This is an exerpt from an article that was published in the Psychiatry and Mental Health section of The full article gives good insights into the condition, but again, does not replace a full evaluation by a qualified professional.

Acute Traumatic Stress
by Kenneth Harbert, PhD, BCETS, CTS, PA-C

Clinician Reviews 12(1):50-57, 2002. © 2002 Clinicians Group, LLC

Abstract and Introduction


Any traumatic event (wartime experience, a natural disaster, an accident, a life-threatening illness -- or an act of terrorism) can present a clear threat to the existing conceptual framework one relies on to understand the world. Acute stress disorder, identified in recent editions of the Diagnostic and Statistical Manual of Mental Disorders, requires timely diagnosis and treatment to prevent development of posttraumatic stress disorder -- which has been estimated to affect one in 12 adults in the US population during their lifetime. Effective treatment strategies include forms of cognitive behavior therapy, with Critical Incident Stress Management being particularly helpful for clinicians, rescuers, and other caregivers affected directly or indirectly by catastrophic events.

Traumatic experiences -- extreme occurrences outside the realm of normal everyday life -- can exert significant impact on psychological functioning.[1] Acute traumatic stress occurs when interpretations of a traumatic event, insufficient coping mechanisms, and limitations in individual or group resources result in stress too severe to be relieved easily. Reactions may be immediate or delayed,[2] as in refugees who experienced persecution in their country of origin; they may be direct or may represent vicarious trauma[3] -- eg, witnessing the events of September 11, 2001, on television.

Of persons who develop acute stress disorder after experiencing a traumatic event, about 80% meet diagnostic criteria for posttraumatic stress disorder (PTSD) six months later, and 75% still do two years after the event.[4] It is important to identify acute traumatic stress and, if possible, to intervene in order to prevent development of PTSD.[2,5]

Traumatic Stress
Traumatic stress differs from general or cumulative stress. Situational variables and the patient's age, previous trauma exposure, personality, expectations, perception of the event (eg, loss vs threat[8]), the psychobiological mechanisms in play, and access to social support all contribute to the potential impact of traumatic stress and the likelihood of recovery.[9] Differences in interpretation can explain in part why, among those exposed to potentially traumatic events, less than half develop stress-related disorders.[10] Appropriate adaptation can lead to a positive change in character or worldview.

Disasters of natural origin, particularly those that can be prepared for, generally have less psychological impact than trauma perpetrated with intent. Acts of terrorism are associated with significant psychological morbidity because they create a dramatic impression of vulnerability and helplessness.[11] Too often, the physical injuries sustained as the result of a terrorist act or other catastrophic event draw needed attention away from the wide-scale psychological damage that has been inflicted.[12]

Recognizing The Patient With Traumatic Stress
Acute stress disorder (ASD), a relatively new category of anxiety disorder described in the DSM-IV,[2] is said to share the following characteristics with PTSD: extreme avoidance of stimuli associated with the trauma; psychic numbing; the sense of a foreshortened life span; and persistent symptoms of anxiety or increased arousal.[2] However, ASD is said to last for less than 30 days and must include dissociative symptoms.[2,10] (Notably, at least one research group questions the validity of separating "essentially continuous clinical phenomena" into two disorders, based on these criteria.[13])

Treatment Modalities For Traumatic Stress
The goal of therapeutic intervention is to prevent "the natural reaction to trauma ... [from becoming] uncontrollably and disastrously intensified,"[18] ie, from developing into a chronic stress disorder.[5,16] Offering patients genuine warmth and empathy, as well as an opportunity to "tell their stories," however painful, should be a part of any strategy.[19] Helping patients identify and reinforce positive aspects and interpretations of their experience can give them a new perspective. (For a handout to give patients after a traumatic experience, see page 46.)

As Americans come to terms with recent horrific events, it is essential for health care providers to offer their patients new therapeutic strategies, new perspectives, and the possibility of achieving positive growth. Patients -- and those who care for them -- must be encouraged to think of themselves as survivors rather than victims.

PAs and NPs must continue to be academically and clinically prepared to provide appropriate health care services, including psychosocial services, to trauma survivors.


Table 1. Potential traumatic events

The following four groupings comprise 19 potentially traumatic experiences, as suggested by DSM-IV definitions of stressors:

  • Assaultive violence: combat, rape, being held captive, being tortured, being shot or stabbed, being sexually assaulted; being mugged, held up, threatened, or badly beaten
  • Other injury or shocking experience: accident, fire, flood, earthquake, life-threatening illness, witnessing violence, discovering a dead body
  • Learning about trauma to a loved one (family member or close friend)
  • Sudden unexpected death of a loved one

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Table 2. Common responses to a traumatic event

Physiological responses

  • Rapid heart beat
  • Elevated blood pressure
  • Difficulty breathing*
  • Chest pain*
  • Cardiac palpitations*
  • Loss of appetite or overeating
  • Gastrointestinal upset
  • Headaches
  • Fainting, vertigo
  • Chills, clammy skin, sweating*

Emotional responses

  • Emotional numbness
  • Denial
  • Dissociation (dazed or apathetic appearance)
  • Panic
  • Fear
  • Intense feelings of aloneness, hopelessness, helplessness, emptiness, uncertainty, horror, terror, anger, hostility, irritability, depression, grief, or guilt

Cognitive responses

  • Impaired concentration and decision making
  • Confusion
  • Disorientation
  • Shortened attention span
  • Suggestibility
  • Forgetfulness
  • Blaming oneself or others
  • Concern with losing control
  • Hypervigilance
  • Perseverative thoughts of the event

Behavioral responses

  • Withdrawal
  • Noncommunicativeness
  • Changes in speech patterns
  • Regression
  • Erratic movements
  • Impulsiveness
  • Reluctance to leave home
  • Aimless walking or wandering
  • Pacing
  • Restlessness
  • Exaggerated startle response
  • Antisocial behavior

*NOTE: These physical symptoms require immediate medical evaluation.

Table 3. When to refer traumatized patients to a mental health specialist

Patients should be referred to a mental health practitioner if their physiological, emotional, cognitive, and/or behavioral reactions last for longer than one month or interfere with day-to-day functioning; or if patients continue to be troubled by one or more of the following:

  • Nightmares about the traumatic experience
  • Recurring thoughts about the event
  • Avoiding thoughts, feelings, or conversations about the event
  • Avoiding places or people that remind them of the event
  • Having a sense of a foreshortened future
  • Ongoing difficulty falling asleep or staying asleep
  • Feeling jumpy or easily startled
  • Being overly concerned about their safety
  • Feeling guilty, worthless, or hopeless
  • Feeling no pleasure in activities they once enjoyed
  • Frequent thoughts about death or suicide


  1. Horowitz M, ed. Person Schemas and Maladaptive Interpersonal Patterns. Chicago, Ill: University of Chicago Press; 1991.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. Washington, DC: American Psychiatric Association; 2000:463-472.
  3. McCann IL, Pearlman LA. Psychological Trauma and the Adult Survivor: Theory, Therapy, and Transformation. New York, NY: Brunner/Mazel; 1990.
  4. Bryant RA. The Acute Stress Disorder Scale: a tool for predicting post-traumatic stress disorder. Aust J Emerg Manage. Winter 1999:13-15.
  5. Bryant RA, Sackville T, Dang ST, et al. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry. 1999;156:1780-1786.
  6. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
  7. Breslau N. The epidemiology of posttraumatic stress disorder: what is the extent of the problem? J Clin Psychiatry. 2001;62(suppl 17):16-22.
  8. Kenardy J. Posttraumatic stress prevention: how do we move forward? Adv Mind Body Med. 2001;17:183-186.
  9. Wilson JP. Trauma, Transformation, and Healing: An Integrative Approach to Theory, Research, and Post-Traumatic Therapy. New York, NY: Brunner/ Mazel; 1989.
  10. Stoddard FJ, Todres ID. A new frontier: posttraumatic stress and its prevention, diagnosis, and treatment. Crit Care Med. 2001;29:687-688.
  11. The Terrorism Research Center, Inc. Next generation terrorism analysis.
  12. Everly GS Jr. Crisis management briefings: large group crisis intervention in response to terrorism, disasters, and violence. Int J Emerg Ment Health. 2000;2:53-57.
  13. Marshall RD, Spitzer R, Liebowitz MR. Review and critique of the new DSM-IV diagnosis of acute stress disorder. Am J Psychiatry. 1999;156: 1677-1685.
  14. Weisæth L. Acute posttraumatic stress: nonacceptance of early intervention. J Clin Psychiatry. 2001;62(suppl 17):35-40.
  15. Bryant RA, Moulds ML, Guthrie RM. Acute Stress Disorder Scale: a self-report measure of acute stress disorder. Psychol Assess. 2000;12:61-68.
  16. Lerner MD, Shelton RD. Acute Traumatic Stress Management. The American Academy of Experts in Traumatic Stress, Inc, 2001. Available at: . Accessed November 8, 2001.
  17. National Mental Health Association. Trauma and your mental health: what is a normal response, and when to seek help. Available at: . Accessed November 14, 2001.
  18. Breslau N. Outcomes of posttraumatic stress disorder. J Clin Psychiatry. 2001;62(suppl 17):55-59.
  19. Lerner MD. Early intervention: a multidisciplinary effort. American Academy of Experts in Traumatic Stress. Available at: . Accessed November 12, 2001.
  20. Ochberg FM. Post-traumatic therapy. In: Everly GS, Lating JM, eds. Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress. New York, NY: Plenum; 1995:245-264.
  21. Everly GS Jr. Five principles of crisis intervention: reducing the risk of premature crisis intervention. Int J Emerg Ment Health. 2000;2:1-4.
  22. Foa EB, Street GP. Women and traumatic events. J Clin Psychiatry. 2001; 62(suppl 17):29-34.
  23. Shapiro F. Eye movement desensitization and reprocessing: evaluation of controlled PTSD research. J Behav Ther Exp Psychiatry. 1996;27:209-218.
  24. Shepherd J, Stein K, Milne R. Eye movement desensitization and reprocessing in the treatment of post-traumatic stress disorder: a review of an emerging therapy. Psychol Med. 2000;30:863-871.
  25. Feske U, Goldstein AJ. Eye movement desensitization and reprocessing treatment for panic disorder: a controlled outcome and partial dismantling study. J Consult Clin Psychol. 1997;65:1026-1035.
  26. Davidson PR, Parker KCH. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. J Consult Clin Psychol. 2001;69:305-316.
  27. Davidson JRT, Connor KM. Management of posttraumatic stress disorder: diagnostic and therapeutic issues. J Clin Psychiatry. 1999;60(suppl 18):33-38.
  28. Esterling BA, L'Abate L, Murray EJ, Pennebaker JW. Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clin Psychol Rev. 1999;19:79-96.
  29. Mitchell JT, Everly GS Jr. The scientific evidence for Critical Incident Stress Management. J Emerg Med Serv JEMS. 1997;22:86-93.
  30. Vargas MA, Davidson J. Post-traumatic stress disorder. Psychiatr Clin North Am. 1993;16:737-748.
  31. Lange JT, Lange CL, Cabaltica RBG. Primary

Key to choosing or recommending any of the following strategies is an awareness that crisis intervention must complement, not interfere with, "natural recovery and restorative mechanisms," as Everly writes.[21]

Cognitive behavior therapy. The most effective form of this goal-oriented, psychoeducational therapy (in one study, found almost four times as effective as supportive counseling in preventing posttraumatic stress disorder [PTSD][5]) combines prolonged exposure to disturbing images, cognitive therapy (adjusting thoughts, beliefs, and perceptions to modify the emotions), and anxiety management.

Exposure therapy. Demonstrated as effective treatment for phobias and for recent sexual or nonsexual assault, this form of cognitive behavior therapy involves systematic exposure to a traumatic memory in a safe environment, then reintroduction to situations the patient may have been avoiding.[22]

Eye movement desensitization and reprocessing (EMDR).[23] Originally developed for combat-related PTSD, EMDR is also used by skilled practitioners to treat noncombat PTSD, phobias, panic attacks, and other anxiety disorders. While holding in mind a trauma-related image with its associated negative thoughts and bodily sensations, the patient tracks the therapist's finger as it is moved within the visual field. In theory, distress associated with the traumatic memory is reduced and adaptation begins. Randomized controlled trials comparing EMDR with other exposure methods have yielded mixed results, however, and EMDR is considered controversial.[24-26]

Stress inoculation training is designed to help patients manage anxiety as it occurs. Its components include relaxation training, thought-stopping, guided self-dialogue, cognitive restructuring, covert modeling, and role-playing.[22,27]

Therapeutic writing. Shortly after severe trauma, single sessions of written disclosure may sensitize rather than benefit certain patients, particularly "high avoidance copers."[8] In the long term, however, writing about both the facts of a traumatic event and one's emotional response to it appears to benefit patients' mental and physical health.[28]

Critical Incident Stress Management (CISM) is a comprehensive, integrated crisis intervention system used by more than 400 teams of specifically trained practitioners. The model can be tailored for individuals, small functional groups or teams, large groups, families, organizations, and even entire communities. Among its best-known features are critical incident stress debriefing, a structured group discussion of a traumatic event; on-scene and one-on-one crisis support that involves peers and significant others; and crisis management briefing, a 45- to 75-minute intervention for groups of 10 to 300 persons affected by an act of violence or terrorism, a disaster, or other crisis.[12] These should be used only within a comprehensive CISM program.[29]

Acute Traumatic Stress Management,[16] combined with traditional emergency medical intervention, seeks to stabilize acute symptoms as traumatic stress occurs and to stimulate healthy, adaptive functioning.

Other effective coping interventions include biofeedback, hypnotherapy, controlled breathing, and other relaxation techniques.

Kenneth Harbert
is Professor and Chair for the Department of Physician Assistant Studies at the Philadelphia College of Osteopathic Medicine and the University of the Sciences in Philadelphia. He also serves on the Clinician Reviews editorial board.

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