Acute stress disorder overview

# Overview
Acute stress disorder is defined as the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events. The exact pathogenesis of acute stress disorder is not fully understood. It is thought that acute stress disorder is caused by either sympathetic nervous system, both directly and indirectly through the release od adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands, or hypothalamic-pituitary-adrenal axis. Acute stress disorder may be caused by either experiencing, witnessing, or being confronted with one or more traumatic events. The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. Females are more commonly affected with acute stress disorder than males. Common risk factors in the development of acute stress disorder are temperamental, environment, and genetic and physiological. If left untreated, 50% of patients with acute stress disorder may progress to develop post traumatic stress disorder. Common complications of acute stress disorder include interference with sleep, energy levels, and capacity to attend to tasks, generalized withdrawal, and progression to post traumatic stress disorder. Prognosis is generally good, and the majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). The diagnosis of acute stress disorder is based on the DSM-5 diagnostic criteria, which include criterion A i.e the exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways such as directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occurred to others, learning that the event(s) occured to a close family member or close friend, and experiencing repeated or extreme exposure to aversive details of the traumatic event(s), criterion B i.e presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening  after the traumatic event(s) occurred, criterion C i.e duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure, criterion D i.e the disturbance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning, and criterion E i.e the disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder. Symptoms of acute stress disorder include dissociative symptoms, symptoms of reexperiencing the traumatic event, avoidence symptoms, symptoms of anxiety or increased arousal,  symptoms of distress, chaotic and impulsive behavior, and post-concussive symptoms. The optimal therapy for acute stress disorder includes cognitive-behavioral therapy and pharmacotherapy. The mainstay of therapy for acute stress disorder is cognitive-behavioral therapy.
Pharmacologic medical therapies for acute stress disorder include beta blockers, alpha adrenergic agents, benzodiazepines and/or SSRIs.

# Historical Perspective
Acute stress disorder was originally made known during world wars 1 and 2, where soldiers exhibited signs of stress up to 1 month after a traumatic event.

# Classification
There is no classification system established for acute stress disorder.

# Pathophysiology
The exact pathogenesis of acute stress disorder is not fully understood. It is thought that acute stress disorder is caused by either sympathetic nervous system, both directly and indirectly through the release of adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands, or hypothalamic-pituitary-adrenal axis.

# Causes
Acute stress disorder may be caused by either experiencing, witnessing, or being confronted with one or more traumatic events.

# Differential Diagnosis
Acute stress disorder must be differentiated from other diseases that closely mimic a range of acute stress disorder symptoms, including depersonalization, derealization, reduced awareness, and dissociative amnesia or from disorders that doesn't meet criteria for acute stress disorder such as post traumatic stress disorder, obsessive-compulsive disorder, anxiety disorders, depression, dissociative disorders, panic disorder, adjustment disorder, effects of analgesic medications, medical conditions involving coma or impaired awareness, effects of  
substance abuse, traumatic brain injury (TBI), exacerbation of a preexisting mental condition, brief psychotic episode, and psychotic disorders.

# Epidemiology and Demographics
The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. Females are more commonly affected with acute stress disorder than males.

# Risk Factors
Common risk factors in the development of acute stress disorder are temperamental, environment, and genetic and physiological.

# Screening
According to the United States Preventive Services Task Force, screening for acute stress disorder is not recommended.

# Natural History, Complications, and Prognosis
If left untreated, 50% of patients with acute stress disorder may progress to develop post traumatic stress disorder. Common complications of acute stress disorder include interference with sleep, energy levels, and capacity to attend to tasks, generalized withdrawal, and progression to post traumatic stress disorder. Prognosis is generally good, and the majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). Of individuals who have cognitive-behavioral therapy (CBT) shortly after frightening events, only about 10% to 20% develop PTSD.

# Diagnosis

## Diagnostic Criteria
The diagnosis of acute stress disorder is based on the DSM-5 diagnostic criteria, which include criterion A i.e the exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways such as directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occured to others, learning that the event(s) occured toa close family member or close friend, and experiencing repeated or extreme exposure to aversive details of the traumatic event(s), criterion B i.e presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening  after the traumatic event(s) occurred, criterion C i.e duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure, criterion D i.e the disturbance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning, and criterion E i.e the disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g.,mild traumatic brain injury) and is not better explained by brief psychotic disorder.

## History and Symptoms
Symptoms of acute stress disorder include dissociative symptoms, symptoms of reexperiencing the traumatic event, avoidence symptoms, symptoms of anxiety or increased arousal,  symptoms of distress, chaotic and impulsive behavior, and post-concussive symptoms.

## Physical Examination
Patients with acute stress disorder usually appear disheveled and unclean and may show the effects of dehydration and failure to care for themselves. Mental status examination of patients with acute stress disorder is usually remarkable for anxious, sad, irritable, apathetic, emotionally labile, angry, or calm, individuals may feel helpless, be confused, be in a state of disbelief, have markedly impaired concentration, have lowered self-esteem, or be driven to search for the deceased, patients may have visual or auditory hallucinations that the deceased person is present; feelings of unreality, flashbacks, numbness, and denial may occur, confusion in combination with preoccupation with those they have lost may be present that impair an individuals judgment and insight, and suicidal thoughts occur in as many as approximately 54% of survivors and may continue up to 6 months after the death; thoughts or plans of homicide may be present.

## Laboratory Findings
There are no diagnostic lab findings associated with acute stress disorder.

## Chest X Ray
There are no chest x ray findings associated with acute stress disorder.

## CT
There are no CT scan findings associated with acute stress disorder.

## MRI
There are no MRI findings associated with acute stress disorder.

## Other Imaging Findings
There are no other imaging findings associated with acute stress disorder.

## Other Diagnostic Studies
There are no other diagnostic studies associated with acute stress disorder.

# Treatment

## Medical Therapy
Pharmacologic medical therapies for acute stress disorder include beta blockers, alpha adrenergic agents, benzodiazepines and/or SSRIs.

## Psychotherapy
The optimal therapy for acute stress disorder includes cognitive-behavioral therapy and pharmacotherapy. The mainstay of therapy for acute stress disorder is cognitive-behavioral therapy.

## Primary Prevention
Effective measures for the primary prevention of acute stress disorder include getting medical treatment with a few hours of experiencing a traumatic event and counseling and preparation training in military personnel.

## Secondary Prevention
There are no secondary preventive measures available for acute stress disorder.