Acute stress disorder
Definition: Acute stress disorder is characterized by re-experiencing, avoidance, and increased arousal, much like PTSD but last less than 1 month after a trauma. Acute stress disorder is also associated with at least three of the dissociative symptoms.
DSM-IV Diagnostic Criteria for Acute Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) 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.
(2) The person's response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three(or more) of the following dissociative symptoms:
(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness
(2) a reduction in awareness of his or her surroundings (e.g., "being in a daze")
(3) derealization
(4) depersonalization
(5) dissociative amnesia (e.g., inability to recall an important aspect of the trauma)
C. 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.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, exaggerated startle response, and motor restlessness).
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, impairs the individual's ability to pursue some necessary tasks, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
H. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.
POSTTRAUMATIC STRESS DISORDER
Definition: It is a syndrome which develops in a person who sees, hears, witnesses or is involved in a traumatic experiences. The person reacts with intense fear or horror,persistently relives the experience,and tries avoiding being reminded of that traumatic experience. The symptoms must persist more than one month after the traumatic event.
DSM-IV Diagnostic Criteria for Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) 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
(2) the person's response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behaviour
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed
(2) recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content
3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in young children, trauma-specific re-enactment may occur.
(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) Inability to recall an important aspect of the trauma
(4) Markedly diminished interest or participation in significant activities
(5) Feeling of detachment or estrangement from others
(6) Restricted range of affect (e.g., unable to have loving feelings)
(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) Difficulty falling or staying asleep
(2) Irritability or outbursts of anger
(3) Difficulty concentrating
(4) hyper vigilance
(5) Exaggerated startle response
E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed onset: onset of symptoms at least 6 months after the stressor
Epidemiology:
Life time prevalence of posttraumatic stress disorder ranging from
10.4 to 12.3 % in women
5.0 to 6.0 % in men.
Life time prevalence in high risk groups is 5-75%
Young adults are more affected than elderly because of higher exposure to traumatic experience.
Men are prone to experience physical attacks, combat experience, and being threatened with a weapon, held captive, or kidnapped.
Women are prone to experience rape, sexual molestation, childhood parental neglect, and childhood physical abuse.
Risk Factors and Comorbidity
- Women are more likely than men to be exposed to high-impact traumas, or traumas that are associated with a high probability of developing posttraumatic stress disorder.
- Once exposed to traumatic events, a higher proportion of women than men go on to develop the disorder.
- Intense emotional distress to the traumatic event
- The perception of inadequate emotional support.
- History of early separation from parents
- Family history of anxiety and neuroticism
- Pre-existing depression or anxiety.
- Dissociation at the moment of the trauma is one of the best predictors of the ultimate development of posttraumatic stress disorder
- The majority of posttraumatic stress disorder patients had a lifetime history of at least one other psychiatric disorder( dissociative or somatization disorders,and borderline personality disorder )
Etiology:
1-Psychological:
i-Biopsychosocial approach:
The interaction of the stressor ( which should be overwhelming and significant to the person) with the biological, psychological factors and the events that happened before and after the trauma.
ii-Psychoanalytic school:
The external trauma reawakened infantile trauma in these conditions.The new trauma revives the old trauma leading to anxiety, the ego re-experiences the old anxiety, and try to master it and reduce it. If the person is alexythymic (unable to verbalize emotions) he will be unable to alleviate himself under stress.
iii-Cognitive- behavioural school:
Posttraumatic stress disorder is a form of conditioning. The trauma is associated with voices, sights; so an association is made between the trauma and the associated events. Exposure to similar associations elicits the same first anxiety and autonomic symptoms. if particular smells present during the original trauma are later present in more innocuous situations, such as when walking down the street or visiting a friend or relative, the patient may eventually evidence a fear response.
iv-Psychodynamic approach:
Dissociative mechanisms in reaction to the acute trauma.(amnesia, depersonalization, derealisation, and emotional numbness i.e. decreased responsiveness)
Later there is an alteration between:
1-Denial of the event
2- Compulsive repetition (re-experiencing) of the event in the form of flash backs and nightmares etc..This represents a re-enactment in a continuous attempt to gain control.
v- Biological factors:
1-Hyperactivity of the noradrenergic system
Stressful trauma-related sound and visual stimuli were used to challenge patients with PTSD. Plasma epinephrine and norepinephrine concentrations rose with temporal relation to subjective psychophysiological arousal elicited by this material.
- Increased 24-hour urine epinephrine concentrations in veterans with PTSD
- Increased urine catecholamine concentrations in sexually abused girls.
-Platelet a2- and lymphocyte b2-adrenoceptors are downregulated in PTSD, possibly in response to chronically elevated catecholamine concentrations.
Opioid System
-Abnormality in the opioid system is suggested by reduced plasma beta-endorphin concentrations in PTSD.
-patients with chronic PTSD have a reduced pain threshold
Dopaminergic System
Increased concentrations of dopamine plasma and urine have been reported in PTSD.
CRF and the Hypothalamic-Pituitary-Adrenal Axis
Dysfunction of the hypothalamic-pituitary adrenal axis
PTSD patients have more glucocorticoid receptors on lymphocytes. Hyperregulation of the hypothalamic-pituitary adrenal axis in PTSD.
Hypothalamic-Pituitary-Thyroid Axis
-Mean total triiodothyronine (T3) levels are significantly higher in veterans with PTSD than in normal
vi-Genetic factor:
Posttraumatic stress disorder (PTSD) is the least studied anxiety disorder with respect to heritable or genetic contributions.
Diagnosis:
To diagnose PTSD
1-one symptom of reexperiencing
2-three symptoms of avoidance
3-two symptoms of increased autonomic arousal.
4-The symptoms persist for at least one month
Differential Diagnosis:
- Recognizing potentially treatable medical contributors to posttraumatic symptomatology is particularly important, because they are potentially treatable(head trauma, psychoactive substance use disorders or withdrawal syndromes)
- panic disorder
-generalized anxiety disorder
- Major depression as co morbid illness affect treatment of PTSD
- Borderline personality disorder
- Dissociative disorders
- Factitious disorders.
Course and prognosis:
Acute PTSD lasts less than three months.
Chronic PTSD lasts three months or longer.
PTSD fluctuates overtime and increases with stressors
Without treatment
30% recover completely
40% mild symptoms
20% moderate symptoms
10% persistent or chronic course
After one year 50% will recover.
Good prognostic factors:
Rapid onset of symptoms
- Short duration of symptoms(less than 6 months)
- Good premorbid functioning
- Strong social support(decrease the incidence,decrease the intensity of symptoms,help recovery)
- Absence of physical, mental, and substance related disorders.
N.B Extreme of ages are vulnerable to traumas
The young have less coping mechanisms than adult
The old are rigid and less flexible than adult in coping in addition they are more liable to physical disabilities.
Treatment:
1-Cognitive behaviour therapy and stress management skills, especially for avoidance, denial, and emotional numbness.
stress management skills are: self-observation, cognitive restructuring, relaxation training, time management, and problem solving.
2-Pharmacotherapy:
Selective serotonin re-uptake inhibitors are the first line of treatment (safe and effective)
Tricyclic antidepressants
The drug should be continued for one year they are effective for depression anxiety and hyperarousal
Alpha and beta blockers
Anticonvulsants
Monoamine oxidase inhibitors
Combined treatment i.epsychotherapy and drugs may be superior to either treatment
1