Acute Stress Disorder Rehabilitation

“Up to 65 per cent of Australians are likely to experience or witness an event which threatens their life or safety” (19). Quite often trauma victims can recover by their own. However, with others it may have a negative reaction to a traumatic event which can then lead to an illness called Acute Stress Disorder (ASD) (16). This disorder is associated with mental and physical conditions combined thus causing reductions in a person’s quality of life and as a consequence includes economic burdens (12). (3) Due to the result of all the accumulating evidence, Diagnostic and Statistical Manual – fifth edition (DSM-5) has marked and modified goals and criteria for ASD. Under new criteria, ASD diagnosis will no longer predict chronic Post-traumatic Stress Disorder (PTSD). It will help to identify more severely affected survivors of trauma prior a diagnosis of PTSD can be made. Furthermore, the acuity people will perhaps get benefit from earlier interventions and short-term rehabilitation programs that are the great help in the recovery process. Early rehabilitation interventions, including self-care strategy, thought control strategy, and cognitive behavior therapy (CBT) would speed up recovery and prevent chronic longer term problems. Besides that, family members, clinicians, and social support networks play an important role in support mechanism for recovery process. Inaddition, some potential barriers are also discussed in predicting of new problems and relapse which may occur in order to manage them.

Potential recovery

According to (2) DSM-5 in 2013, ASD was relocated in Trauma- and Stressor-Related Disorders. ASD is a psychological and physical shock which usually appears in response to a traumatic event in a person’s life. The acutely traumatized person can be directly exposed to or be the witness of a traumatic events such as serious accident (21%), physical assault (19%), rape or witnessing a mass shooting (50%) or natural disaster (10%)(19). (9) Symptoms of ASD occur immediately right after the trauma, and it lasts for more than 2 days and less than 1 month (4). The victim usually suffers from anxiety, distress, intense fear, helplessness, avoidance behaviours or re-experience the event (16). (15) It has been recorded that 15% to 45% of children and adolescents directly experience to at least one traumatic event. There is no statistics of how many distressed people can fully recover due to these traumas; however in many studies it has been confirmed that ASD patients can have a full recovery under appropriate treatments. This study strongly emphasis on ASD rehabilitation rather than attempting to predict subsequent PTSD. Due to ASD timeframe is short, many victims are usually been ignored. Particularly, children and adolescent are in high risk of developing PTSD which leads to long-term psychological sequel in their life and causes a burden on health care systems. Therefore, (15) highlighted that recognizing ASD symptoms is an important step in toward enhancing intervention in the right time and speed up the recovery process. Additionally, with a formal diagnosis, it will allow highly distressed people to claim compensations from the health care service and payment for recovery treatment (4). In order to get appropriate diagnosis and early intervention, physicians play a critical role for assessments and monitoring all physical and psychological symptoms.

Recovery process

Whenever a referral from a physician has been made, the traumatized patients will go through a rehabilitation process. This process needs self-care strategy, thought control strategy, and CBT to support patients’ recovery and to decrease the future incidence of PTSD. (7) With self-care strategies, it focuses on personal strengths and their own judgment. Whether any kind of psychotherapies are provided to traumatic people, they should rely on their own recovery ability first. Without their own effort, all the supports will become ineffective. Traumatic patients, then, will receive reassurance and support, such as simple information and advices on self-care to overcome the normal recovery process. However, if the person cannot scope with these extremely severe events, and express a prolonged distress, or interfere with daily activities, they will need to be referral to another level of psychotherapy.

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Currently, it has been found that thought control strategy is an acceptable strategy for managing trauma related distress in the short term rehabilitation. Use of thought control strategy will aim to reduce the emotional distress by sharing the traumatic stories in the unforgettable period of time (14). There are four components (worry, distraction, social element and re-appraisal) which are the most commonly used to focus on helping the patient to normalize reactions to trauma (22). The first being Worry/Stress, it is best trying to get the patient to not concentrate on the stressful thought itself. Encouraging the patient to try and replace worry or stress with other day to day concerns that may hold a more minor bearing. The second is distraction. Finding a healthy distraction could be simple as think about things that provide a positive feeling or immerse the patient in an activity that is pleasurable. This will stop the patient concentrating on the traumatic event and allow them to go about a daily routine. The third would be social elements that could help. This could be asking or speaking with friends about their thoughts and how they have dealt with such events in their lives. Asking about what worked for them or what may have helped them avoid concentrating on the stressful event. This would be discussed fully so that the patient could reflect and understand how this could apply to their situation. The fourth is re-appraisal, trying and interpreting their feelings and understanding why these things are affecting them emotionally and rationalize their reactions to these feelings. From here they should challenge the validity of their emotions and feelings in order to control positive or negative feelings.

If these self-care strategy and thought control strategy still have not worked well for recovery, CBT would be the next step of treatment in rehabilitation. (12) CBT will be given in five therapy sessions this comprising prolonged exposure (PE) and cognitive restructuring (CR). (12) found that these sessions provide brief forms of treatment in reducing acute symptoms of ASD in the initial month after trauma exposure. (8) PE focuses in emotional processing of thoughts. It helps interrupt and reserve recovery process by blocking cognitive and behavioral avoidance. This is accomplished through in vivo and imaginal expose. Vivo exposure involves repeatedly activities and situations that are avoided because of trauma. Overtime, the patient can reduce distressing emotion and fear. Then, they can cope effectively through these distresses. Imaginal exposure is related to repeatedly describe the event aloud in details, then recording. After that, they listen to their record in order to help them to realize their coping skill.

Following initial assessment, patients were informed that they would be reassessed after 6 weeks

Support mechanism

Besides psychotherapy in rehabilitation process and early supportive care structure being delivered is an important step which supports the recovery process. Its result last long in reductions of ASD symptoms. Supportive care deliverers are family members, physician or social support network will help the traumatic patient go though the acute phase. (17on) In most cases, family members usually ask for advices on how to help their love in stressful situation. This will let the family to be able to utilize a communal experience in order to enhance the therapeutic growths. The use of positive family members has also been shown effectively assisted their traumatic member to manage their stressful conditions. They provide support, love and reinforce coping strategy with the trauma. The individual does not feel isolated, but also they feel warm and being caring. The individual, therefore, can describe what happened and how they response though this hard time.

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However in some cases family sometimes is not enough to support traumatic patients. If the trauma patients and their family feel unable to cope with this traumatic event, they can seek professional help from a physician such as an Australian Psychological Society (APS) psychologist. An APS psychologist will help the severe distress people to understand and manage the symptoms associated with the trauma. An APS psychologist would develop effective coping strategies for affected individual as well as their family to support the recovery process (18). If not, traumatic people also seek help from social support network such as Beyondblue, Sane or Mental Health organizations. Beyondblue is a support service designed to support, give advice and create actions. Whatever the situation is, Beyondblue always listens to their distress stories and share their misfortune. Beyondblue members can really help patients come to terms with their illness and help them to move forward (23). Similarly, The Australian Centre for Posttraumatic Mental Health is a not-for-profit organization which its aim to reduce the impact of trauma causing to the victims. They connect the capability of individual’s family with their organizations within the community. Therefore, they can understand about the traumatic victims, then, help them to prevent and recover from the adverse mental health effects of trauma.

Barrier : wrong diagnosis, overwhelm with treatment, comorbid psychiatric disorders

Due to a shorten timeframe of ASD, there appear some barriers which prevent the recovery process such as late diagnosis, overwhelmed treatments. Besides that some will subsequently develop comorbid psychiatric disorders. In case of traumatic events happen, the victims are late identified. Then, they will receive some simple advices how to overcome that situations. They are supposed to recover on their own. However, there are still significant people who cannot go through this recovery process by themselves. They need help from physicians to be assessed in order to receive a formal diagnosis. This process somehow is taken time which lead to a late diagnosis. If this is too late for appropriate treatment of stress disorder, it will develop further into PTSD. Furthermore, without this proper diagnosis, traumatic patients will not get the benefit from standard rehabilitation treatments (4). This problem can be predicted by the role of physicians who can manage clinical judgments in order to give their patient an early diagnosis.

For those patients who have received treatments within hours or days after an acute trauma incident, they sometime do not response well to treatment plan due to overwhelm of different interventions. They will present a psychosocial and environment difficulties related to problems such as agitation, emotional pain, and dissociation. Quickly treatment but also slowly explanation and monitoring the response from patients will enhance effective support to recovery process. With patients that respond positively and appear to be recovered from ASD, they sometimes sudden relapse when new event happen to their life. They suffer from fear about safety for themselves as well as their family. The relapse can be recognized by close family members who help the patients to report it to physician in order to get continual treatment (17).

Treatment of ASD is usually focused on its specific symptoms. However, some subsequently develop with ASD might be appear such as depression, withdrawal, shame or drug and alcohol abuse, and even suicidal behavior (17). The comorbid psychiatric disorders occur due to the inability scoping with that such traumatic events. These occurssing will significantly affect the recovery process; therefore, it is a requirement for careful attention in both pharmacologically and psychotherapeutically. The patient at high risk of suicide or drug and alcohol abuse should be highlighted during initial assessment. It is necessary to evaluate this potential harm which gets into the treatment pathway and the recovery process.

Conclusions

In conclusion, (4) the criteria set for ASD in DSM-V will allow identifying the people who had negative reaction to a traumatic event. Because of the short duration, it is necessary to assess severe traumatic people as quickly as possible. Then, they can receive an appropriate diagnosis in order to get benefit from rehabilitation treatments. Having an early treatment will move towards healing and recovery process. Moreover, as a result of suffering both physical and psychological conditions, these fragile people require a high level of support from family member, physicians as well as social support network to be back to normal life.