Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0106Other Neurotic DisordersJerome J. Schulte and David BienenfeldWright State University, School of Medicine, OH, USAREACTION TO SEVERE STRESS, ANDADJUSTMENT DISORDERSBefore World War II it was generally held that psychiatric patientswere constitutionally different from ‘‘normals’’. During WorldWar II it was observed that previously asymptomatic individualsexperiencing unusual environmental stress sometimes sufferedfrom transient psychiatric difficulties. This observation led to areclassification of psychiatric disorders to allow for behavioral andemotional symptoms in people who would return to theirpremorbid state with the removal of the unusual environmentalprecipitant 1 . DSM-I and ICD-6 classified these transient difficultiesas ‘‘gross stress reaction’’ and ‘‘adult situational reaction’’;DSM-II and ICD-8 classified them as ‘‘transient situationaldisturbances’’. ICD-9 introduced the categories of ‘‘acute reactionto stress’’ and ‘‘adjustment disorder’’. ICD-10 defines ‘‘acute stressreaction’’, ‘‘post-traumatic stress disorder’’ and ‘‘adjustmentdisorder’’; although DSM-III-R recognized only the latter twoof these, DSM-IV recognizes all three.ACUTE STRESS REACTIONClinical FeaturesAccording to ICD-10, acute stress reaction is a transientdisturbance, occurring in persons without apparent mentaldisorder, in response to exceptional physical and/or mental stressand subsiding in hours or days. The diagnosis should not be madefor an exacerbation of symptoms of a diagnosable psychiatricdisorder already present, except for accentuation of personalitytraits. Previous history of another psychiatric disorder does notinvalidate this diagnosis. An immediate, clear connection betweenthe stressor and the onset of symptoms should be seen.Symptoms of this disorder show a mixed and changing picture,with no one symptom predominating for long. They appearwithin minutes of the stress and resolve rapidly when the stressoris removed or, if the stress remains, symptoms decrease after 24–48 h and are minimal after 3 days.Typical symptoms include an initial state of ‘‘daze’’, constrictionof consciousness, narrowing of attention, decreased comprehensionof stimuli and disorientation. Withdrawal, agitation oroveractivity may follow. Autonomic signs of panic (tachycardia,sweating, flushing) are common. Amnesia for the traumaticpresent may also be present. In the elderly, organic factors andlife stage events can be predisposing factors to acute stressreaction 2 . The multiple bereavements which are not uncommon inlate life can be the precipitants for acute stress reaction.DSM-IV differs somewhat from ICD-10 in its diagnosticclassification of acute stress disorder. Unlike ICD-10, whichrequires that symptoms appear within minutes of the stress anddiminish to minimal intensity after 3 days, DSM-IV requiressymptoms to last a minimum of 2 days and allows for persistenceup to 4 weeks. DSM-IV also includes dissociative symptoms notincluded under ICD-10: a subjective sense of numbing, detachmentor absence of emotional responsiveness; derealization anddepersonalization. Another DSM-IV requirement is that thetraumatic event is persistently re-experienced in at least one of thefollowing ways: recurrent images, thoughts, dreams, illusions,flashback episodes, or a sense of reliving the experience; or distresson exposure to reminders of the traumatic event. DSM-IV alsorequires marked avoidance of stimuli that arouse recollections ofthe trauma 3 .Differential DiagnosisThe differential diagnosis includes post-traumatic stress disorder(PTSD) and adjustment disorder. PTSD (see below) occurs after alatency period of weeks or longer, while the symptoms of acutestress reaction begin immediately after the traumatic event. Therepetitive, intrusive imagery characteristic of PTSD is not usually afeature of the ICD-10 diagnosis of acute stress reaction. DSM-IV,however, does include repetitive intrusive imagery among thefeatures of acute stress disorder. If psychotic symptoms follow anextreme stress, acute (brief) psychotic disorder should be considered.Adjustment disorders are less severe, and longer lasting, thanacute stress reactions. Events that precipitate adjustment disordersare also less intense than those responsible for acute stress reactions.TherapyBy definition, the symptoms of acute stress reaction are timelimitedand will resolve without specific therapeutic intervention.Treatment may be requested, however, for intolerable tension orinsomnia. For tension, short-term use of benzodiazepines withsimple metabolic pathways and short half-lives, such as lorazepamor oxazepam, are safest in the elderly. For insomnia, temazepamor the non-benzodiazepine sedative hypnotic zolpiden 4 arejustified. Families and patients may be reassured that the acuteresponse does not indicate a psychotic decompensation, and thatthe prognosis for rapid recovery is favorable. Acutely, and in theaftermath of the traumatic event, it is useful to help the patientgain mastery over the trauma 5 by using a brief treatment model,consisting of fostering abreaction and integration of the event asPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd