation of others, learning of such harm coming to a close relative or close friend or undergoing repeated or extreme exposure to aversive details of unnatural death, serious injury, or serious assault or sexual violation of others.
Anxiety and exaggerated emotional response. Acute stress disorder(ASD) is a psychiatric disorders consisting of physiological and psychological responses resulting from exposure to an event or events involving death, serious injury, or a threat to physical integrity. Emotional response is one of three main components of a normal response to stress, which is exaggerated in ASD. Anxiety is the main emotional response along with restlessness an[1][2]
Numbing and other dissociative symptoms. Numbing is an unexpected absence of feelings about the traumatic event. According to DSM-5, 8 out of 14 symptoms must be present for the diagnosis of ASD. A subjective sense of numbing, detachment from others, or reduced responsiveness to events that would normally elicit an emotional response (B1) and an altered sense of the reality of one’s surroundings or oneself (B2) are the first 2 of these 14 symptoms. [3]
Difficulty in recalling Repression is the exclusion from consciousness of impulses,emotions or memories that would otherwise cause distress. It is an unconscious defense mechanism which is part of the psychological response to stress. Inability to remember at least one important aspect of the traumatic event that was probably encoded (B3) is the 3rd of the 14 symptoms aiding in the diagnosis of ASD according to DSM-5.[1] [2]
Flashbacks, nightmares and illusions Spontaneous or cued recurrent, involuntary and intrusive distressing memories of the event (B4), recurrent distressing dreams related to the event(B5) and dissociative reactions where the individual acts or feels as if the traumatic event were recurring(B6) are 3 out of the 14 symptoms mentioned in DSM-5, for the diagnosis of ASD.
Marked avoidance of stimulus related to stressful event Patients with ASD experience marked distress and sense of reliving the traumatic experience, on exposure to related stimuli. Therefore DSM-5 incorporates the following symptoms into the diagnostic criteria for ASD: -Intense or prolonged psychological distress or physiological reactivity at exposure to external or internal cues which symbolize or resemble an aspect of the traumatic event (B7) - Persistent and effortful avoidance of thoughts, conversations, or feelings that arouse recollections of the trauma (B8) - Persistent and effortful avoidance of activities, places, or physical reminders that arouse recollections of the trauma (B9)
Depression Most stressful and traumatic events are associated with significant loss and threat to self. [2]
Impaired concentration, irritability and insomnia ASD is associated with a heightened emotional response to stress as well as an increased arousal. [1][2]
Autonomic features- palpitations, sweating and tremors Autonomic response is another component of the normal stress response. Exposure to any stressor will activate the hypothalamic-pituitary-adrenocortical system and thereby the sympathoadrenal . This will result in elevation of circulating ephinephrine levels which acts on various receptors to bring about the physical symptoms of increased arousal. [4]
Impaired functioning Some amount of distress and impediment of lifestyle is expected in any stressful situation. The symptoms need have caused clinically significant distress or impairment in occupational, social or other important areas of functioning for a diagnosis of ASD to be made.
References
  1. BRYANT RA, FRIEDMAN MJ, SPIEGEL D, URSANO R, STRAIN J. A review of acute stress disorder in DSM-5. Depress Anxiety [online] 2011 Sep, 28(9):802-17 [viewed 28 May 2014] Available from: doi:10.1002/da.20737
  2. GELDER Michael, MAYOU Richard, GEDDES John. Psychiatry. 3rd Ed. Oxford University Press. 2005
  3. MORGAN CA 3RD, HAZLETT G, WANG S, RICHARDSON EG JR, SCHNURR P, SOUTHWICK SM. Symptoms of dissociation in humans experiencing acute, uncontrollable stress: a prospective investigation. Am J Psychiatry [online] 2001 Aug, 158(8):1239-47 [viewed 30 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11481157
  4. KVETNANSKý R, PACáK K, FUKUHARA K, VISKUPIC E, HIREMAGALUR B, NANKOVA B, GOLDSTEIN DS, SABBAN EL, KOPIN IJ. Sympathoadrenal system in stress. Interaction with the hypothalamic-pituitary-adrenocortical system. Ann N Y Acad Sci [online] 1995 Dec 29:131-58 [viewed 30 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8597393

Examination

Fact Explanation
Mental State Examination: Appearence Features of motor restlessness such as fidgeting movements of hands and feet and sympathoadrenal activation such as sweaty palms. Anxiety features, horizontal lines of the forehead, wide eyed stare etc. Hypervigilance and exaggerated startled response maybe demonstrated due to state of increased arousal and are included in the diagnositic criteria of ASD in DSM-5. Irritable, angry ,aggressive and anti Social behavior can be present.[1]
Mental State Examination: Speech Spontaneous speech may not be present. Patients are unresponsive due to numbing and dissociation. Speech maybe slow and incomprehensible. Refusal/avoidance of any discussions about the traumatic event can be present due to fear of stimulus causing flashbacks and difficulty in recalling events [1] [2]
Mental State Examination: Mood Mood maybe dysphoric(sad,hopeless, depressed) as the stressful event is often associated with loss and the exaggerated emotional response can cause depression.Mood may also be anxious,angry, or apathetic. Blunt or flat affect maybe present if dissociative symptom are prominent.[2] [3]
Mental State Examination: Depersonalization and Derealization Depersonalization is the experience of being unreal, detached and unable to feel emotion, Derealization is experiencing that the environment is unreal and therefore not able to cause any affect in ones self.
Mental State Examination: Thoughts Thoughts are centered around the traumatic event/stressor. Flashbacks, illusions and dreams regarding the event contribute to this.
Mental State Examination: Cognitive function Orientation may not be present if dissociative symptoms are prominent. Attention and concentration will be poor due to increased arousal and heightened emotional response. Dissociative response impedes access to memories and feelings thereby limiting emotional processing. This can cause dissociative amnesia. Also the significant distress caused by symptoms impede functionality in all aspects of lifestyle. [1][3]
Mental State Examination: insight Most affected patients, especially those with dissociative symptoms, do not have any insight.
References
  1. BRYANT RA, FRIEDMAN MJ, SPIEGEL D, URSANO R, STRAIN J. A review of acute stress disorder in DSM-5. Depress Anxiety [online] 2011 Sep, 28(9):802-17 [viewed 28 May 2014] Available from: doi:10.1002/da.20737
  2. GELDER Michael, MAYOU Richard, GEDDES John. Psychiatry. 3rd Ed. Oxford University Press. 2005
  3. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. APA Practice guidelines. [online] December [viewed 28 May 2014] Available from: doi:10.1176/appi.books.9780890423363.52257

Differential Diagnoses

Fact Explanation
Acute stress response A normal stress response develops in response to any traumatic/stressful event. It consists of an emotional response,psychological responses and coping strategies, which are all exaggerated in acute stress disorder. [1] But the diagnosis of acute stress disorder also requires at least three or more dissociative symptoms which are not commonly manifested in a normal acute stress response. The acute stress disorder can also be differentiated from acute stress response by duration of symptoms being a minimum of 2 days to maximum of 4 weeks [2]
Post Traumatic Stress Disorder (PTSD) PTSD is a delayed or extended stress response to following the aftermath of an exceptionally threatening or catastrophic event , which outlasts a period of 4 weeks. [3][4] The temporal limitation to 4 weeks is the main criteria to differentiate acute stress disorder from PTSD.[5]
Adjustment disorder Adjustment disorder is a more gradual response to stressors in life, such as a significant change of lifestyle due to loss, change of role, relationship or psychological issues. It also includes a more wide emotional response including anger, guilt and depression. [2]
References
  1. GELDER Michael, MAYOU Richard, GEDDES John. Psychiatry. 3rd Ed. Oxford University Press. 2005
  2. BRYANT RA, FRIEDMAN MJ, SPIEGEL D, URSANO R, STRAIN J. A review of acute stress disorder in DSM-5. Depress Anxiety [online] 2011 Sep, 28(9):802-17 [viewed 28 May 2014] Available from: doi:10.1002/da.20737
  3. The ICD- !0 classification of Mental and Behavioral Disorders. World Health Organization. 1992
  4. KOREN D, ARNON I, KLEIN E. Acute stress response and post traumatic stress disorder in traffic accident victims: a one-year prospective, follow-up study. Am J Psychiatry [online] 1999 Mar, 156(3):367-73 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10080550
  5. BREWIN CR, ANDREWS B, ROSE S, KIRK M. Acute stress disorder and post traumatic stress disorder in victims of violent crime. Am J Psychiatry [online] 1999 Mar, 156(3):360-6 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10080549

Management - General Measures

Fact Explanation
Ensuring safety Acute stress disorder occurs in response to an exceptional stressor which can be associated with an actual or potential threat. Removal of threat should be the first most priority. All other measure should be carried out once the patient is an environment which is perceived as safe. Hospital admission maybe necessary for acutely disturbed persons.
Provide basic needs In situations where patients are faced with drastic change of environment or lifestyle as a result of stressor, extra measures need to be taken to provide basic needs. [1]
Supportive counselling Acute stress disorder occurs as a result of an exceptional stress and is associated with significant anxiety, fear, emotional instability and functional disability. [1] [2]
Enhancing coping stratergies Maladaptive coping strategies such as regression, repression, aggression and substance abuse need to be discouraged and helpful coping strategies such as ventilation of emotions and social participation should be encouraged.[1] [3]
References
  1. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. APA Practice guidelines. [online] December [viewed 28 May 2014] Available from: doi:10.1176/appi.books.9780890423363.52257
  2. BRYANT RA, SACKVILLE T, DANG ST, MOULDS M, GUTHRIE R. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry [online] 1999 Nov, 156(11):1780-6 [viewed 30 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10553743
  3. GELDER Michael, MAOYU Richard, GEDDES John. Psychiatry. 3rd Ed. Oxford University Press. 2005

Management - Specific Treatments

Fact Explanation
Anxiolytics if arousal symptoms are severe anxiolytic drugs (benzodiazepines) maybe used as short term treatment measures. Also anxiety management also reduces development of post traumatic disorder. [1] [2]
Hypnotics If insomnia is a significant symptom. [2]
Antidepressants: Selective Serotonine reuptake inhibitors (SSRIs) SSRIs reduce symptoms common to both ASD and PTSD such as flashbacks, hyperarousal and numbing. [2]
Cognitive Behavioral Therapy Prolonged imaginal exposure, cognitive therapy and behavioral interventions are coupled with anxiety management to prevent the progression of acute stress disorder to post traumatic stress disorder. [1,3,4]
References
  1. BRYANT RA, SACKVILLE T, DANG ST, MOULDS M, GUTHRIE R. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry [online] 1999 Nov, 156(11):1780-6 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10553743
  2. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. APA Practice guidelines. [online] December [viewed 28 May 2014] Available from: doi:10.1176/appi.books.9780890423363.52257
  3. SIJBRANDIJ M, OLFF M, REITSMA JB, CARLIER IV, DE VRIES MH, GERSONS BP. Treatment of acute posttraumatic stress disorder with brief cognitive behavioral therapy: a randomized controlled trial. Am J Psychiatry [online] 2007 Jan, 164(1):82-90 [viewed 28 May 2014] Available from: doi:10.1176/appi.ajp.164.1.82
  4. ROBERTS NP, KITCHINER NJ, KENARDY J, BISSON JI. Systematic review and meta-analysis of multiple-session early interventions following traumatic events. Am J Psychiatry [online] 2009 Mar, 166(3):293-301 [viewed 30 May 2014] Available from: doi:10.1176/appi.ajp.2008.08040590