Acute Stress Reaction

Acute Stress Reaction (ASR), also known as psychological shock, mental shock, or simply shock, is a psychological response to a terrifying, traumatic, or surprising experience. It is often referred to as Acute Stress Disorder (ASD) when symptoms persist. The condition may develop into post-traumatic stress disorder (PTSD) if not properly addressed.

Causes

ASR is typically triggered by exposure to a traumatic event, such as natural or human-made disasters, combat, serious accidents, sexual violence, or assault. Combat stress reaction (CSR) is a similar response specific to war trauma.

Signs and Symptoms

The reactions to trauma can vary widely but often include intrusive or dissociative symptoms and reactivity symptoms such as avoidance or arousal. These can manifest as:

• Intrusion: Recurring distressing dreams, flashbacks, or memories related to the traumatic event.
• Negative Mood: Inability to experience positive emotions.
• Dissociation: Numbing, detachment from emotional reactions, physical detachment, decreased awareness of surroundings, perception that the environment is unreal, and dissociative amnesia.
• Emotional Arousal: Sleep disturbances, hypervigilance, concentration difficulties, exaggerated startle response, and irritability.

In children, ASR can include somatic symptoms like stomachaches or headaches, disruptive behaviour, regression, hyperactivity, tantrums, concentration problems, irritability, withdrawal, excessive daydreaming, increased clinginess, bedwetting, and sleep disturbances. Adolescents may exhibit substance use and risk-taking behaviours.

Diagnostic Criteria

ICD-11

According to ICD-11, acute stress reaction refers to symptoms experienced from a few hours to days after exposure to a traumatic event. These symptoms typically subside within a few days or weeks, provided the individual is removed from the stressor.

DSM-5

DSM-5 defines acute stress disorder as symptoms experienced 48 hours to one month following the event. Symptoms persisting beyond one month may indicate PTSD. Diagnosis requires exposure to actual or threatened death, serious injury, or sexual violation and significant impairment in life domains.

Diagnostic Assessment

Diagnosis involves a close examination of emotional responses and self-reported symptoms. Evaluation focuses on the severity and impact of symptoms on personal functioning.

Development and Course

ASR shares many symptoms with PTSD. Research indicates even a single stressful event can have long-term effects on cognitive function, challenging the traditional distinction between acute and chronic stress.

Risk Factors

Risk factors for developing ASR include pre-existing mental health conditions, avoidant coping mechanisms, exaggerated appraisals of events, prior trauma history, and heightened emotional reactivity. Females have a higher prevalence due to higher risk of experiencing traumatic events and neurobiological gender differences.

Types

Sympathetic

This type is caused by the release of excessive adrenaline and norepinephrine, leading to increased pulse, respiratory rate, and temporary pain masking. It evolved as a survival mechanism.

Parasympathetic

Characterised by faintness and nausea, often triggered by the sight of blood. It involves the release of acetylcholine, slowing the heart rate and potentially causing unconsciousness.

Pathophysiology

Stress triggers specific physiological responses. Hans Selye's "general adaptation syndrome" describes stages of alarm, resistance, and exhaustion. The sympathetic nervous system's "fight or flight" response increases heart rate, blood pressure, and glucose release.

An acute stress response involves adrenaline and noradrenaline release, facilitating physical reactions. The hypothalamic-pituitary-adrenal axis also plays a role, producing neuro-biological changes that increase survival chances.

Studies show overactive right amygdalae and prefrontal cortices in patients with ASR, indicating these structures' involvement in fear-processing pathways.

Treatment

ASR may resolve independently or develop into PTSD. Early pharmacotherapy and trauma-focused cognitive behavioural therapy (TF-CBT) can prevent chronic PTSD. Cognitive behavioural therapy, including exposure and cognitive restructuring, has proven effective in preventing PTSD. Mindfulness-based stress reduction programmes also aid stress management.

Pharmacological treatments include Prazosin for relaxing patients and improving sleep, and Hydrocortisone as an early preventative measure. In wilderness contexts, treatment involves allowing the patient to lie down, providing reassurance, and removing the stressor.

History

The term "acute stress disorder" was first used to describe soldiers' symptoms during WWI and WWII, also known as combat stress reaction (CSR). The American Psychiatric Association included ASD in the DSM-IV in 1994.

Despite criticisms, ASD remains a diagnosis to distinguish early stress reactions and predict PTSD development. However, it may not fully cover the range of stress reactions.

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Self-assessment MCQs (single best answer)

What is another name for Acute Stress Reaction (ASR)?

Which of the following is a common cause of ASR?

Which symptom category involves recurring distressing dreams or memories related to the traumatic event?

What type of symptom is characterised by sleep disturbances, hypervigilance, and concentration difficulties?

According to DSM-5, what is the time frame for diagnosing acute stress disorder following a traumatic event?

Which factor is NOT a risk factor for developing ASR?

Which type of ASR is characterised by faintness and nausea?

What is the physiological response called that involves stages of alarm, resistance, and exhaustion?

Which treatment is used to relax patients and improve sleep in ASR?

In what context was the term "acute stress disorder" first used to describe symptoms?