Acute Stress Disorder Clinical Presentation

Traumatic events can lead to a wide variety of emotional reactions. The treating clinician must understand that underneath the individual’s reaction is an attempt to cope with the traumatic event. Most individuals have some symptoms after a significant traumatic event. A minority have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or posttraumatic stress disorder (PTSD).

The following symptoms are relatively common after traumatic events:

• Emotional reactions - Shock, daze, grief, anxiety, guilt, anger, numbness, helplessness, shame, and emptiness; decreased ability to feel pleasure, interest, or love; children may regress

• Cognitive reactions - Nightmares, poor concentration, unwanted memories of the disaster, self-blame, confusion, disorientation, indecisiveness, and worry

• Physical reactions - Difficulty sleeping, exaggerated startle response, tension, fatigue, irritability, aches and pains, tachycardia, nausea, and changes in appetite or libido

• Interpersonal reactions - Distrust, conflict, withdrawal, work problems, school problems, irritability, decreased intimacy, domineering demeanor, and a feeling of being rejected or abandoned; children may become clingy or oppositional

More significant symptoms that call for professional consultation include the following:

• Severe persistent problematic symptoms - Marked depression (eg, hopelessness, a feeling of worthlessness, or overwhelming worry), marked hyperarousal (eg, panic attacks, rage, extreme irritability, or intense agitation), extreme numbness, inability to control emotions even when it is important to do so, persistent problems in work or school, and significant problems in self-care

• Exacerbation or reoccurrence of preexisting psychiatric problems

• Dissociative symptoms (eg, depersonalization, derealization, fugue, and amnesia)

• Intrusive reexperiencing - Terrifying memories, persistent nightmares, and flashbacks

• ASD

• PTSD (occurs in 10-30% of individuals who are highly exposed to the traumatic event)

• Substance abuse

• Aggression

• In children, aggression, risk taking, or sexual acting out

The following are signs that the patient needs help:

• Task-oriented activities are not being performed

• Task-oriented activity is not goal-directed, organized, or effective

• The survivor is overwhelmed by emotion most of the time

• Emotions cannot be modulated when necessary

• The survivor inappropriately blames himself or herself, and the self-blame generalizes to the entire self

• The survivor is isolated and avoids the company of others

• The survivor contemplates or plans suicide or homicide

Traumatic grief

Traumatic grief is an example of a complicated grief reaction that occurs after the traumatic death of someone close. It may occur when the death results from war, disasters, accidents, suicide, or homicide. In traumatic bereavement, the individual is preoccupied with images of the traumatic event, rather than of the person who is deceased, as is typical in normal bereavement. Moreover, the individual has difficulty passing through the mourning process and moving on with his or her life.

A person experiencing traumatic grief needs treatment for both trauma and grief. He or she also needs help in remembering an intact representation of the deceased person rather than being filled with images of the person being killed. If no body is present after the death, placing a picture of the individual in nondegradable plastic in the coffin can be helpful.

The patient’s mental status must be assessed. Common findings in patients with acute stress disorder (ASD) are as follows:

• Appearance - Individuals may be disheveled and unclean and show the effects of dehydration and failure to care for themselves

• Affect and mood - Patients may appear sad, anxious, irritable, emotionally labile, apathetic, angry, or calm; depressive illness occurs in 17-27% of survivors during the first year after a death

• Thought content - Individuals may feel helpless, be in a state of disbelief, be confused, have markedly impaired concentration, have lowered self-esteem, or be driven to search for the deceased

• Perceptions - Patients may have hallucinations (visual or auditory) that the deceased person is present; flashbacks, feelings of unreality, numbness, and denial may occur

• Judgment and insight - Confusion in combination with preoccupation with those they have lost may impair individuals’ judgment and insight

• Suicidal or homicidal ideation - Suicidal thoughts occur in as many as 54% of survivors and may continue up to 6 months after the death; thoughts or plans of homicide may arise

Physical complaints arising from grief may include the following:

• Loss of appetite

• Changes in weight

• Trouble going to sleep or staying asleep

• Fatigue

• Chest pain

• Headache

• Palpitations

• Hair loss

• Gastrointestinal distress