A 32-year-old woman comes to the office due to "feeling anxious and down" for the past 2 weeks. The patient cries frequently and has been making mistakes in her accounting job due to poor concentration. She feels tense throughout the day and has difficulty staying asleep most nights because she is awakened by episodes of palpitations, shortness of breath, and sweating. The patient was mugged 3 weeks ago while walking home from work but is reluctant to discuss what happened. She does not use alcohol or illicit drugs and takes no medication. Temperature is 36.9 C (98.4 F), blood pressure is 125/70 mm Hg, pulse is 88/min, and respirations are 14/min. Physical examination shows no abnormalities. On mental status examination, the patient makes minimal eye contact, looks down at the floor, and wrings her hands repeatedly. She tearfully says, "I feel like I'm in a daze, and I can't snap out of it." Which of the following is the most likely diagnosis?
Acute stress disorder | |
Clinical features |
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Management |
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CBT = cognitive-behavioral therapy; PTSD = posttraumatic stress disorder. | |
This patient who recently experienced trauma (a mugging event) has a 2-week history of anxiety, impaired concentration, insomnia, dissociative symptoms (eg, being in a "daze"), and avoidance of discussing the traumatic event, consistent with acute stress disorder (ASD). Her negative mood and tearfulness are also characteristic. Other ASD symptoms include intrusive memories, nightmares, and flashbacks. Symptoms must last for ≥3 days and ≤1 month following trauma exposure.
If the symptoms persist for >1 month and meet criteria for posttraumatic stress disorder (PTSD), the diagnosis is changed from ASD to PTSD (Choice F). Early recognition and intervention (eg, trauma-focused cognitive behavioral therapy) are important because patients with ASD are at a higher risk for subsequent PTSD.
(Choice B) Depersonalization/derealization disorder is characterized by a sense of unreality of self or environment. If symptoms occur as part of an acute or posttraumatic stress reaction, a separate diagnosis is not required.
(Choice C) Individuals with generalized anxiety disorder (GAD) also have insomnia, tension, and difficulty concentrating. However, anxiety in GAD is about multiple everyday concerns (rather than being trauma related) and has a duration of ≥6 months.
(Choice D) This patient's sad mood, sleep disturbance, and impaired concentration are a response to trauma and better explained as symptoms of ASD rather than major depressive disorder.
(Choice E) This patient's panic symptoms are likely triggered by bad dreams resulting from the trauma. She does not experience recurrent, unexpected panic attacks necessary for the diagnosis of panic disorder.
Educational objective:
Acute stress disorder is a severe anxiety response characterized by re-experiencing of trauma, dissociation, negative mood, avoidance, and hyperarousal lasting ≥3 days and ≤1 month after exposure to a traumatic event.