| 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
Group, LLC
Abstract and Introduction
Abstract
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.
Introduction
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.
Tables
Table 1. Potential traumatic events
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The following four groupings comprise 19 potentially traumatic experiences, as suggested by DSM-IV definitions of stressors:
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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Table 2. Common responses to a traumatic event
|
Physiological responses
Emotional responses
Cognitive responses
Behavioral responses
|
*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:
|
References
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.
