Trauma & Acute Stress Reaction
Pages 277-281 from the Management of Mental Disorders, published by World Health Organization, Sydney, Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.
Acute stress reaction is a transient condition that develops in response to a traumatic event. The symptoms of acute stress reaction begin within minutes of the traumatic event and disappear within days (even hours). Symptoms include a varying mixture of:
* An initial state of `daze’ · Narrowing of attention
* Reduced levels of consciousness · Disorientation
* Agitation or overactivity · Depression
* Withdrawal · Amnesia
* Anxiety symptoms (e.g., sweating, increased heart rate, flushing)
The traumatic events that can lead to an acute stress reaction are of similar severity to those involved in post-traumatic stress disorder (see Section 4.9).
According to the World Health Organization’s (WHO) International Classification of Diseases (ICD)-10th Edition, acute stress reaction is diagnosed when:
* The individual has been exposed to a traumatic event.
* Symptoms begin within 1 hour of the traumatic experience.
* Relevant symptom criteria are met (see ICD-10 for details)
* Symptoms begin to diminish within 2 days.
* The reaction occurs in the absence of any other mental or behavioural disorder.
The diagnostic criteria for this condition as outlined in DSM-IV (acute stress disorder) differ quite markedly from those required by ICD-10. For example, according to DSM-IV:
* The disturbance occurs within 4 weeks of the traumatic event and lasts anywhere from 2 days to 4 weeks.
* The individual experiences distress on exposure to reminders of the trauma, or the event is re-experienced through dreams, imagery, illusions, or flashbacks.
* There is a marked avoidance of stimuli that trigger memories of the trauma (e.g., people, places, thoughts).
For further detail about diagnostic criteria for this disorder, refer to ICD-10 or DSM-IV.
Adjustment disorder involves a short term anxiety reaction to a life stressor, however, in adjustment disorder the stressor (e.g., such as loss of a job, a relationship break-up) is usually less traumatic than in acute stress reaction.
Acute stress reaction should not be diagnosed if the symptoms are simply an exacerbation of existing symptoms of another psychiatric disorder (with the exception of personality disorders).
By definition, acute stress reaction disappears within days and often within hours of the stressor. Individual vulnerability and coping style may affect the severity and occurrence of acute stress reaction since most individuals who are exposed to major stressors do not develop this disorder.
4.8.2 Management plan for acute stress reaction
Management strategies will always vary from one individual to the next depending on the individual’s particular problems. However, the management of acute stress reaction generally involves:
1. Help with the removal of any ongoing traumatic event. This help could involve minimising further traumas that may arise from the initial traumatic event. For example, practical assistance with finding safe accommodation if necessary or protecting against further loss (possessions, job) (See Section 1.1.9 – Structured Problem Solving).
2. Discussion about what happened during the traumatic event: (e.g., what was seen, how the individual acted or felt, or what he or she thought at the time). Discussion may help the individual reduce any negative appraisals of his or her reaction during the experience. For example, some individuals may feel guilty about their sense of helplessness during the trauma (e.g., that they did not do anything to stop the trauma). These negative appraisals are a common reaction to a traumatic event. In most cases it is highly unlikely that, when faced with such a trauma, the individual could have acted in any other way.
3. Provision of education about the typical responses to a traumatic event and guidelines for how to best cope in the hours and days following the event (see Section 4.14.10).
4. Encourage the individual to confront the trauma by talking about the experience to family and friends.
5. Time. Reassure the individual that the acute stress reaction is likely to pass in a short period of time.
6. Social support will be critical for helping the individual cope after a trauma has occurred. It may be necessary to identify potential sources of support and facilitate support from others (e.g., partners, family, friends, work colleagues, and work supervisors).
7. Use of simple relaxation methods. These methods provide effective and productive ways of coping with the anxiety and tension associated with the stress reaction (e.g., breathing control (Section 4.1.2), exercise, relaxation (Section 4.1.3), or pleasant activities).
8. Encourage the individual to gradually confront situations associated with the traumatic event (e.g., returning to work but perhaps only for a few hours at a time).
9. Advise the individual not to use drugs or alcohol to cope with his or her reaction to the trauma. Instead, encourage the individual to use simple relaxation methods as per item 7 above.
10. Ensure that the individual receives follow-up consultations. Persistent symptoms may require more specialised treatment and a revised diagnosis of Post-Traumatic Stress Disorder and/or depression.
4.9 Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is characterised by the development of a long-lasting anxiety response following a traumatic or catastrophic event. Typically, the individual experiences or witnesses a traumatic event such as actual or threatened death, serious injury to oneself or another person, or a threat to the personal integrity of oneself or others. The individual’s response involves helplessness, intense fear, or horror.
Typical traumatic events include: violent assault (e.g., sexual or physical assault or mugging); torture, being taken hostage, kidnapped, or held as a prisoner of war; terrorist attacks; severe car accidents; being victims of natural or man-made disasters; being diagnosed (or having a loved one diagnosed) with a life-threatening illness; witnessing or learning about the unexpected death or injury of another person.
PTSD usually develops within 3-6 months of the traumatic event (although sometimes longer) and involves:
* Images, dreams, or flashbacks of the traumatic event
* Avoidance of cues which act as reminders of the traumatic event
* Amnesia about important aspects of the traumatic event
* Intense arousal and anxiety on exposure to trauma cues
* Depressed or irritable mood
* Social withdrawal
* Concentration and memory difficulties
* Nightmares and disturbed sleep
* Being easily startled
According to the World Health Organization’s (WHO) International Classification of Diseases (ICD)-10th Edition, post-traumatic stress disorder is diagnosed when:
* The individual has experienced an extremely traumatic event as described previously.
* The individual experiences repetitive and intrusive re-enactments of the trauma in memories, daytime imagery, and dreams.
* The individual has developed actual or preferred avoidance of cues associated with the traumatic event.
* The individual does not have full memory recall of the traumatic event, OR
* The individual experiences increased psychological sensitivity and arousal indicated by at least 2 of the following: sleep disturbance; irritability or anger; difficulty concentrating; hypervigilance; or being easily startled.
In adjustment disorder (see Section 4.10) the stressor is not as severe as in PTSD, and individuals do not tend to relive the unpleasant experience/s as they do in PTSD. Although there are differences in the diagnostic systems, PTSD is usually distinguished from acute stress disorder in terms of the time frame in which symptoms are experienced. Acute stress disorder would be diagnosed when symptoms are experienced immediately after the trauma, whereas PTSD refers to the experiencing of symptoms after at least one month and over a longer period. Depression may co-occur with PTSD.
About half of all adults report experiencing a PTSD candidate event but only 5% of males and 11% of females develop PTSD as a result. As indicated by the prevalence rates, PTSD is about twice as common among females. The age at onset varies according to the age at which the traumatic experience occurred.
PTSD is often a chronic disorder associated with significant disability and handicap, affecting relationships, work, and physical health. Half recover within five years, the speed of recovery being greater for individuals who have received professional treatment.
4.9.2 Management plan for PTSD
PTSD is a severe disorder that is very difficult to treat. Referral to a clinician who has expertise in the treatment of PTSD is recommended. Effective treatment involves helping the individual to systematically confront experiences, memories, and situations associated with the traumatic event. This treatment can result in intense emotional responses to memories of the trauma and requires considerable therapeutic skill.
Special Population: Refugees
Migrants, being self selected, often have a superior mental health but a large proportion of refugees have been victims of torture or trauma in their home countries. Torture is a systematic and calculated assault that aims to destroy the will, personality, and autonomy of the victim. This torture may involve beatings, rape, electric shock, near suffocation, burning, psychological abuse, sleep deprivation, and many other forms of physical abuse. Sometimes individuals are forced to witness this kind of torture in others – often their loved ones.
Not only do these individuals carry with them life-long physical scars and injuries, but they may also suffer immense psychological distress including depression, shame, anger, suicidal ideas, grief over loss of loved ones, guilt about informing on others, or guilt about giving in to the perpetrators and managing to survive when many others have died.
Torture victims are often reluctant to speak out about their horrifying experiences since in their home country they may have been threatened with further torture or death if they talk about what has happened. Unfortunately, doctors and other helping professionals have often been involved in the delivery of torture in the refugees’ home countries, therefore, these health professionals are not always trusted in this country. Cunningham and colleagues suggest the following strategies when caring for refugees who may be possible torture survivors:
1. Arrange for an interpreter who is acceptable to the individual.
2. Identify the nature of the individual’s complaints, the country of origin, date of migration, and residency status (those who are Asylum Seekers, Refugees, or on Special Humanitarian Programmes are likely to have been exposed to torture or trauma).
3. Explain to the individual about the extent of confidentiality of the interview, and avoid writing down any notes that may be politically sensitive.
4. When taking a history, avoid sounding interrogatory and preface all enquiries by explaining simply and clearly your purpose for asking each question.
5. Focus on the individual’s specific complaints but encourage the individual to share with you any other problems he or she may be experiencing. Individuals are often reluctant to volunteer information about their torture experiences but are likely to present with other complaints, often physical, mood related, or social.
6. Organise for an empathic and informed doctor to physically examine the individual if appropriate. The doctor should explain the purpose of each section of the examination and will need to take special care with any invasive techniques or potentially threatening instruments.
7. Assist the individual in such areas as social welfare, housing, education, language tuition, employment, legal needs, and social and leisure activities, and develop a trusting relationship with the individual.
If the individual begins to talk about his or her torture experiences, referral to a clinician who is experienced in the treatment of PTSD is recommended.
AUSTRALIAN POSTTRAUMATIC STRESS DISORDER GUIDELINES LAUNCHED
Australian guidelines are now available to help people with acute stress disorder and posttraumatic stress disorder (ASD and PTSD).
Approved by the National Medical Health and Research Council, these new Guidelines assist health practitioners to determine when is the right time for professional intervention and what’s the best approach for helping people affected by trauma.
The Australian Centre for Posttraumatic Mental Health developed the Guidelines in consultation with trauma experts from a range of disciplines, as well as people affected by trauma.
Visit www.acpmh.unimelb.edu.au to download copies.