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Trigger warning: this episode contains discussion about rape, assult, violence robbery and gun crime.
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Acute stress disorder
Introduction and statistics
Acute stress disorder or acute stress reaction is a mental health condition similar to Post traumatic stress disorder, diagnosed within a month of the traumatic experience occurring. These traumatic events involve a threat or actual death, series injury, physical violation (rape, robbery/assault) to individuals or others
Within one month of a trauma, survivors show rates of Acute Stress Disorder ranging from 6% to 33%.
Rates differ for different types of trauma. For example, survivors of accidents or disasters such as typhoons show lower rates of ASD. Survivors of violence such as robbery, assaults, and mass shootings show rates at the higher end of that range
Prevalence of acute stress disorder:
- Motor vehicle accident – 13% to 21%
- Mild traumatic brain injury – 14%
- Assault – 16% to 19%
- Burn – 10%
- Industrial accident – 6% to 12%
- Witnessing a mass shooting – 33%
- Rape – 94%
Definition of 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. In psychiatry, trauma has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, and which often results in lasting mental and physical effects.
DSM-5 diagnostic criteria
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
- Directly experiencing the traumatic event(s).
- Witnessing, in person, the events(s) as it occurred to others.
- Learning that the traumatic events(s) occurred to a close family member or close friend. Note: In cases of actual or threatened by death of a family member or friend, the events(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the events(s). Note: In children older than 6, there may be frightening dreams without recognizable content.
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). Note: In children, trauma-specific reenactment may occur in play.
- Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic events.
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
- An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing.)
- Inability to remember an important aspect of the traumatic events(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
- Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)
- Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
- Problems with concentration
- Exaggerated startle response
C. The duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or aocohol) or other medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.”
Acute stress reaction F43.0
A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of “daze” with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor – F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.
- Crisis reaction
- reaction to stress
- Combat fatigue
- Crisis state
- Psychic shock
ICD-11 Beta draft
QF64 Acute stress reaction
Acute stress reaction refers to the development of transient emotional, somatic, cognitive, or behavioural symptoms as a result of exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature (e.g., natural or human-made disasters, combat, serious accidents, sexual violence, assault). Symptoms may include autonomic signs of anxiety (e.g., tachycardia, sweating, flushing), being in a daze, confusion, sadness, anxiety, anger, despair, overactivity, inactivity, social withdrawal, or stupor. The response to the stressor is considered to be normal given the severity of the stressor, and usually begins to subside within a few days after the event or following removal from the threatening situation.
- Acute crisis reaction
- Acute reaction to stress
- Post traumatic stress disorder (6B70)
Symptoms fall into the following five categories:
- Intrusion symptoms/re-experiencing the trauma (involuntary and intrusive distressing memories of the trauma or recurrent distressing dreams)
- Negative mood / distress (persistent inability to experience positive emotions such as happiness or love)
- Dissociative symptoms (feeling numb, detached, emotionally unresponsive (daze) time slowing, seeing oneself from an outsider’s perspective, thoughts or feelings don’t seem real or don’t seem like they belong to you, reduced awareness of surroundings)
- Avoidance symptoms (avoidance of memories, thoughts, feelings, people, objects, activities, or places associated with the trauma)
- Arousal symptoms/ anxiety (difficulty falling or staying asleep, irritable behavior, problems with concentration, unable to stop moving/sit still, being constantly tense and on guard, becoming startled too easily)
Who’s at risk?
Several factors can place you at higher risk for developing ASD after a trauma:
- Having gone through other traumatic events
- Having had ASD or PTSD in the past
- Having had prior mental health problems
- Tending to have symptoms, such as not knowing who or where you are, when confronted with trauma
- a history of dissociative symptoms during traumatic events
Cognitive behavioral therapy (CBT) has been shown to have positive results. Research shows that survivors who get CBT soon after going through a trauma are less likely to get PTSD symptoms later.
Another treatment called psychological debriefing (PD) has sometimes been used in the wake of a traumatic event. However, there is little research to back its use for effectively treating ASD or PTSD. I
- SSRI’s or benzodiazepines
Risk of developing PTSD
- The diagnosis was established to identify those individuals who would eventually develop post-traumatic stress disorder.
- Those that do not get ASD can develop PTSD later on and that is 4-13% of people who have suffered a traumatic event.
- 80% of people who are diagnosed with Acute stress disorder go on to develop PTSD
Prevention or more reducing the likelihood of developing Acute Stress Disorder
Early treatment – within hrs of the trauma. People who are at high risk jobs/situations could find benefit from preparation training and counselling to reduce the individual’s risk.
DSM-5 Criteria for PTSD
Full copyrighted criteria are available from the American Psychiatric Association (1). All of the criteria are required for the diagnosis of PTSD. The following text summarizes the diagnostic criteria:
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):
- Intrusive thoughts
- Emotional distress after exposure to traumatic reminders
- Physical reactivity after exposure to traumatic reminders
Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):
- Trauma-related thoughts or feelings
- Trauma-related reminders
Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):
- Irritability or aggression
- Risky or destructive behavior
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
Criterion F (required): Symptoms last for more than 1 month.
Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).
Criterion H (required): Symptoms are not due to medication, substance use, or other illness.
- Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
- Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
- Derealization. Experience of unreality, distance, or distortion (e.g., “things are not real”).
- Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.
Note: DSM-5 introduced a preschool subtype of PTSD for children ages six years and younger.