Clinical Features

According to ICD-10, acute stress reaction is a transient disturbance occurring in persons without apparent mental disorder, in response to exceptional physical and/or mental stress and subsiding in hours or days. The diagnosis should not be made for an exacerbation of symptoms of a diagnosable psychiatric disorder already present, except for accentuation of personality traits. Previous history of another psychiatric disorder does not invalidate this diagnosis. An immediate, clear connection between the stressor and the onset of symptoms should be seen.

Symptoms of this disorder show a mixed and changing picture, with no one symptom predominating for long. They appear within minutes of the stress and resolve rapidly when the stressor is removed or, if the stress remains, symptoms decrease after 24–48 hours and are minimal after three days. Typical symptoms include an initial state of ‘daze’, constriction of consciousness, narrowing of attention, decreased comprehension of stimuli and disorientation. Withdrawal, agitation or overactivity may follow. Autonomic signs of panic (tachycardia, sweating, flushing) are common. Amnesia for the traumatic present may also be present. In the elderly, organic factors and life stage events can be predisposing factors to acute stress reaction³. The multiple bereavements that are not uncommon in late life can be the precipitants for acute stress reaction. However, recent data do suggest the older population may tolerate acute stress better than the younger and middle-aged⁴.

DSM-IV differs somewhat from ICD-10 in its diagnostic classification of acute stress disorder. Unlike ICD-10, which requires that symptoms appear within minutes of the stress and diminish to minimal intensity after three days, DSM-IV requires symptoms to last a minimum of two days and allows for persistence up to four weeks. DSM-IV also includes dissociative symptoms not included under ICD-10: a subjective sense of numbing, detachment or absence of emotional responsiveness; derealization and deperson-alization. Another DSM-IV requirement is that 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. DSM-IV also requires marked avoidance of stimuli that arouse recollections of the trauma⁵.

Differential Diagnosis

The differential diagnosis includes post-traumatic stress disorder (PTSD) and adjustment disorder. PTSD (see below) occurs after a latency period of weeks or longer, while the symptoms of acute stress reaction begin immediately after the traumatic event. The repetitive, intrusive imagery characteristic of PTSD is not usually a feature of the ICD-10 diagnosis of acute stress reaction. DSM-IV, however, does include repetitive intrusive imagery among the features of acute stress disorder. If psychotic symptoms follow an extreme stress, acute (brief) psychotic disorder should be considered. Adjustment disorders are less severe, and longer lasting, than acute stress reactions. Events that precipitate adjustment disorders are also less intense than those responsible for acute stress reactions.

Therapy

By definition, the symptoms of acute stress reaction are time-limited and will resolve without specific therapeutic intervention. Treatment may be requested, however, for intolerable tension or insomnia. For tension, short-term use of benzodiazepines with simple metabolic pathways and short half-lives, such as lorazepam or oxazepam, are safest in the elderly. For insomnia, temazepam or the non-benzodiazepine sedative hypnotic zolpidem⁶ are justified. Families and patients may be reassured that the acute response does not indicate a psychotic decompensation, and that the prognosis for rapid recovery is favourable. Acutely, and in the aftermath of the traumatic event, it is useful to help the patient gain mastery over the trauma⁷ by using a brief treatment model, consisting of fostering abreaction and integration of the event as quickly as possible, with the expectation that the trauma victim will return to full functioning. Abreaction can be fostered through individual or group psychotherapy⁸.

Post-traumatic stress disorder (PTSD) first appeared in DSM-III but was based on older concepts tied to the history of warfare. Da Costa wrote of ‘irritable heart’ following the American Civil War. In the First World War the disorder was known as ‘shell shock’. Early twentieth century psychoanalytic theory called it ‘traumatic neurosis’ and in the Second World War it was known as ‘traumatic war neurosis’ or ‘combat neurosis’.’ In DSM-I it was renamed ‘gross stress reaction’, a reaction to great stress in a normal personality. During the relatively peaceful time between the Second World War and the Vietnam War, the category was omitted from DSM-II⁹. ICD-9 defined catastrophic stress and combat fatigue as two diagnoses under the category of acute reaction to stress. DSM-III defined intrusive re-experience of the trauma, together with emotional numbing, as the central features of PTSD. DSM-III-R placed more emphasis on the avoidance of stimuli associated with the trauma and less on numbing. DSM-IV changed the definition of the trauma to an event where a person experienced, witnessed or was confronted with threatened death or serious injury or threat to physical integrity of self or others. Here, the response to the trauma involves intense fear, helplessness or horror. Also, where DSM-III-R required either numbing or avoidance behaviour, DSM-IV requires both⁵. ICD-10 criteria more closely resemble those of DSM-III, highlighting the restriction of emotional responsiveness. In ICD-10 the late chronic sequelae of devastating stress (i.e. those manifesting decades after the stressful experience) should be classified under enduring personality change after catastrophic experience³.

Clinical Features

The prevalence rate of PTSD in the elderly is about 1%^10–12. The ICD-10 diagnosis of PTSD requires evidence of trauma, or a response to a stressful event or situation of exceptionally threatening or catastrophic nature, likely to cause pervasive distress in anyone. The central symptoms are repetitive and intrusive recollections (flashbacks) or re-enactment of the event in memories, daytime imagery or dreams. The onset follows the trauma with a latency period of a few weeks to months (rarely exceeding six months).

There may also be a sense of ‘numbness’ and emotional blunting, and avoidance of activities and situations reminiscent of trauma. Anxiety, depression, suicidal ideation and insomnia are also common in many PTSD patients, particularly with advancing age⁹. PTSD is also associated with alcohol and drug abuse, possibly reflecting attempts to cope with PTSD symptoms. Dissociative symptoms, commonly described in younger PTSD victims, become less prevalent with increasing age^13,14. However, psychotic symptoms tend to be more common in older PTSD patients¹⁵.

It remains a subject of debate what factors, if any, predispose individuals to the development of the post-traumatic stress syndrome. Some traumas, particularly the concentration camp experience, are so severe that symptoms are almost universal in survivors. Because retrospective assessment of function before the traumatic event is always coloured by the response to the event, correlations are difficult to draw and empirical analyses have been inconclusive¹⁶. Certain personality traits (e.g. compulsive, asthenic), neurotic illness, and a history of adverse events in early childhood¹⁰ may all lower the threshold for manifestation of the disorder³. PTSD can also develop from bereavement. One study surveyed surviving spouses two months after their spouses’ deaths and found that 10% of those whose spouses died after a chronic illness met criteria for PTSD; 9% of those whose spouses died unexpectedly met PTSD criteria; and 36% of those whose spouses died from ‘unnatural’ causes (suicide or accident) had PTSD¹⁷. Other late life events, including falls, stroke, myocardial infarction and breast cancer, have also been shown to put the elderly at increased risk of developing PTSD^18–21.

Although PTSD symptoms can persist for many years, with increased frequency of symptoms towards the end of life²², the typical course is one of fluctuating symptoms²³. One study, examining current PTSD symptoms in elderly Second World War and Korean War prisoners of war (POWs), suggested that severity of exposure to trauma and lack of post-military social support were moderately predictive of PTSD. In this study, 53% of POWs met criteria for lifetime PTSD, with 29% meeting criteria for current PTSD, but for those POWs most severely traumatized, the lifetime PTSD rates were 83%, with current PTSD at 59%²⁴.

There are two types of PTSD to which the elderly seem susceptible: delayed-onset PTSD and chronic PTSD. In delayed-onset PTSD, patients may exhibit signs of the disorder decades after the trauma, and in chronic PTSD symptoms have been persistent since the time of the trauma. Delayed-onset PTSD may be a reactivation of remote PTSD earlier in life. A typical pattern is the onset of symptoms after initial exposure, a gradual decline in symptoms over several decades, followed by a reemergence in late life²⁵. In some elderly Second World War veterans, media coverage commemorating the 50th anniversary of the end of the War triggered PTSD symptoms²⁶. Commonly, guilt, distorted memory, emotional numbing, estrangement and feelings of detachment are seen²⁷. Patients in this group can present with physical symptoms of cardiovascular, gastrointestinal and musculoskeletal diseases¹⁶.

In general, the onset of severe symptoms can be linked to a profound recent life event, such as death of a wife, job retirement or loss of physical integrity from illness²⁷. Most often, the contemporary precipitant reawakens emotions and perceptions from the original trauma. Holocaust survivors and POWs have been noted to begin displaying symptoms of PTSD after admission to nursing homes, where they re-experience a loss of freedom and autonomy. Second World War veterans found the loss of physical integrity due to somatic illness particularly upsetting, since it evoked memories of a traumatic period when their physical integrity was in jeopardy¹⁴.

Differential Diagnosis

Although adjustment disorders also occur in response to life events, these events are in the normal range of human experience, unlike the extraordinary traumas responsible for PTSD. Specific features of numbing and flashbacks do not occur, and adjustment disorders, by definition, do not last more than six months. Acute stress reaction is characterized by a more variable clinical picture that resolves within days. Whether PTSD is predicted by acute stress reactions remains unclear²⁸. While anxiety and depression are common features of PTSD, generalized anxiety disorder and phobic disorder have anxiety as a more specific and central symptom. Major depression is marked by deep and persistent mood disturbance, usually with loss of reactivity; dysthymia results in chronic, indolent dysphoria. None of these disorders includes the specific symptom of intrusive recollections.

Therapy

The signs and symptoms of PTSD include distorted expectations and perceptions, mood disturbances, psychophysiological symptoms and social withdrawal. Thus, common sense dictates, and empirical data confirm, that multimodal treatment is most advisable^11,29. Psychosocial intervention and pharmacotherapy each has its place. Historically, dynamic psychotherapy has been a useful approach, but recent treatment guidelines support exposure-based psychother-apies as the most evidence-based form of treatment for PTSD²⁹. Antidepressants can offer symptomatic relief by diminishing dys-phoria, intrusive thoughts, insomnia and nightmares³⁰. In particular, selective serotonin re-uptake inhibitors (SSRIs) have been shown to be effective pharmacotherapeutic treatment for PTSD, especially in reducing avoidant symptoms^31–37.

Other second-generation antidepressants do show promise in the management of PTSD but sufficient evidence is lacking at this time³⁵