Acute stress disorder and Post-traumatic stress disorder

Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) are trauma-related psychiatric conditions that develop following exposure to a severely distressing or life-threatening event. The traumatic event may involve actual or threatened death, serious injury, sexual violence, or perceived threat to oneself or others.

During the traumatic experience, individuals commonly experience intense fear, helplessness, or horror. While both disorders share similar symptom profiles, they differ primarily in timing and duration of symptoms.

• Acute Stress Disorder: Symptoms occur within 4 weeks of trauma and last up to 4 weeks.

• Post-Traumatic Stress Disorder: Symptoms persist longer than 4 weeks or may appear months after the traumatic event.

Untreated trauma-related disorders may significantly impair psychological, occupational, and social functioning.

Risk Factors

• Exposure to severe trauma (violence, accidents, disasters, war)

• Sexual or physical assault

• Childhood abuse or neglect

• Previous psychiatric illness

• Prior trauma exposure

• Lack of social support

• Female gender

• Severe perceived threat during event

• Physical injury during trauma

• Ongoing stress after trauma

• Substance use disorders

Signs and Symptoms

Symptoms cluster into characteristic domains:

1. Re-experiencing Symptoms

• Intrusive memories

• Flashbacks

• Trauma-related nightmares

• Emotional distress when reminded of trauma

• Physiological reactions to reminders

2. Avoidance Symptoms

• Avoidance of places or people linked to trauma

• Avoidance of thoughts or conversations about event

• Emotional numbing

• Social withdrawal

3. Hyperarousal Symptoms

• Hypervigilance

• Exaggerated startle response

• Irritability or anger outbursts

• Poor concentration

• Insomnia

• Anxiety

4. Negative Mood and Cognitive Changes

• Persistent fear or guilt

• Reduced interest in activities

• Feelings of detachment

• Hopelessness

• Memory difficulties related to trauma

Diagnostic Criteria

Common Features

• Re-experiencing of traumatic event (flashbacks, dreams)

• Avoidance of trauma-related stimuli

• Increased arousal or anxiety symptoms

• Functional impairment

Key Diagnostic Difference

Diagnosis requires exclusion of:

• Substance intoxication or withdrawal

• Traumatic brain injury

• Psychotic disorders

• Major depressive disorder

• Medical causes of delirium

Investigations

There is no specific laboratory test for ASD or PTSD. Investigations aim to exclude alternative diagnoses.

Clinical Assessment

• Detailed trauma history

• Mental status examination

• Suicide risk assessment

• Functional impairment evaluation

Screening Tools

• Acute Stress Disorder Scale (ASDS)

• PTSD Checklist (PCL-5)

• Depression and anxiety screening tools

Medical Evaluation (When Indicated)

• Toxicology screening

• Neuroimaging (head injury suspected)

• Thyroid function tests

• Substance use assessment

Management

Management focuses on symptom relief, psychological recovery, and prevention of chronic PTSD.

Non-Pharmacological Management

Early Supportive Care

• Reassurance and emotional support

• Education about normal stress reactions

• Family involvement

• Restoration of safety and routine

Psychotherapy (First-Line Treatment)

• Trauma-focused Cognitive Behavioural Therapy (CBT)

• Supportive psychotherapy

• Exposure-based therapy

• Stress management techniques

• Relaxation therapy

• Group therapy when appropriate

Early psychological intervention significantly reduces progression to PTSD.

Pharmacological Management

Medication is indicated when symptoms are severe, persistent, or impair functioning.

Acute Stress Disorder

For acute anxiety or agitation:

• Clonazepam 0.5–2 mg orally in divided doses

Important Note:Benzodiazepine use beyond 1 week may interfere with psychological adaptation and increase risk of developing PTSD.

Post-Traumatic Stress Disorder

Tricyclic Antidepressant

• Amitriptyline

  • Initial: 50–75 mg orally at night

  • Gradually increase up to 150 mg daily

  • Elderly: start 25–50 mg (maximum 75 mg)

Selective Serotonin Reuptake Inhibitors (First-Line)

Fluoxetine

• Initial: 20 mg each morning

• Increase to 40 mg after 4–8 weeks if needed

OR

Citalopram

• Initial: 20 mg daily

• Increase to 40 mg after 4–8 weeks if tolerated

Treatment Duration

• Adequate antidepressant trial: 8–12 weeks

• Continue treatment for 6–12 months after improvement to prevent relapse.

Complications

• Chronic PTSD

• Major depressive disorder

• Substance misuse

• Panic disorder

• Suicide risk

• Occupational dysfunction

• Relationship difficulties

Prevention

• Early psychological first aid after trauma

• Rapid identification of high-risk individuals

• Community disaster mental health support

• Strengthening social support systems

• Early counselling interventions

• Workplace and military trauma programs

Prognosis

Many individuals with Acute Stress Disorder recover fully with early intervention. Without treatment, a significant proportion may progress to PTSD. Long-term outcomes improve with trauma-focused psychotherapy and appropriate pharmacological therapy.

Patient Education

• Stress reactions after trauma are common and treatable

• Seeking help early prevents chronic psychological illness

• Avoid alcohol or substance use as coping mechanisms

• Maintain sleep, routine, and social support

• Persistent symptoms beyond one month require medical evaluation