D . Are Trauma Related Symptoms Present?

OBJECTIVE

Identify people exposed to trauma who are at risk for developing acute stress reaction (ASR) acute stress disorders (ASD) or Post-Traumatic Stress Disorder (PTSD).

BACKGROUND

Warning Signs of Trauma Related Stress (APA)

Individuals who have experienced a traumatic event oftentimes suffer psychological stress related to the incident. In most instances, these are normal reactions to abnormal situations. Individuals who feel they are unable to regain control of their lives, or who experience the following symptoms for more than a month, should consider seeking outside professional mental health assistance. The American Red Cross is now working with mental health professionals trained in trauma. For information or a referral, contact the local American Red Cross chapter or the American Psychological Association at 202-336-5800.

The symptoms to watch out for include:

• Recurring thoughts, mental images, or nightmares about the event
• Having trouble sleeping or changes in appetite
• Experiencing anxiety and fear, especially when exposed to events or situations reminiscent of the trauma
• Being on edge, being easily startled or becoming overly alert
• Feeling depressed, sad and having low energy
• Experiencing memory problems including difficulty in remembering aspects of the trauma
• Feeling "scattered" and unable to focus on work or daily activities
• Having difficulty making decisions
• Feeling irritable, easily agitated, or angry and resentful
• Feeling emotionally "numb," withdrawn, disconnected or different from others
• Spontaneously crying, feeling a sense of despair and hopelessness
• Feeling extremely protective of, or fearful for, the safety of loved ones
• Not being able to face certain aspects of the trauma, and avoiding activities, places, or even people that remind you of the event

RECOMMENDATION

1. Individuals who are presumed to have symptoms of PTSD or who are positive for PTSD on the initial 4-item screening should receive specific assessment of their symptoms.
2. Useful information may include details such as time of onset, frequency, course, severity, level of distress, functional impairment, and other relevant information.
3. The elapsed time since the exposure to trauma is very important in assessing the risk of developing PTSD and determining the appropriate intervention. The following definition will help providers select the appropriate treatment algorithm.

Stress Related Disorders & Syndromes Definitions

Trauma
An extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person's response to the event must involve intense fear, helplessness, or horror

Acute Stress Reaction (ASR) during an Ongoing Military Operation or, Combat and Operational Stress Reactions (COSR)
Broad group of physical, mental and emotional signs, which result from heavy mental and emotional work during difficult conditions. Onset of at least some signs and symptoms may be simultaneous with the trauma, itself or may follow the trauma after an interval of hours or days. Symptoms include depression, fatigue, anxiety, decreased concentration/memory, hyperarousal or any of the four clusters above that have not resolved within 4 days after the event, after a rule-out of other disorders.

Acute Stress Disorder (ASD)
Clinically significant (causing significant distress or impairment in social, occupational, or other important areas of functioning) symptoms >2 days, but <1 month after exposure to a trauma as defined above (may progress to PTSD if symptoms last >1 month).

• Exposure to trauma as defined above.
• Either while experiencing or after experiencing the distressing event, the individual has at least three of the following dissociative symptoms:
  1. A subjective sense of numbing, detachment, and/or absence of emotional responsiveness.
  2. A reduction in awareness of his/her surroundings (e.g., "being in a daze").
  3. Derealization (the feeling that familiar surroundings or people are unreal or have become strange).
  4. Depersonalization (the feeling in an individual that (s)he is no longer him/herself. His/Her personality, body, external events, the whole world may be no longer appear real).
  5. Dissociative amnesia (i.e., the inability to recall an important aspect of the trauma)
• The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
• Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people, sounds, smells, etc.)
• Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, and motor restlessness)

Post Trauma Stress Disorder (PTSD)
Clinically significant (causing significant distress or impairment in social, occupational, or other important areas of functioning) symptoms more than 1 month after exposure to a trauma. Symptoms include:

• Exposure to trauma as defined above.
• The traumatic event is persistently re-experienced in one (or more) of the following ways:
  1. Recurrent and intrusive recollections of the event, including images, thoughts, or perceptions.
  2. Recurrent distressing dreams of the event.
  3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
  4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  5. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
• Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
  1. Efforts to avoid thoughts, feeling, or conversations associated with the trauma.
  2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
  3. Inability to recall an important aspect of the trauma.
  4. Markedly diminished interest or participation in significant activities.
  5. Feeling of detachment or estrangement from others
  6. Restricted range of affect (e.g., unable to have loving feelings).
  7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
• Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
  1. Difficulty falling or staying asleep
  2. Irritability or outbursts of anger
  3. Difficulty concentrating
  4. Hypervigilance
  5. Exaggerated startle response

Acute PTSD
Above clinically significant (causing significant distress or impairment in social, occupational, or other important areas of functioning) symptoms lasting >1 month, but <3 months after exposure to trauma.

Chronic PTSD
Above clinically significant (causing significant distress or impairment in social, occupational, or other important areas of functioning) symptoms lasting >3 months after exposure to trauma.

• Simple chronic PTSD – consist of symptoms from the above clusters
• Complex – persistent difficulties in interpersonal relations, mood, somatization and profound identity problems. Complex PTSD is often associated with sustained or repeated trauma during childhood or adolescence (such as longstanding incest or physical abuse), but it may also be associated with sustained trauma in later life or may appear as a late consequence of chronic PTSD, even if the original traumatic stressor was a single event.
• Comorbid – also meeting DSM criteria for another disorder such as substance abuse, depression, or anxiety disorder.

PTSD with Delayed Onset
Onset of above clinically significant (causing significant distress or impairment in social, occupational, or other important areas of functioning) symptoms at least 6 months after exposure to trauma.

DISCUSSION