|This is an exerpt from an article that was published in the Psychiatry and Mental Health section of Medscape.com. The full article gives good insights into the condition, but again, does not replace a full evaluation by a qualified professional.|
Clinician Reviews 12(1):50-57, 2002. © 2002 Clinicians
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. 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, as in refugees who experienced persecution in their country of origin; they may be direct or may represent vicarious trauma -- 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. It is important to identify acute traumatic stress and, if possible, to intervene in order to prevent development of PTSD.[2,5]
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), the psychobiological mechanisms in play, and access to social support all contribute to the potential impact of traumatic stress and the likelihood of recovery. Differences in interpretation can explain in part why, among those exposed to potentially traumatic events, less than half develop stress-related disorders. 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. 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.
Recognizing The Patient With Traumatic Stress
Acute stress disorder (ASD), a relatively new category of anxiety disorder described in the DSM-IV, 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. 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.)
Treatment Modalities For Traumatic Stress
The goal of therapeutic intervention is to prevent "the natural reaction to trauma ... [from becoming] uncontrollably and disastrously intensified," 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. 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:
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Table 2. Common responses to a traumatic event
*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:
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.
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]) 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.
Eye movement desensitization and reprocessing (EMDR). 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." 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.
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. These should be used only within a comprehensive CISM program.
Acute Traumatic Stress Management, 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.