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Acute Traumatic Stress

By Kenneth Harbert, PhD, BCETS, CTS, PA-C
Originally published in Clinician Reviews 12(1):50-57, 2002

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 trauma3—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

In the 1995 National Comorbidity Survey of nearly 6,000 subjects,6 it was found that lifetime prevalence of any trauma was 60.7% among men and 51.2% among women—but that women were twice as likely as men to experience PTSD during their lifetime (10.4% vs 5.0%, respectively). The investigators concluded that one in 12 members of the US adult population (7.8%) experience PTSD during their lifetime. For a similar survey reported in 2001, Breslau7 created a list of 19 traumatic events that illustrate the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition of stressors2 (see Table 1).

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 threat8), 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)

Screening tools are currently in development for ASD; structured interviews appear more effective than self-report methods.4 According to Norwegian researchers, four "early response" variables that are effective predictors for development of subsequent PTSD are the degree of sleep disturbance, startle reaction, fear or phobia of the site of the trauma, and degree of social withdrawal.14 Bryant et al4,15 have investigated use of a 19-item Acute Stress Disorder Scale, which effectively confirmed ASD but yielded numerous false-positive predictions of PTSD. Thus, its use should be supplemented by careful clinical assessment, the researchers advise.

Until a standardized ASD screening tool is proven useful for a wide range of traumatic situations, clinicians can make an early evaluation of patients' symptoms and their intensity and duration since the traumatic event. Common physiological, emotional, cognitive, and behavioral reactions are listed in Table 216,17; note physical symptoms that should prompt immediate medical evaluation. Patients should be referred to a mental health professional for further evaluation and treatment if these reactions last longer than one month; if they interfere with daily social or occupational functions; or (as advised by the National Mental Health Association and the American Academy of Experts in Traumatic Stress) if they are joined by one or more symptoms listed in Table 316,17 (page 54).

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.)

The primary care practitioner may then proceed with an educational approach, using discussion and reading materials to help the patient understand the physiological and psychological effects of trauma; or a holistic approach, which emphasizes good nutrition, exercise, spirituality, and even humor as supportive healing measures. Social integration strategies, including family therapy and group psychotherapy, can reduce the patient's feelings of isolation and reinforce effective coping methods.19,20 See "Psychological Interventions for Traumatic Stress,"5,8,12,16,21-29 page 55.

Pharmacotherapy

Acute traumatic stress is a complex entity, requiring a multidimensional treatment approach. It may be advisable for the primary care provider to focus on issues of dysfunction and coping, and to limit medication use to treating symptoms. For example, clonidine may be prescribed to reduce hyperarousal; propranolol, clonazepam, or alprazolam to decrease symptoms of anxiety and panic; fluoxetine to relieve avoidance symptoms and explosiveness; and trazodone, clonidine, or topiramate for relief of insomnia and nightmares.30-33 A variety of antidepressant medications are available as adjunctive therapy for patients who suffer from PTSD and other stress-related disorders. These include the selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants.27

Health Professionals at Risk

Researchers have acknowledged the importance of debriefing activities for emergency service workers involved in traumatic events.8 Too often, caregivers (including professional rescuers, health care practitioners, therapists, and counselors) are expected to withstand the physical and emotional demands of a traumatic event without developing serious emotional problems themselves.

During the recent catastrophic events, NPs and PAs may have cared for seriously injured or dying patients; others participated in identifying recovered remains. Whether they found the volume of work debilitating or waited for patients who never came, clinicians may be questioning their sense of self-worth. For emergency responders who do not fully recover within days or weeks of any traumatic event, debriefing or another intervention may be appropriate.

Many health care facilities have formed an interdisciplinary Critical Incident Stress Management (CISM) team—including physicians, PAs, NPs and other nurses, social workers, emergency medical personnel, mental health specialists, pastoral care personnel, and appropriate administrators—to provide rapid first response for caregivers in situations requiring primary, secondary, and/or tertiary crisis intervention. With basic or advanced training from the International Critical Incident Stress Foundation34 (see www.icisf.org), CISM team members respond to requests for help from the caregiver in question or from a concerned coworker or supervisor.35 Practitioners who are assaulted by patients, for example, may benefit from a CISM-based program called the Assaulted Staff Action Program (ASAP).36

Clinicians without access to a CISM team should consider the recommendations in the patient handout on page 46. If symptoms of acute stress persist for more than one month, clinicians should seek help from a professional skilled in treating traumatic stress.

Conclusion

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 events7

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 event16,17

Physiological responses

*NOTE: These physical symptoms require immediate medical evaluation.

Emotional responses

Cognitive responses

Behavioral responses

Table 3. When to refer traumatized patients to a mental health specialist16,17

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

  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. Available at: www.terrorism.com/terrorism/def.shtml. Accessed: December 18, 2001.
  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: www. aaets.org. 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: www.nmha.org/reassurance/when_to_seek_help_printpage.cfm. Accessed November 14, 2001. 18. Breslau N. Outcomes of posttraumatic stress disorder. J Clin Psychiatry. 2001;62(suppl 17):55-59.
  18. Lerner MD. Early intervention: a multidisciplinary effort. American Academy of Experts in Traumatic Stress. Available at: www.aaets.org/arts/art9.htm. Accessed November 12, 2001.
  19. 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.
  20. Everly GS Jr. Five principles of crisis intervention: reducing the risk of premature crisis intervention. Int J Emerg Ment Health. 2000;2:1-4.
  21. Foa EB, Street GP. Women and traumatic events. J Clin Psychiatry. 2001; 62(suppl 17):29-34.
  22. Shapiro F. Eye movement desensitization and reprocessing: evaluation of controlled PTSD research. J Behav Ther Exp Psychiatry. 1996;27:209-218.
  23. 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.
  24. 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.
  25. Davidson PR, Parker KCH. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. J Consult Clin Psychol. 2001;69:305-316.
  26. Davidson JRT, Connor KM. Management of posttraumatic stress disorder: diagnostic and therapeutic issues. J Clin Psychiatry. 1999;60(suppl 18):33-38.
  27. 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.
  28. Mitchell JT, Everly GS Jr. The scientific evidence for Critical Incident Stress Management. J Emerg Med Serv JEMS. 1997;22:86-93.
  29. Vargas MA, Davidson J. Post-traumatic stress disorder. Psychiatr Clin North Am. 1993;16:737-748.
  30. Lange JT, Lange CL, Cabaltica RBG. Primary care treatment of post-traumatic stress disorder. Am Fam Physician. 2000;62:1035-1040.
  31. Warner MD, Dorn MR, Peabody CA. Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares. Pharmacopsychiatry. 2001;34:128-131.
  32. Berlant JL. Topiramate in posttraumatic stress disorder: preliminary clinical observations. J Clin Psychiatry. 2001; 62(suppl 17):60-63.
  33. International Critical Incident Stress Foundation. CISM in the healthcare setting. Available at: www.icisf.org. Accessed November 8, 2001.
  34. Harbert K. The history and development of an interdisciplinary crisis intervention team within a rural tertiary care center. Submitted for publication, 2001.
  35. Flannery RB Jr. The Assaulted Staff Action Program (ASAP): ten year empirical support for Critical Incident Stress Management (CISM). Int J Emerg Ment Health. 2001;3:5-10.

SIDE BAR: Psychological Interventions for Traumatic Stress

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 (for information, go to www.cismtraining.com). 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.

Copyright © 2002 Clinicians Group, LLC