Strategies for Acute Stress Reactions and Acute Stress Disorder (ASD)




(1)
U.S. Department of Veterans Affairs, National Center for PTSD, White River Junction, VT, USA

(2)
Departments of Psychiatry and Pharmacology & Toxicology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA

 



Keywords
Acute stress reactionsCombat operational stressResiliencePreventionPsychological first aidForward psychiatryDSM-5Acute stress disorderCBTCritical incident stress debriefing (CISD)


This chapter answers the following:



  • What are Normal Acute, Posttraumatic Distress Reactions?—This section defines the four types of normal reactions people have to traumatic events.


  • What is Acute Stress Disorder (ASD)?—This section defines ASD and presents prevalence information.


  • What Challenges Exist for Diagnosing ASD?—This section covers risk factors for PTSD, differentiating ASD from PTSD, DSM-5 diagnostic criteria, and assessing ASD in clinical interviews using assessment and diagnostic tools.


  • What Treatment Approaches Are Used for Traumatic Event Survivors?—This section covers immediate interventions as well as psychological and pharmacological interventions.

Immediately after a traumatic event, those exposed may experience severe and incapacitating psychological distress—avoid traumatic stimuli and have startle reactions, hypervigilance, or other symptoms associated with PTSD. However, these distressing symptoms appear to be within the normal, immediate human response to overwhelming events.

Most people exposed to traumatic events never develop PTSD, depression, alcoholism, or any other DSM-5 psychiatric disorder. A review of 160 studies on disaster victims suggests that two-thirds will not develop a clinically significant chronic psychiatric disorder [13]. Most reactions were transient with symptom dissipation within a month of the disaster for 42 % of the victims, and within a year for an additional 23 %. Only a substantial minority, 30 %, experienced chronic symptoms lasting more than a year.

Consider the reactions of two, US World Trade Center disaster survivors, Kevin W. and William G.



  • Kevin, who was lucky enough to flee his office in the South Tower shortly after the North Tower was hit, was not injured physically but witnessed terrifying death and destruction all around him.


  • William was led from the 64th floor of the South Tower by firefighters and experienced all that Kevin had plus breathing problems from the smoke.

Both were extremely distressed during the immediate posttraumatic aftermath and might characterize their feelings as in the first “From the Patient’s Perspective” box


From the Patients’ Perspective



Kevin W. or William G.—Immediate Post-Trauma Aftermath

It’s been two days now, and I’m a nervous wreck. I know I should be thankful that I got out alive, but I’m climbing the walls. I jump at the slightest noise. I’m glued to the TV, and every time the instant replay shows those planes hitting the Twin Towers, I go into a panic, start to sweat, can’t calm down, can’t stop thinking about all those who didn’t make it, and can’t sleep because of the nightmares, can’t stop smelling the awful smoke, and can’t stop hearing the cries for help from those trapped on the upper floors.

However, what they report two weeks later (below) refl ects symptoms that may differentiate an acute stress reaction (ASR) from an acute stress disorder (ASD).


Kevin W. and William G.—2 Weeks Later

Kevin W.: Acute Stress Reaction

It’s been two weeks since the Twin Towers were attacked. In the beginning, I couldn’t seem to get a grip. Sally said, for the first few days, I was screaming in my sleep and thrashing about in the bed. When awake, she said I seemed to be off somewhere else when she tried to get my attention or comfort me. Thankfully, I’ve moved way beyond that point and no longer have the nightmares, anxiety, or spacey feelings. Although I’ll never forget what happened, things are returning to normal, and my life continues to progress beyond September 11th.


William G.: Acute Stress Disorder

It’s been two weeks, and I’m still not myself. I jump at the slightest sound, can’t focus on anything at work or at home, can’t sleep, and can’t stop thinking about how my panic got even worse when I couldn’t breathe because of the thick smoke in the stairway as I frantically tried to get out of the building. And, my internal world seems completely different. It’s like living in a dream world instead of real life. I’m not connected to my feelings. It almost seems like I’m outside, looking in. Watching someone who looks like me but really isn’t.

Most people (like Kevin W.) exposed to a traumatic event who exhibit Acute Stress Reaction (ASR) will recover spontaneously within a few days. Only a minority will develop ASD (like William G.), or some other psychiatric problem. However, since the vast majority of people who survive a catastrophic stressor will be very distressed during the immediate post-disaster aftermath, it is usually impossible to distinguish those who are most likely to recover on their own from those at greatest risk to develop a chronic psychiatric disorder [4].

Within 3–5 days of the September 11, 2001 World Trade Center attacks, 90 % of Americans surveyed nationally reported at least moderate distress while 44 % of respondents reported one or more substantial symptoms of severe distress [5]. In contrast to the high prevalence of normal posttraumatic distress, a much smaller percent of New Yorkers, 7.5 %, developed PTSD within weeks of the World Trade Center attacks [6].

This chapter considers this challenge and reviews current thinking about the best approach for ameliorating normal distress and treating clinically significant problems.


Military Considerations


The wars in Iraq and Afghanistan have resulted in PTSD among approximately 15 % US service men and women. Indeed, given the remarkable advances in military medicine and the efficiency of the medical evacuation system, only 10 % of those wounded in battle have died from their injuries compared to 25 % in previous wars [7]. Higher survivor rates are no doubt one reason why psychiatric casualties have assumed such prominence. Another reason is the growth of knowledge regarding the recognition and treatment of posttraumatic reactions and disorders that has informed current military policy and practice [8, 9].

Acute psychological distress or functional incapacity has been a long-time concern of military psychiatry and psychology. Whereas, in the civilian sector, this is called ASR, in a military context, it is called Combat Operational Stress Reaction (COSR). In this chapter we will review COSR as well as ASR since there are specific interventions (e.g., PIES and BICEPS, see below) that the military has developed that are not only important in their own right but because they have greatly influenced interventions developed for civilians such as Psychological First Aid (PFA).

Furthermore, the desire to make troops more resilient, and therefore less likely to develop behavioral, emotional, or psychiatric problems after exposure to traumatic events has caused US military leaders to develop programs with the hope that they will produce psychological, as well as physical, toughness among troops preparing for deployment. The army, marines, navy, and air force have each established resilience programs to enable troops to obtain the psychological protection they need in a war zone. This development coincides with the recent growth in our scientific understanding of resilience which is a very complicated set of attributes that has genetic, psychobiological, cognitive, emotional, behavioral, and social dimensions. We await rigorous evaluation of these military resilience programs to see whether they make a positive difference in post-deployment outcomes.

Many combat injuries have been caused by powerful explosions from roadside bombs, suicide bombers, and explosive devices detonated from vehicles, or rocket propelled grenades and other explosives directed at convoys and troops. In addition to the psychological trauma of exposure to such powerful explosions (which often cause death, injury and major destruction), servicemen and women who survive such events may also have serious head injuries. These concussive injuries are popularly called traumatic brain injuries (TBIs) which may be mild, (which is most common), moderate, or severe (which may cause serious impairment of brain function as well as blindness and other neurological losses).

Since any concussive injury serious enough to, literally, rattle your brain is serious enough to cause traumatic stress, it is not uncommon for PTSD and TBI to occur in the same individual at the same time. For clinicians evaluating such servicemen and women weeks, months, or years after the explosive encounter, it is often difficult to distinguish which symptoms are due to PTSD and which to TBI since there is much overlap, especially with mild TBI [10]. Since this chapter focuses on short-term evaluation and treatment, such long-term issues will not be addressed. What does seem pertinent to the present discussion, however, is that at the present time, it appears that individuals with PTSD and mild (but not moderate or severe) TBI should be offered the same interventions and treatment as those with PTSD, alone. This is obviously a matter of great importance and a high priority area for current treatment planning and research.


What are Normal Acute, Posttraumatic Distress Reactions?


Identification of a person with ASR or COSR is based primarily on observation of the severity of their emotional distress and functional impairment. Acute stress reactions may present in a number of ways with different individuals exhibiting different symptoms. In addition to intrusion, dissociative, avoidance, arousal and reactivity symptoms, people with ASR/COSR may exhibit the following symptoms for days or weeks following the trauma [4]:



  • Emotional reactions—Shock, fear, grief, anger, resentment, guilt, shame, helplessness, hopelessness, and constricted affect.


  • Cognitive reactions—Confusion, disorientation, dissociation, indecisiveness, difficulty concentrating, memory loss, self-blame, and unwanted memories.


  • Physical reactions—Tension, fatigue, edginess, insomnia, startle reactions, racing heart beat, nausea, loss of appetite, and change in sex drive.


  • Interpersonal reactions—Distrust, irritability, withdrawal, and isolation; feeling rejected or abandoned; being distant, judgmental, or being overcontrolling.

These reactions may vary from mild to severe. In some cases, there is evidence of more clinical symptoms, such as: intrusive recollections, marked avoidance, dissociation, constricted affect, panic attacks, intense agitation, incapacitating anxiety, severe depression, and grief reactions (over the death or injury of loved ones as well as personal material losses).


Counseling the Patient with an Acute Stress Reaction


At an early stage, the appropriate professional stance is that these are transient reactions from which normal recovery should be expected. In the first meeting following a traumatic event, the following educational information about strong emotional reactions following exposure to traumatic stress should be emphasized.



  • Almost everyone has a strong emotional reaction


  • It usually resolves within days or weeks


  • It typically does not lead to any permanent psychological scars or psychiatric problems

Key recommendations for these patients include:



  • Avoid re-exposure to traumatic reminders (e.g., not watching traumatic images on TV)


  • Spend as much time as possible with friends and family


  • Be patient so that normal recovery can take place


What Treatment Approaches are Used for Traumatic Event Survivors?


There is growing consensus that the best mental health intervention during the immediate aftermath of a traumatic event is Psychological First Aid (PFA). This is an approach designed to ameliorate immediate posttraumatic distress based on the expectation that every survivor, no matter how upset, will achieve normal recovery [11]



  • Provision of basic needs—safety, security, and survival (food and shelter)


  • Orientation to disaster and recovery efforts


  • Reduction of physiological arousal through self-calming and relaxation techniques, avoiding upsetting stimuli, and (occasionally) taking medication (for no more than 5 days)


  • Mobilization of support for those most distressed through reunion with family/friends and provision of needed professional services


  • Providing education about available resources and coping strategies


  • Using effective risk communication techniques to provide accurate, necessary information to survivors in a calm, honest, and straightforward manner without increasing anxiety

Following exposure to a traumatic event, individuals should be encouraged to live their lives as normally as possible and avoid isolating themselves from family, friends, or community-based natural support systems (e.g., neighborhood, school, church, or workplace organizations).

In the event of a natural or man-made disaster, public health approaches in the vicinity of the terrorist attack or disaster site should have both educational and outreach components. Such large-scale, community/societal interventions should be designed to promote resilience and foster recovery among the majority of the population, temporarily suffering from acute posttraumatic reactions. They also need to provide widely accessible information about clinically significant posttraumatic symptoms so that people can make accurate appraisals concerning the magnitude of their own distress as well as that of loved ones and friends. Such a proactive approach should also indicate what type of mental health services might be helpful and where they can be found [11, 12].

Information available through print and broadcast media, Internet sites, and toll-free telephone hotlines rank among key vehicles for carrying out such a public health approach.


Project Liberty

New York City’s post-9/11 disaster mental health program, Project Liberty, illustrates effective media–public health partnerships that benefit the general public after a major catastrophe. A broad-scale, public media campaign such as this should have four objectives [13]:



1.

Branding a disaster-response program to provide recognition of available services

 

2.

Broadcasting the overall message that posttraumatic distress is a normal reaction

 

3.

Promoting a sense of security for the community at large by announcing that mental health services are available to those in need

 

4.

Identifying and legitimizing outreach staff conducting face-to-face and door-to-door outreach services

 

Two weeks following the attack, Project Liberty developed and aired a 30-s TV commercial directing people to available mental health services. Within 2 months, 25 % of New Yorkers knew about Project Liberty, and 70 % reported that they had learned about it through television [13].

Project Liberty also used radio announcements, printed brochures, a toll-free phone number, and information on the Internet. In addition, the project’s community-directed interventions were tailored specifically for school children, the elderly, the workplace, and for many distinct ethnic communities [13].


Forward Psychiatry for Combat Operational Stress Reaction (COSR)


In the military, clinicians found that active duty personnel who had an incapacitating anxiety attack (e.g., “battle fatigue” or “combat operational stress reaction”) had better outcomes if treated at a medical unit close to the war zone, such as a mobile army surgical hospital (MASH) unit [14]. Thought to produce rapid resolution of battle fatigue and prevent the later development of what is now called PTSD, military psychological debriefing (PIES) included four main components:

1.

Proximity—Providing intervention at a location as close to the active combat zone as possible

 

2.

Immediacy—Intervening as soon as possible after the onset of battle fatigue

 

3.

Expectancy—Providing education that the acute stress reaction is a normal human response to an overwhelming and abnormal event, including the expectation that the individual will quickly recover and return to military duties within a few days without immediate or long-term consequences from the acute stress reaction

 

4.

Simplicity—Use brief straightforward methods to restore physical and psychological well-being and self-confidence

 

Although the military PIES approach has not been rigorously tested, its apparent success fostered the use of similar interventions for civilians who experienced natural disasters or man-made catastrophes as exemplified by PFA.

A later version of PIES is called BICEPS which is currently utilized by the military.

1.

Brevity—Initial rest and replenishment (“3 hots and a cot”) at Combat Operation Stress control facilities located close to the service member’s unit lasting no more than 1–3 days

 

2.

Immediacy—Treatment should begin as quickly as possible

 

3.

Contact—The service member is encouraged to continue to think of her/himself as a war fighter and not as a patient or sick person

 

4.

Expectancy—Explicit message that this is a normal reaction to war zone stress from which complete recovery is expected with a return to full duty in a few hours or days

 

5.

Proximity—If care cannot be adequately provided in the unit, it is provided at the batallion aid station or medical company nearest the unit; the locus of care is separated from that provided to medical or surgical patients

 

6.

Simplicity—Using brief and straightforward methods

 

Approaches such as this have been provided to US military personnel in Iraq and Afghanistan by Army Combat Stress Control (CSR) mental health units. The marine’s approach is somewhat different and is provided by Operational Stress Control and Readiness (OSCAR) units. Both CSR and OSCAR approaches are evidence-informed but have yet to be tested rigorously.


Resilience


Concern about mental fitness among fighting troops has naturally led to development of programs to foster mental toughening or resilience among troops before deployment to a war zone. It is obvious that greater resilience should result in fewer incidents of COSR and therefore significantly reduce COSR and more chronic trauma-related mental health problems among servicemen and women. As a result, the US army, navy, marines, and airforce have each developed resilience programs to improve psychological preparation for troops, which are currently operational. The basic principles of such programs are:

1.

Provide realistic training (with simulations, if possible) of war zone scenarios

 

2.

Strengthen perceived ability to cope with trauma and its aftermath

 

3.

Create supportive interpersonal work environments (such as increased unit cohesion) to optimize social support

 

4.

Develop and maintain adaptive beliefs about realistic expectations, confidence in leadership, confidence in the meaningfulness of the military mission, and confidence in one’s own coping abilities

 

5.

Develop comprehensive stress management programs and increase awareness of their availability while reducing stigma attached to seeking help for stress-related problems

 

Understanding resilience has become one of the major challenges in the trauma field. It is a very complex construct consisting of genetic, psychobiological, cognitive, emotional, behavioral, and social aspects. Since everyone will encounter stress throughout life and more than half of us will be exposed to traumatic stress, it behooves us to learn as much about resilience as possible so that we can equip our children and ourselves, (as well as our military, police, firefighter, and first responder personnel) to prepare for stress as much as possible and to have the necessary coping abilities to confront stressful/traumatic situations when they arise. (See Chap. 5, pages XX–YY, for further discussion of resilience.)


Psychological Debriefing


This is an intervention conducted by trained professionals shortly after a catastrophe, allowing victims to talk about their experience and receive information on “normal” types of reactions to such an event. It was first developed for police, firefighters, and first responders to help them cope with the traumatic situations that they encountered on a daily basis as part of their professional responsibilities. It was later adapted by the military and utilized in the war zone. It was predicated on the assumption that the best approach for those who experience a catastrophic event is early detection and timely intervention.

Proponents of psychological debriefing assert that it can abort the onset of a serious mental disorder, can reduce severity and duration once it has taken hold, or can prevent ASR or COSR from progressing to a chronic and incapacitating PTSD or some other debilitating psychiatric disorder [11, 15, 16].

The best known form of psychological debriefing is Critical Incident Stress Debriefing (CISD) [17].. However, its many modifications and variations have led to use of the more general term, psychological debriefing

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Jun 22, 2017 | Posted by in PSYCHIATRY | Comments Off on Strategies for Acute Stress Reactions and Acute Stress Disorder (ASD)

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