Acute Stress Disorder Treatment & Management

Basic principles of intervention after emotional trauma include the following:

• Reduce stress 

• Ensure that survivors have a safe environment

• Promote contact with loved ones and other sources of support (eg, religious organizations)

• Support self-esteem; help patients understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology

• Reassure and help survivors concerning immediate needs, such as rest, food, shelter, social supports, or a sense of belonging to a community (some feel cut off and detached)

• Promote coping mechanisms

• Help patients reframe any destructive cognitions (eg, beliefs that they acted terribly and are terrible people or are weak for being so distraught, that life is hopeless or worthless, or that the world is totally unsafe)

• Administer medication (eg, beta-blockers, alpha-agonists, or nonactivating selective serotonin reuptake inhibitors [SSRIs]), Benzodiazepines have not been shown to be effective, although they are often given.  They are particularly risky in the elderly, individuals with subsance abuse problems and traumatic brain injury.

• Avoid increasing stress - Avoid prompting discussion of issues that cannot be resolved; avoid abreaction in groups and the resulting contagion effect; respect defenses, and do not force reality on people who cannot handle it yet; keep in mind that debriefing may be harmful

• Discuss the experience with patients who want to talk about it, and avoid pressuring those who do not wish to discuss it

• Identify persons at high risk - Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, or toxins)

• Have faith in the normal healing processes

It is essential for caregivers to remain available and not to allow a grieving person to become isolated. The following are helpful for adults who are grieving:

• Take action (eg, call, send a card, give hugs, or help with practical matters)

• Be available after others get back to their own lives

• Be a good listener, but do not give advice

• Do not be afraid to talk about the loss

• Talk about the person who died by name

• Do not minimize the loss; avoid clichés and easy answers

• Be patient with the bereaved; there are no shortcuts

• Encourage bereaved individuals to care for themselves

• Remember significant days and memories

• Do not try to distract the bereaved from grief through forced cheerfulness

When dealing with children who are grieving or traumatized, it is particularly important to offer reassurance regarding their own safety and the safety of their loved ones (insofar as is possible). It should be emphasized to these children that such devastating events are very rare, that people are there to take care of them, and that they will always be loved. The following are helpful for grieving or traumatized children:

• Be emotionally available to children despite personal loss (or fears)

• Give children more time than usual

• Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings

• Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them; sharing personal feelings of sadness with them is all right as well

• Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and take pains to reassure them or correct any misunderstanding; do not assume children are fine just because they are not saying anything

• Understand that children probably know more than you think they do; make sure to ask what the child knows and what questions he or she has

• Monitor and limit television watching after a disaster, lest this flood them or desensitize them to violence; when they do watch, watch it with them and discuss the events

• In discussing traumatic events with children, share only the details they can deal with; be honest, but do not overload them with facts

• Encourage action, such as sending letters to victims, to keep them from feeling helpless

• Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma

• Do not force children to go to the funeral if they do not want to, but help them create a ritual

• Maintain as normal a schedule as possible

• Encourage patients to eat balanced meals on time and drink fluids; to get enough sleep, relaxation, and exercise; and to avoid alcohol and caffeine

If serious signs appear and last more than a couple of weeks, help should be sought. Signs that help is needed include the following:

• Extended depression and loss of interest in activities and events

• Inability to sleep, loss of appetite, or prolonged fear of being alone

• Extended period of marked regression

• Excessive imitation of the deceased or repeated statements about wanting to join the deceased

• Withdrawal from friends

• Serious drop in school performance or refusal to go to school

• Persistent fears

• Persistent irritability and being easily startled

• Behavior problems

• Physical complaints

Rescue workers may develop the same symptoms as victims, including those of acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). As many as 1 in 3 rescue workers develop PTSD. Measures for helping rescue workers deal with stress after traumatic events include the following:

• Encourage staying in touch with family and friends

• Be sure that rescue workers get rest, food, exercise, and relaxation

• Encourage understanding of survival guilt

• Explain how chaos and confusion inevitably lead to upset between individuals and groups that are participating in the rescue effort

• Develop a buddy system, and encourage support of coworkers

• Encourage workers to defuse after troubling incidents and after each shift

• After the rescue operation, encourage workers to take a few days to decompress and attend a debriefing

• Do not overwhelm children with talk of experiences as a rescue worker; ask about their activities

Debriefing

Critical incident stress debriefing is one of the most commonly considered interventions after a traumatic event. ^{[2, 3, 4, 5, 6]} Classically, critical incident stress debriefing is carried out in 7 stages, as follows:

• Introduction (purpose of the session)

• Description of the traumatic event

• Appraisal of the event

• Exploration of the participants’ emotional reactions during and after the event

• Discussion of the normal nature of symptoms after traumatic events

• Discussion of ways of dealing with further consequences of the event

• Discussion of the session and formulation of practical conclusions

It should be kept in mind that research efforts have not shown critical stress debriefing to be effective in preventing PTSD, depression, or anxiety. In some cases, if performed poorly, debriefing can even harm survivors by increasing arousal and overwhelming their defenses. Operational debriefing, which focuses on normalizing emotional response, informing patients of services available to them, and providing general support, is safer.

In engaging in a 1- to 2-session intervention after a traumatic event, there are several guidelines that should be followed to help avoid harm and maximize the chance of benefit, as follows:

• Provide trained individuals to perform the intervention

• Avoid ventilating feelings at high levels; this can lead to contagion and flooding rather than calming and improved ability to cope with feelings

• Do not pressure individuals to talk about things they do not want to talk about; respect their defenses, including denial

Critical tasks to cover include the following:

• Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation

• Discussion of ways to improve coping skills, including getting adequate rest, recreation, food, and fluids

• Avoidance of excessive exposure to media coverage of the traumatic incident

• Discussion of common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe

• Explanation of the signs and symptoms indicating that the survivor should get professional help

Cognitive-behavioral therapy

Whereas 70% of those receiving supportive therapy or no therapy after a traumatic event develop PTSD, only about 10-20% of those who receive cognitive-behavioral therapy (CBT) shortly after such an event develop PTSD. ^{[7, 8, 9, 10, 11, 12]} Moreover, patients who receive CBT with or without hypnosis report less reexperiencing and fewer avoidance symptoms than patients who receive supportive counseling. Individuals are aided by the following:

• Seeing that people are concerned about them

• Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)

• Being reminded to take care of concrete needs (eg, food, fluids, and rest)

• Cognitive restructuring (changing destructive schema to more constructive ones [see the Table below])

• Learning relaxation techniques

• Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo

• Desensitization to painful memories via repeated controlled exposures and systematic desensitization

Table. Cognitive Interventions: Changing Malignant Schemata to Constructive Schemata (Open Table in a new window)

Current data suggest that if the resources are available, a course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and may have to be addressed.

Brief school intervention

A brief school intervention lasts 1-2 hours and uses 4 therapists per class. A teacher is present, and parents are informed. The intervention includes the following steps:

• Introduce the therapists, and ask students to guess why they have come to the classroom

• Explain that therapists have come to talk about the disaster, and encourage students to share what they know for 10-30 minutes; validate correct information, and be calm

• Have children draw while therapists circulate, and ask students to tell them about their drawings

• Reassure students that their symptoms are normal and will ease; that people have different symptoms; that disasters are rare; and that teachers, parents, and counselors are available to help them

• Having students do a second drawing in which they depict a future and a positive state of the world is very important; the first picture is likely to focus on the trauma, their loss, and its effect on them; ideally, the second picture should show healing and restoration of normal life

• Thank the students and the teachers, and redirect their attention to learning.

The use of medications to decrease arousal and insomnia may have a long-term impact.

Beta blockers (as well as alpha-adrenergic agents) may limit hyperarousal both initially and over the longer term. ^[13] For extreme agitation, aggression, psychosis, or dissociation, an atypical neuroleptic or mood stabilizer may be needed.

Diphenhydramine and other medications may be helpful for improving sleep. Benzodiazepines, by limiting hyperarousal and fostering sleep, can be helpful in the initial stages; however, continuous administration may interfere with grieving and readaptation, because these agents can interfere with learning. ^[14] Longer-acting agents are particularly beneficial when medication is administered at the emergency site and follow-up treatment is in short supply.

SSRIs can be helpful in dealing with the core symptoms (including anxiety, depression, withdrawal, and avoidance) and can play a central role in longer-term treatment.

Comorbid conditions such as attention deficit hyperactivity disorder (ADHD) should be targeted. Reduction in even 1 disabling symptom (eg, insomnia or hyperarousal) may have a powerful positive impact on the individual’s ability to re-compensate.