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Acute stress reaction and post-traumatic stress disorder

Essentials

  • The psychological responses to highly traumatic events are usually divided into two categories: stress reactions and stress disorders.
    • A stress reaction is in principle a normal reaction to an excessively traumatic event and does not always require medical care. An acute stress reaction is not anymore a diagnosis, but instead it is regarded as a factor affecting a person's state of health.
    • A stress disorder usually requires medical intervention.
  • Consider the possibility of post-traumatic stress disorder if the patient has experienced an exceptionally stressful and psychologically traumatic incident or event within the past six months.

Epidemiology

  • After a major disaster 50–90% of those involved will experience at least a brief stress shock, which usually matches with the symptom pattern of an acute stress reaction. Symptoms in the acute phase do not necessarily predict the development of long-term disorders.
  • It has been estimated that the lifetime incidence of post-traumatic stress disorder (PTSD) is 1–11%, depending on the group being studied and the sex of the individual. In addition, up to 15% of the population will experience milder forms of the condition. The proportion of affected individuals may be considerably higher in predisposed populations.
  • Stress disorders occur among people of all ages, including children.
  • Typical causes for the disorder include major accidents, acts of war and terrorism, witnessing or experiencing violence and, among women, rape.
  • A clear majority of the patients with PTSD also experience one or two other associated mental health disorders during their lifetime, usually alcoholism or an affective disorder.

Acute stress reaction

Symptoms

  • Transient physical and emotional symptoms of generalized anxiety disorder emerge immediately after an severely stressful experience, possibly including specific symptoms connected with mood and social behaviour, and alleviating within a few days after the exposure has subsided.

Differential diagnosis and investigations

  • Similar acute symptoms may also be attributable to a physical illness, poisoning or a complication of an injury.
  • Panic disorder
  • Diagnosis is based on observing and listening to the patient.

Treatment

  • In the case of a major incident the general guidelines detailed below are to be followed.
  • Hypnotics or short-acting benzodiazepines may be prescribed for a couple of days to treat sleep disorders and anxiety symptoms.

Acute stress disorder (DSM-5)

Symptoms

  • The symptoms are the same as in post-traumatic stress disorder but they occur 2–28 days after the stressful event and, moreover, often also dissociative symptoms are present.

Treatment

  • Stabilisation of intense stress responses, an offer of further contact and psychosocial support as well as help with coping skills
  • In severe cases, antidepressant medication and/or focused cognitive behavioural psychotherapy may be commenced as in PTSD.

Psychological first aid and follow-up after a major incident

General guidelines

  • Proximity
  • Immediacy
  • Expectancy
  • Simplicity

Guidelines for psychological first aid

  • Help people meet basic needs (food, shelter, urgent medical care)
  • Listen to people who wish to share their experiences. Remember, there is no ”right” or ”wrong” way to feel or experience events.
  • Try to remain friendly, compassionate and realistically hopeful even if people are difficult or demanding.
  • Give as accurate information as possible about the accident or disaster and the rescue operations underway.
  • Help people contact friends and family members.
  • Keep families together whenever possible.
  • Give practical advice that steers people towards helping themselves.
  • Encourage and guide people towards meeting their own needs if possible.
  • Help people to contact local authorities and organisations.
  • Remind people that help and support is on its way (if you know this to be the case).

Instructions particularly for doctors

  • If possible, consider the possibility of multiple injuries and pay attention to physical or mental illnesses that were present before the time of the disaster.
  • Delegate the psychological first aid to trained volunteers of the rescue team (para-professional workers) as much as possible.
  • Transfer people in severe stress shock to a designated treatment area to be cared for and observed by the crisis team. Aim to identify panic-prone victims to avoid the spread of panic.
  • If possible, restrain from using psychopharmacological drugs, and do not use alcohol for medicinal purposes.
  • Act calmly and be an example to others.

Organising psychological follow-up

  • The arrangement of medical-psychological intervention, i.e. psychological follow-up, is the responsibility of the health care professionals. Para-professional workers may continue to offer some of the psychological support.
  • In order to promote the self-directed coping of the victims, written and electronic information should be freely available, meetings and discussions should be arranged etc.
  • Those with severe stress-related symptoms at the onset should be referred to the care of their health centre or to their occupational health crisis management team or similar.
  • A stress defusing session should be arranged for the rescue and medical personnel who have been involved in a stressful rescue operation, usually on the day of the incident or within 24 hours. Demobilisation is arranged when the rescue operations are fully completed.
  • A psychological debriefing session can be arranged as needed for groups of working personnel (10–15 persons per group) 1–5 days after the incident, particularly if the same group of people is going to work together in the future. Debriefing may improve the group’s future work capacity.
  • In some cases, debriefing may also be beneficial for a homogeneous group of victims, for example workers at an industrial site, who are going to continue working together after the incident. Participation in psychological debriefing is entirely voluntary (unless it forms a part of a person’s professional duties).
  • Group debriefing sessions do not replace the need for individual crisis intervention, nor is there evidence that psychological debriefing is effective in preventing the development of PTSD.
  • Debriefing should not be used as psychological follow-up after more commonplace disturbing events, where adequate information, counselling and an opportunity to talk with a professional should usually be considered as appropriate support for the victims and their family.
  • Further therapy primarily in groups may be offered in the form of peer support guided by an appropriately trained professional.
  • Those in need of guidance, help or other support provided by the social services should be referred to the care of appropriate personnel.
  • Organization of rehabilitation should be early dealt with if the psychosocial problems become prolonged. Specific rehabilitation for PTSD is often poorly available.

Post-traumatic stress disorder (PTSD): symptoms and diagnosis

Symptoms

  • Persistent re-experiencing of the traumatic event
    • Recurrent distressing recollections of the event
    • Nightmares of the event
    • Dissociative flashback episodes and a sense of reliving the event
    • Intense distress when exposed to reminders of the traumatic event
    • Physiological reactions when exposed to stimuli resembling an aspect of the traumatic event
  • Avoidance of stimuli associated with the trauma and numbing of general responsiveness
    • Efforts to avoid thoughts, feelings, activitites, places or people associated with the trauma
    • Inability to recall important aspects of the trauma
    • Diminished interest in significant activities, feeling of detachment, restricted range of mood, sense of foreshortened future
  • Persistent symptoms of emotional sensitisation and hyperalertness
    • Difficulty falling or staying asleep
    • Irritability or outbursts of anger
    • Concentration difficulties
    • Hypervigilance
    • Exaggerated startle response
  • In the DSM-5 criteria adopted in 2013, also negative alterations in cognition and mood have been introduced as an own group of symptoms.
  • The diagnosis of PTSD can usually be considered when the symptoms have persisted for 4 weeks or longer. The delay between the traumatic event and the onset of symptoms should not exceed 6 months because the causal connection is usually doubtful thereafter.
  • The criteria for PTSD diagnosis specify that the person must have been exposed to an event or series of events of an exceptionally threatening or catastrophic nature. The diagnosis also necessitates that the disorder significantly impairs social relations, working life or some other important area of functioning.
  • The ICD-11 version for preparing implementation in WHO Member States, released in 2018 and to be endorsed by Member States in May 2019 http://www.who.int/classifications/icd/revision/timeline/en/, includes now also complex PTSD, which, in addition to the core symptoms described above, also involves trauma-related long-lasting problems particularly in emotional life and social relations.

Differential diagnosis

  • Generalized anxiety disorder without the impact of a preceeding traumatic event
  • Panic disorder
  • Dissociative disorder
  • Specific phobia
  • Prolonged depressive reaction after trauma
  • Adjustment disorders and other reactions to severe stress
  • Relapse of a mental disorder following exposure to stress

Diagnostic examination

  • A careful interview with the patient and a detailed history of the symptoms, preferably with the aid of standardized questionnaires
  • An examination by a clinical psychologist
  • Exclusion of physical causes of autonomic hyperactivity (e.g. hyperthyroidism, factors causing excessive adrenaline secretion, use of stimulants)

Post-traumatic stress disorder: treatment

Psychotherapy

  • A therapeutic relationship with a psychotherapeutic component offered by, for example, the primary health care or occupational health services; this type of intervention involves the monitoring of the patient and an opportunity to talk with staff members trained in crisis management, but not yet care by a professionally trained psychotherapist.
  • Supportive contact therapy carried out by a primary care physician, often combined with pharmacotherapy.
  • In severe cases, early intervention with brief cognitive behavioural therapy/exposure therapy in a mental health unit or by a private therapist.
  • An inpatient period of investigations and treatment in a psychiatric ward of a general hospital, or in an open ward of a psychiatric hospital, for patients with poor treatment response or whose functional capacity is significantly impaired.
  • If the disorder lasts for more than three months, trauma-focused cognitive behavioural therapy (see (Cognitive psychotherapy)) or eye movement desensitisation and reprocessing (EMDR) in a mental health unit or by a private therapist [Evidence Level: C].

Pharmacotherapy

  • For lowering initial anxiety and improving sleep, normal doses of benzodiazepines may with strict deliberation be used in the initial phase with the aim to reduce and withdraw medication rapidly. Benzodiazepines are not beneficial in longer-term use, and the risk of developing dependence is particularly high.
  • Antidepressants [Evidence Level: C]. Suggested order:
    • selective serotonin reuptake inhibitors (SSRI; primarily paroxetine or sertraline) [Evidence Level: C]
    • serotonin-noradrenaline reuptake inhibitors (primarily mirtazapine or venlafaxine)
    • amitriptyline (if the above-mentioned are not suitable).
  • Medication is started with a small initial dose which is gradually increased whilst monitoring the patient for the emergence of possible adverse effects. The correct medication is usually found by trial and error. In PTSD, significant response may be achieved with antidepressants, even in cases where the patient has no obvious symptoms of depression.
  • In prolonged sleep disorders, an antidepressant at bedtime is preferable.
  • Beta-blockers (particularly propranolol), clonidine or other drugs that lower sympathetic activity can be tried for symptoms of autonomic hyperarousal.
  • In PTSD, the patient's proneness to self-treatment with alcohol should be borne in mind.
  • In persistent cases, the combination of psychotherapy and pharmacotherapy is often beneficial. However, psychotherapy remains the treatment of choice.

Evidence Summaries


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Citation

"Acute Stress Reaction and Post-traumatic Stress Disorder." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/456830/all/Acute_stress_reaction_and_post_traumatic_stress_disorder.
Acute stress reaction and post-traumatic stress disorder. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/456830/all/Acute_stress_reaction_and_post_traumatic_stress_disorder. Accessed March 24, 2019.
Acute stress reaction and post-traumatic stress disorder. (2019). In Evidence-Based Medicine Guidelines. Available from https://evidence.unboundmedicine.com/evidence/view/EBMG/456830/all/Acute_stress_reaction_and_post_traumatic_stress_disorder
Acute Stress Reaction and Post-traumatic Stress Disorder [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2019 March 24]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/456830/all/Acute_stress_reaction_and_post_traumatic_stress_disorder.
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TY - ELEC T1 - Acute stress reaction and post-traumatic stress disorder ID - 456830 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/456830/all/Acute_stress_reaction_and_post_traumatic_stress_disorder PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -