Acute stress disorder in adults: Treatment

INTRODUCTION — Acute stress disorder (ASD) is characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event. The disorder includes symptoms of intrusion, dissociation, negative mood, avoidance, and arousal. Some patients who experience ASD go on to experience posttraumatic stress disorder (PTSD), which is diagnosed only after one month of symptoms following exposure to trauma.

Treatment for ASD is discussed in this topic. The epidemiology, clinical manifestations, and diagnosis of ASD are discussed separately. Topics related to PTSD, including diagnosis and treatment, are also discussed separately.

●(See "Acute stress disorder in adults: Epidemiology, clinical features, assessment, and diagnosis".)

●(See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

●(See "Posttraumatic stress disorder in adults: Treatment overview".)

●(See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions".)

TREATMENT GOALS — Treatment is aimed at curtailing symptoms of acute stress responses and preventing the development of PTSD.

TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY AS FIRST CHOICE

Indications — For most individuals with acute stress disorder (ASD), our preference is initial treatment with trauma-focused cognitive-behavioral therapy (TF-CBT). However, in some cases only some of the components of TF-CBT are available or tolerated. While evidence does not consistently support one form of treatment over another in the treatment of ASD or the prevention of posttraumatic stress disorder (PTSD), TF-CBT is the most extensively studied and has the most evidence in support of its use [1-12].

●However, in more severe cases of trauma, individuals may not tolerate exposure therapy due to the distress it may illicit. In these individuals, we treat with cognitive therapy without exposure therapy. (See 'For those who do not tolerate or refuse exposure therapy' below.)

●Additionally, in cases where the individual refuses to engage in cognitive therapy or in those cases where the individual is unable to benefit from cognitive therapy (eg, limited insight) we treat with exposure therapy without cognitive therapy. (See 'For those that cannot engage in cognitive therapy' below.)

When to start treatment — In most cases, our preference is to wait at least two weeks after trauma exposure to allow for transient symptoms to abate and stressors to minimize. Treatment is better delayed if patients experience factors in the acute phase that may interfere with treatment, including severe pain, opioid medication, or ongoing stressors that may impede treatment success (eg, postdisaster relocation or temporary housing, criminal procedures). In these cases, it can be more beneficial to provide supportive counseling rather than active exposure or cognitive therapy. These more active treatment modalities can be introduced when the acute stressors have settled to the extent that the patient can manage the requirements of therapy. At one month after trauma exposure, the person may qualify for a PTSD diagnosis and PTSD treatment guidelines should be followed.

The risk in commencing treatment immediately after trauma exposure is that treatment can be provided to the many patients who do not require it. Clinical experience suggests that commencing exposure therapy at approximately two weeks is optimal because it balances the benefits of early intervention while minimizing the likelihood of treating transient stress reactions that will abate naturally. (See "Overview of psychotherapies", section on 'Supportive psychotherapy'.)

In some cases, such as when symptoms are severe (eg, suicidal ideation, severe psychosocial dysfunction) or when there is restricted opportunity to provide treatment after two weeks (eg, military personnel who are being redeployed, patients being discharged from hospital and will not have access to subsequent specialist mental health services) we agree with beginning treatment sooner [13].

Administration — We typically provide cognitive-behavioral therapy (CBT) for ASD over six weekly sessions of 60 to 90 minutes.

TF-CBT for ASD is typically composed of multiple components including patient education, cognitive restructuring, and exposure therapy [14]. These are briefly discussed below. Further discussion of administration of TF-CBT for trauma and other stressor-related disorders is found elsewhere. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Trauma-focused therapy as first-line treatment' and "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

●Patient education – We discuss stressful reactions to trauma, trauma-related disorders, and treatment options with the patient. Using patient education, we aim to normalize the response to stress, learn that reminders of the trauma are not dangerous, and heighten expectations for recovery.

●Cognitive restructuring – Cognitive restructuring is used to address maladaptive or unrealistic belief that individual has about the traumatic event and its implications on their life. This is done by examining thoughts and feelings and learning to challenge maladaptive thoughts and overgeneralized beliefs [14]. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Cognitive-behavioral therapy' and "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

●Exposure – Exposure therapy for ASD optimally includes both imaginal and in vivo exposure methods. Exposure therapy assists patients in confronting their feared memories in a therapeutic manner. Re-experiencing the trauma through exposure allows it to be emotionally processed so that extinction learning, or the gradual decrease in response to a stimulus when the stimulus is presented without reinforcement [15,16]. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Exposure-based therapies'.)

•Imaginal exposure – Imaginal exposure is often used when the stimulus is too costly or too infrequent to recreate. Additionally, imaginal exposure is used as part of a hierarchy leading to in vivo exposure if an individual is not ready to engage directly with the feared stimulus. In imaginal exposure, the patient provides a detailed narrative of their traumatic experience through verbal description, writing or other means. Typical imaginal exposure therapy sessions include at least 30 minutes of imaginal exposure.

•In vivo exposure – In in vivo exposure, the patient confronts the feared stimulus accompanied by the clinician or other mental health worker. This is often done during several different sessions with a gradual increase in intensity of the stimulus. For example, in an individual with trauma related to a dog attack, we might aim first for the patient to be in the room with the dog, and gradually work towards touching or petting the dog.

Further discussion of the administration of exposure-based therapies for trauma and other stressor-related disorders is discussed elsewhere. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions".)

Alternative trauma-focused cognitive-behavioral therapy approaches — In cases where the individual does not tolerate exposure therapy (eg, severe symptoms, distress it may illicit), we treat with cognitive therapy without exposure. In cases where the individual refuses cognitive therapy or is unable to benefit from cognitive therapy (limited insight), we treat with exposure therapy alone. (See 'For those who do not tolerate or refuse exposure therapy' below and 'For those that cannot engage in cognitive therapy' below.)

For those who do not tolerate or refuse exposure therapy — In more severe cases of traumatic stress, individuals may not tolerate exposure therapy due to the distress it may illicit in the acute aftermath of trauma [17]. Clinicians may decide to commence with cognitive therapy in the initial weeks after trauma exposure if the patient may not tolerate exposure therapy, and progress to exposure therapy when they are stable enough to benefit from exposure therapy.

For individuals with the following presentations, we may delay exposure therapy and provide alternate treatment modalities, such as cognitive therapy, until the patient can benefit from exposure therapy. Note that after one month after trauma exposure, the person may qualify for a PTSD diagnosis and PTSD treatment guidelines should be followed (which are similar to the recommended treatments for ASD).

●Extreme avoidance or dissociative responses – These presentations may indicate extreme stress responses that may be complicated by exposure. (See "Acute stress disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnostic criteria' and "Acute stress disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Pathogenesis'.)

●A primary response of anger – Anger often does not respond optimally to exposure exercises and may respond better to cognitive therapy and anger management.

●Acute grief response – Exposure therapy may complicate normal grieving. It can be more beneficial to provide support, and consider exposure therapy for ASD after several months [14].

●Persisting PTSD responses to childhood trauma – Addressing childhood trauma in the weeks after a recent trauma may be counterproductive because the distress arising from the recent trauma may complicate the patient’s capacity to manage long-standing developmental issues arising from childhood trauma. Our preference is to support the patient until the acute stress has settled, or the contextual stressors have abated before treating the posttraumatic stress, and then consider if exposure therapy should focus on childhood or recent adult trauma (depending on which is the prevailing focus of intrusive symptoms).

●Borderline or psychotic features – Exposure therapy may complicate the presentation of individuals with these disorders (eg, promote or worsen psychosis).

●Suicidal risk – Individuals with suicidal thoughts or at high risk of suicide require management of these symptoms as a priority.

For those that cannot engage in cognitive therapy — In cases where the individual refuses to engage in cognitive therapy or in those cases where the individual is unable to benefit from cognitive therapy (eg, limited insight, moderate or severe traumatic brain injury), other treatment modalities such as exposure therapy without cognitive component are preferred. (See 'Efficacy of trauma-focused cognitive-behavioral therapy' below.)

EFFICACY OF TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY — Trauma-focused cognitive-behavioral therapy (TF-CBT) appears to be effective in treatment of symptoms of acute stress disorder (ASD) and in reducing the likelihood of transition to posttraumatic stress disorder (PTSD) when offered to individuals in the initial weeks after trauma exposure in some, but not all, trials [1-5,7-9,18]. Most trials of ASD measure the efficacy of the intervention in terms of the severity of PTSD symptoms at least one month after trauma exposure, when the diagnosis of PTSD is relevant.

In a systematic review, TF-CBT as compared with either waitlist/treatment as usual or supportive counseling each led to a greater reduction in symptoms of trauma- or stressor-related disorders at treatment end (four trials, n = 273; mean difference -0.49, 95% CI -0.93 to -0.05, and seven trials, n = 271; mean difference -0.7, 95% CI -1.13 to -0.27, respectively) [7]. Additionally, among trials using a brief exposure-based intervention as TF-CBT, as compared with supportive counseling, symptom reduction was also greater (standardized mean difference 0.61, 95% CI 1.01-0.22).

In cases where both cognitive and exposure components of TF-CBT cannot be offered we offer treatment with one component or the other. (See 'Alternative trauma-focused cognitive-behavioral therapy approaches' above.)

Treatment with either cognitive therapy or exposure therapy may be helpful in reducing the risk of transition to PTSD in individuals with ASD. As examples:

●In individuals who cannot engage in cognitive therapy (eg, limited insight, severe traumatic brain injury), exposure therapy without cognitive therapy appears to be effective in preventing the development of PTSD [8,9] (see 'For those that cannot engage in cognitive therapy' above). For example, in a randomized trial investigating early interventions for reducing PTSD, 137 individuals with recent trauma were assigned to receive three sessions of modified prolonged exposure or “assessment-only” control beginning an average of 11.8 hours after exposure to trauma [9]. At both 4- and 12-week follow-up, prolonged exposure, as compared with control, led to greater reduction in severity of PTSD symptoms and depressive symptoms (Beck Depression Inventory, PTSD Symptom Scale, interview version). At four weeks posttrauma, the proportion not meeting criteria for PTSD was similar between the treatment and control group (54 versus 49 percent, respectively). However, at 12 weeks, a greater proportion who received prolonged exposure did not meet criteria for a PTSD diagnosis compared with controls (74 versus 53 percent, respectively).

●In individuals being treated with cognitive therapy without exposure therapy addition to being a component of TF-CBT (see 'For those who do not tolerate or refuse exposure therapy' above), cognitive therapy as monotherapy has also shown evidence of efficacy in preventing PTSD as compared with waitlist. In a trial, 242 patients with recent trauma were randomly assigned to 12 weeks of treatment with one of five different methods (cognitive therapy, exposure therapy, pharmacologic intervention, placebo intervention, and waitlist). At five months after trauma exposure, individuals assigned to cognitive therapy as compared with those assigned to waitlist had a lower likelihood of PTSD (18 versus 58 percent, respectively). However, at nine months, similar rates of PTSD between these two groups were reported (23 percent each) [8].

●Comparisons between exposure therapy and cognitive therapy appear to show greater efficacy for exposure therapy in lowering the likelihood of developing PTSD [8,10]. For example, in a randomized trial 90 individuals who met diagnostic criteria for ASD were randomly assigned to receive imaginal and in vivo exposure, cognitive restructuring (a form of cognitive-behavioral therapy [CBT]), or to a waitlist control group [10]. After six weeks of treatment, fewer patients in the exposure group met diagnostic criteria for PTSD as compared with those in the cognitive restructuring or waitlist groups (33 versus 63 versus 77 percent, respectively). At six-month follow-up, fewer patients in the exposure therapy group, as compared with those in the cognitive restructuring group met diagnostic criteria for PTSD (37 versus 63 percent) and a higher percentage of those in the exposure group achieved full remission (47 versus 13 percent, respectively). Further studies are needed to firmly support one treatment over another.

ADJUNCTIVE PHARMACOTHERAPY — We use adjunctive pharmacotherapy in cases where severity of symptoms preclude the ability to work in psychotherapy or cause significant psychosocial distress. We also treat with adjunctive medication, such as selective serotonin reuptake inhibitors (SSRIs), in individuals with co-occurring disorder that is typically responsive to medication, such as depression, acute anxiety, insomnia, or other arousal symptoms.

Selective serotonin reuptake inhibitors for most — For most individuals who are treated with adjunctive medication for acute stress disorder (ASD), we prefer SSRIs.

As clinical trials have not consistently found a benefit in reducing symptoms of ASD or preventing posttraumatic stress disorder (PTSD) for any particular SSRI over another or as compared with placebo, our preference for initial agent is based on history of treatment, level of comfort with a particular agent, and patient preference [8,19,20]. As examples:

●In a randomized trial investigating treatments for prevention of PTSD in individuals with recent trauma (mean 9.6 days after traumatic event), treatment with either SSRI escitalopram or placebo led to similar rates of PTSD prevalence at a mean of 144 days follow-up (61.9 versus 55.6 percent; odds ratio 0.77, 95% CI 0.21-2.77) [8].

●In a randomized trial, 31 subjects with symptoms of ASD assigned to receive 10 to 20 mg of escitalopram or placebo for 24 weeks. At 56-week follow-up, both groups experienced a decline in PTSD symptoms, as measured by the Clinician-Administered PTSD Scale; however, the reduction was greater in the placebo group as compared with the SSRI treated group [19].

Most long-term treatment planning occurs at least one month after trauma exposure. SSRI medication has been found to reduce symptoms of PTSD as compared with placebo [21]. Pharmacologic management of PTSD is discussed elsewhere. (See "Posttraumatic stress disorder in adults: Treatment overview", section on 'Serotonin reuptake inhibitors as alternative first-line or adjunctive treatment'.)

Benzodiazepine for arousal or intrusion symptoms — For individuals with prominent arousal symptoms such as sleep disturbance, irritable behavior, hypervigilance, or angry outbursts that limit the ability to work in psychotherapy our preference is to use a low dose of a benzodiazepine.

We limit the treatment to two to four weeks as prolonged treatment with a benzodiazepine may lead to dependence. Benzodiazepines may be useful in the short-term for extreme agitation or sleep problems; however, we are cautious of adverse reactions (sedation) and the development of tolerance on the medication. Additionally, as discontinuation from benzodiazepines can worsen symptoms, we are extremely cautious in beginning treatment.

When using clonazepam, we typically begin at 0.5 mg per day and increase as needed over one to two weeks to a maximum dose of 2 mg/day in divided doses.

Our preference for benzodiazepines in individuals with acute agitation, anxiety, or sleep disturbance in the immediate aftermath of a traumatic event is based on our clinical experience. Clinical trials have not yielded sufficient evidence to determine the efficacy of benzodiazepines in comparison with placebo or with other medications in patients who have experienced acute trauma or have been diagnosed with ASD. Small nonrandomized trials of benzodiazepine in the treatment of ASD have shown conflicting results. For example:

●One case series described benzodiazepine treatment of four patients, within one to three weeks of trauma exposure, who had ASD symptoms that included disturbed sleep [22]. Temazepam 30 mg was administered orally at bedtime for five days, followed by two days at 15 mg. All patients experienced improved sleep and reduced ASD symptoms.

●However, in another study, 13 individuals treated with a benzodiazepine within one week of trauma exposure were compared with 13 individuals with comparable trauma exposure who did not receive a benzodiazepine. Participants in the two groups were pair matched for gender and symptom severity [23]. At both one month and six months after the trauma, participants in the two groups experienced similar reductions of PTSD symptoms. Furthermore, nine participants in the benzodiazepine group met diagnostic criteria for PTSD at six months, as compared with three subjects in the control group.

OTHER AGENTS OR INTERVENTIONS WITH MINIMAL SUPPORT

●Psychologic debriefing – This intervention is intended to assist people cope and is not intended to treat acute stress disorder (ASD) or prevent posttraumatic stress disorder (PTSD). The intervention involves recollecting, articulating, and reworking of the traumatic event, typically in a group format. Despite extensive use following disasters and other traumatic events, psychologic debriefing (also known as "critical incident stress debriefing") has not been found to be effective in reducing PTSD symptoms among individuals experiencing a traumatic event [24,25].

Meta-analyses of numerous clinical trials found no evidence of effectiveness for either the initial, single-session intervention [24] or for subsequent, multiple-session version of psychologic debriefing [25]. In the context of no evidence for psychologic debriefing serving a preventive role in mitigating posttraumatic stress, “Psychological First Aid” is commonly provided to ensure that people have required support and safety needs met [26].

●Hydrocortisone – Hydrocortisone has been studied as an early pharmacologic intervention to reduce acute and longer-term posttraumatic stress because of evidence that lowered cortisol levels are predictive of subsequent PTSD [27]. Pilot studies have indicated that this can be beneficial in reducing subsequent PTSD severity [28]. Findings and methods of clinical trials have been insufficient to suggest the use of hydrocortisone as a treatment to prevent PTSD in individuals with ASD. Although meta-analyses indicate promising evidence for hydrocortisone, the quality of the available evidence precludes recommending it as a treatment for ASD until further research is conducted [20,29].

●Propranolol – Propranolol has been tested in the immediate aftermath of trauma exposure [30-34], with the hypothesis that reducing noradrenergic activation would result in reduced conditioning of the trauma memories and prevent the development of PTSD. In one observational study, patients who refused treatment with propranolol were more likely to develop PTSD [30]. However, in a small randomized trial, 17 patients treated with propranolol had similar depressive and PTSD symptoms compared with those on placebo [32].

●Morphine – Several uncontrolled studies have noted that morphine (which reduces norepinephrine), used for pain control in the initial 48 hours after trauma exposure, is linked to reduced subsequent PTSD symptoms, although the relationship between morphine and the development of PTSD has not been tested in randomized trials [35-38]. They may point to the importance of pain management in preventing PTSD [35-38].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Trauma-related psychiatric disorders in adults".)

SUMMARY AND RECOMMENDATIONS

●Goals of trauma-focused cognitive-behavioral therapy (TF-CBT) – The goals of treatment are to reduce the severity of acute stress disorder (ASD) symptoms and to prevent the development of posttraumatic stress disorder (PTSD). (See 'Treatment goals' above.)

●TF-CBT as first line – For most individuals with ASD, we suggest TF-CBT as first-line treatment rather than other psychotherapies or medication management (Grade 2C). (See 'Trauma-focused cognitive-behavioral therapy as first choice' above.)

●Alternative treatment approaches – In specific cases, only some components of TF-CBT may be administered. (See 'Alternative trauma-focused cognitive-behavioral therapy approaches' above.)

•For those who do not tolerate or refuse exposure therapy – In more severe cases of trauma, we are wary of administering exposure therapy due to the distress it may illicit. For individuals with the following presentations, we often delay exposure therapy and provide cognitive therapy as monotherapy until the symptoms are less acute (see 'For those who do not tolerate or refuse exposure therapy' above):

-Extreme avoidance or dissociative responses

-A primary response of anger

-Acute grief response

-Persisting PTSD responses to childhood trauma

-Borderline or psychotic features

-Suicidal risk

•For those that cannot engage in cognitive therapy – In cases where the individual refuses to engage in cognitive therapy or in those cases where the individual is unable to benefit from cognitive therapy (eg, limited insight), we treat with exposure therapy alone. (See 'For those that cannot engage in cognitive therapy' above.)

●Adjunctive pharmacotherapy – We use medication, such as an SSRI, combined with psychotherapy for individuals with severe symptoms that limit the ability to work in psychotherapy or cause significant psychosocial distress. We also treat with adjunctive medication for those with a co-occurring disorders such as depression. (See 'Adjunctive pharmacotherapy' above.)

●Arousal or intrusions – For patients with ASD and intense anxiety, hyperarousal, agitation, or sleep disturbance in the immediate period following the traumatic event, we suggest short-term (up to four weeks) treatment with a benzodiazepine rather than other pharmacotherapy agents (Grade 2C). (See 'Benzodiazepine for arousal or intrusion symptoms' above.)

●Other agents or interventions with minimal support – Minimal evidence supports other medications (eg, propranolol, morphine, hydrocortisone) or interventions (eg, psychologic debriefing) in the treatment of ASD. (See 'Other agents or interventions with minimal support' above.)