Stress Disorders

Acute Stress Disorder

Acute stress disorder is a brief period of intrusive recollections occurring very soon after a witnessed or experienced overwhelming traumatic event.

Geriatric Essentials

• Elderly people who have witnessed the death of a friend may experience acute stress disorder for a short period when exposed to the setting where the death occurred.

In acute stress disorder, the person has been through a traumatic event, has recurring recollections of the trauma, avoids stimuli that remind the person of the trauma, and has increased arousal. Symptoms begin within 4 wk of the traumatic event and last a minimum of 2 days but, unlike posttraumatic stress disorder, last no more than 4 wk. A person with this disorder may experience a sense of numbness, detachment, or absence of emotional responsiveness; reduced awareness of surroundings (eg, being dazed); a feeling of not being real or that things are not real; or amnesia for an important part of the trauma.

Most people recover once they are removed from the traumatic situation, are shown understanding and empathy, and are given an opportunity to describe what happened and their reaction to it. Drugs to assist sleep may help, but other drugs are usually not indicated. (A practice guideline on treating patients with acute stress disorder and posttraumatic stress disorder is available from the American Psychiatric Association.)

Posttraumatic Stress Disorder

Posttraumatic stress disorder is recurring, intrusive recollections of an overwhelming traumatic event. The pathophysiology of the disorder is incompletely understood. Symptoms also include avoidance of stimuli associated with the traumatic event, nightmares, and flashbacks. Diagnosis is based on history. Treatment consists of exposure and drug therapies.

Geriatric Essentials

• Overall, elderly people are at lower risk of developing posttraumatic stress disorder than younger adults; however, risk may be increased for elderly people who live in unsafe neighborhoods where they are more likely to be assaulted.

In posttraumatic stress disorder (PTSD), an overwhelmingly traumatic event is reexperienced, causing intense fear, helplessness, horror, and avoidance of stimuli associated with the trauma. The stress may have occurred long ago; the adverse effect of severe stress during childhood or young adulthood on late-life psychologic functioning has long been recognized. Psychologic trauma may also occur in late life, although the incidence of new-onset PTSD among the elderly is low. Usually, events likely to evoke PTSD are those that invoke feelings of fear, helplessness, or horror. These events might include experiencing serious injury or the threat of death or witnessing others being seriously injured, threatened with death, or actually dying.

Most commonly, people have frequent, unwanted memories that replay the triggering event. Nightmares of the event are common. The person avoids stimuli associated with the trauma and often feels emotionally numb and disinterested in daily activities. Sometimes symptom onset is delayed, occurring many months or even years after the traumatic event. PTSD is considered chronic if present > 3 mo. Depression, other anxiety disorders, and substance abuse are common in people with chronic PTSD.

Diagnosis is based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). If untreated, chronic PTSD often diminishes in severity without disappearing, but some people remain severely handicapped by it. The primary form of psychotherapy used, exposure therapy, involves exposure to situations that the person avoids because they may trigger recollections of the trauma. SSRIs such as paroxetine (initial dose of 10 mg, can be gradually increased to 40 mg once/day; initial dose of the continuous-release form is 12.5 mg, can be gradually increased to 50 mg once/day) may be effective in patients who do not respond adequately to psychotherapy. (A practice guideline on treating patients with acute stress disorder and posttraumatic stress disorder is available from the American Psychiatric Association.)

This topic was last updated September 2005.