Acute Stress Disorder

SYMPTOMS
Acute Stress Disorder is characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stressor (e.g., witnessing a death or serious accident). As a response to the traumatic event, the individual develops dissociative symptoms. Individuals with Acute Stress Disorder have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities, and frequently feel guilty about pursuing usual life tasks. A person with Acute Stress Disorder may experience difficulty concentrating, feel detached from their bodies, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia). In addition, at least one symptom from each of the symptom clusters required for Posttraumatic Stress Disorder is present. First, the traumatic event is persistently reexperienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided. Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness). 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 - Feelings of unreality (e.g., feeling detached from ones surroundings, perceptual changes, such as ones surroundings seeming dream-like) (4) depersonalization (i.e., feeling detached from ones body or self) (5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma) C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashbackepisodes, 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, hypervigilance, exaggerated startle response, motor restlessness). F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, 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. The disturbance is 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 preexisting Axis I or Axis II disorder.

Effective Treatments for PTSD and Acute Stress Disorder Biological treatments (i.e., medications), psychological treatments, and their combination, have been found to be effective for treatment of PTSD and related problems.
Biological Treatments

A number of medications have been shown to be useful for treating PTSD. The most common of these are the antidepressants (see list below), particularly the SSRIs. In addition, mood stabilizers such as divalproex (Depakote) may be used in cases where a person experiences only a partial response to an antidepressant. The addition of a mood stabilizer (along with an antidepressant) is also recommended for particular PTSD symptoms, such as marked irritability or anger. In addition to antidepressants and mood stabilizers, anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonapin or Rivotril), and lorazepam (Ativan) may be useful on a short term basis. Caution should be used with these medications, due to the potential for dependence. Antidepressants for PTSD
Type of Medication Generic Name Brand Name

SSRI Antidepressants

Tricyclic Antidepressant Other Antidepressants

Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Amitriptyline Imipramine Nefazodone Venlafaxine

Celexa Prozac Luvox Paxil Zoloft Elavil Tofranil Serzone Effexor

Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following psychological treatment. Among medications, selective serotonin reuptake inhibitors (SSRIs) have the most data supporting them. These medications are most effective for PTSD in nonveterans. When symptoms have lasted less than three months (acute PTSD) it is generally recommended that medication be continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication be continued for one to two years. Longer treatment may be required if significant symptoms are still present. The decision of whether to take medication for PTSD, and which medication to take should be based on the individuals past treatment history, the individuals medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors.

Psychological Treatments

The psychological treatment shown to be most effective for PTSD is cognitive behavior therapy (CBT). CBT for PTSD involves a number of useful strategies including: Psychoeducation includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individuals emotional reactions and need to retell the event. Anxiety Management involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training. Cognitive Therapy involves identifying anxious thoughts (e.g., guilty thoughts about the trauma, exaggerated thoughts about danger) and replacing them with more realistic thoughts. For example, if an individual has the thought I will never be safe again, the world is a very dangerous place, cognitive therapy would focus on helping the individual to consider evidence for and against the belief. Exposure to Trauma Cues and Feared Situations involves confronting feared situations or triggers repeatedly, in a gradual way, until fear is extinguished. For example, a person who is avoiding driving after being in a very severe car accident is encouraged to drive again, beginning in easier situations (e.g., light traffic) and gradually progressing to more difficult situations (e.g., heavy traffic, night, in the rain). Exposure to Trauma Memories involves confronting trauma memories repeatedly until they are no longer associated with extreme distress. This strategy is combined with anxiety management strategies and cognitive therapy. For children, play therapy is often used to treat PTSD. Topics are addressed in an indirect manner using games to facilitate processing of traumatic memories.
Controversial Psychological Treatments for PTSD and Related Problems

Eye Movement Desensitization and Reprocessing (EMDR) EMDR is a therapy that was developed in the late 1980s by psychologist, Francine Shapiro. It involves bringing to mind an image of a traumatic event while visually tracking a therapists finger as it moves back and forth in front of the patients visual field. A number of variations on this treatment have been developed, including tracking a light moving back and forth, or listening to tones alternating from one ear to the other. Research on EMDR suggests that it does lead to a reduction in PTSD symptoms, though it is no more effective than other forms of CBT. Interestingly, the eye movements and other forms of sensory stimulation appear to have nothing to do with the effectiveness of EMDR. Critics of EMDR have argued persuasively that the main reason EMDR works is the exposure to the traumatic image. In other words, EMDR is thought to be no more than dressed up form of imaginal exposure. Critical Incidence Stress Debriefing (CISD) CISD is a procedure that is often used with groups of individuals within one to three days of having experienced a trauma (e.g., a natural disaster, accident, terrorist attack, etc.). The treatment encourages trauma victims to share their thoughts and experiences, and the therapist discusses thoughts and emotional reactions that the individuals are likely to experience. Participants are typically encouraged to stay with the procedure. The strategies listed here are similar to those listed earlier in the

section on psychoeducation for PTSD. The difference is that in CISD, all trauma victims are exposed to the treatment, not just those who develop PTSD or other adjustment problems. The data on CISD are mixed, but generally not supportive of the procedure. Some studies have shown the people having undergone CISD following a trauma are no better off than people who did not receive this treatment. Furthermore, a few studies have actually shown that people who undergo CISD are functioning more poorly later on, relative to those who have not undergone the procedure. Critics of CISD have recommended against using this procedure for all trauma victims. Instead, they encourage professionals to help victims with their basic needs (e.g., contacting insurance companies, etc.), provide support, and allow them to discuss the trauma only if they want to. More intensive treatment should be reserved for people who are still experiencing anxiety symptoms some time after the trauma has passed.
Combining Medications and CBT

There is a lack of research comparing CBT to medications or examining the combination of these approaches for treating PTSD. In other anxiety disorders, CBT, medications, and combined treatments are often similar in effectiveness across groups of individuals, although any one person may respond better to one of these approaches than to the other treatments. For most anxiety disorders, the effects of CBT tend to be more long lasting than the effects of medication. In other words, once treatment has stopped, anxious individuals who have been treated with CBT are less likely to experience a return of their symptoms than are individuals who have been treated with medication. In light of these findings, CBT may be the best approach initially. For individuals who do not respond to CBT, adding an SSRI is a reasonable next step in treatment. More research is needed before recommendations regarding the relative and combined effectiveness of medications and CBT can be made with confidence. Did you know ...? PTSD is generally more severe or long-lasting when the trauma is of human design (e.g., torture, terrorist attack) vs. a natural disaster (e.g., earthquake) The chance of developing PTSD increases as the severity, duration, and physical proximity to the trauma increases. Other factors that increase the risk for developing PTSD include history of previous trauma and negative reactions from friends and family. When the duration of PTSD symptoms is less than three months it is termed acute. If the duration of PTSD symptoms is three months or more it is termed chronic. Although symptoms of PTSD usually begin within the first three months after the trauma, there may be a delay of months or even years before symptoms appear. Delayed onset of PTSD is said to have occurred when the symptoms begin at least six months after the trauma. PTSD is related to increased rates of major depressive disorder, substance-related disorders, and other anxiety disorders. Research on individuals at-risk for the development of PTSD has found the highest rates of onset (30 to 50%) in survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. PTSD can occur at any age, including childhood.

 Individuals with PTSD often report painful feelings of guilt about surviving when others did not or about things they had to do to survive.

Somatization Disorder
This Somatoform Disorder may be diagnosed when a pattern of medically unexplained complaints of multiple physical symptoms begins before age 30. The diagnostic criteria further specify a minimum number of complaints from several organ systems.

Diagnostic criteria for 300.81 Somatization Disorder

(DSM IV - TR) (cautionary statement) A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: (1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination) (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) (3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) (4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) C. Either (1) or (2): (1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the

direct effects of a substance (e.g., a drug of abuse, a medication) (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings D. The symptoms are not intentionally feigned or produced (as in Factitious Disorder or Malingering).

Hypochondriasis
When a patient remains preoccupied with the fear that they have a serious medical illness despite the fact that medical evaluation has ruled out such an illness, this Somatoform Disorder can be diagnosed. Although the belief is not of delusional intensity, attempts at reassurance fail. monosymptomatic hypochondriasis syphilomania

Diagnostic criteria for 300.7 Hypochondriasis

(DSM IV - TR) (cautionary statement) A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder). D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder. Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable