Beyond the physical injury: Acute stress reaction

Aug. 12, 2021

Note: This content was created prior to the coronavirus disease 2019 (COVID-19) pandemic and does not demonstrate proper pandemic protocols. Please follow all recommended Centers for Disease Control and Prevention guidelines for masking and social distancing.

Trying to avoid a large piece of tire on Interstate Highway 65 outside Indianapolis, a recent master's graduate jerked the wheel of her sedan to dodge the object. One tire hit the gravel lining the edge of the left lane, causing her to lose control of the vehicle. The car spun out in a doughnut pattern, into the median and then oncoming traffic, clipping another vehicle's back corner. The graduate's car crashed into the guardrail and then caught fire under the hood.

An off-duty EMT traveling nearby ran over to help the driver out of the vehicle and laid her on the ground. Another traveler extinguished the fire under the car's hood, and a third good Samaritan offered to call a family member or friend about the crash. She rode by ambulance to a nearby small hospital, where providers examined her, took images and released her with contusions.

In the ensuing days at a relative's home in Kentucky, she noted she wasn't quite herself. Not only was she extremely sore but also scared. Crash scenes flashed before her eyes, and even a ringing phone prompted fear that an insurance agent was calling to get details about the crash. She was afraid to leave her relative's home — and especially to get back in a car and drive. She kept thinking, "Do I possibly need counseling for this? But almost everyone in America gets into an accident sometime."

She thought she was weak because she couldn't just get over it.

How trauma can affect mental state

As mentioned in this true anecdote, exposure to traumatic events not only may cause physical injury but also may affect a patient psychologically, causing acute traumatic stress symptoms. Known as acute stress disorder by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM–5) and acute stress reaction (ASR) by the International Classification of Diseases Revision 10 (ICD-10), this trauma may affect patients' mental health. It merits ASR screening.

"When you think about it, if any of us goes through a traumatic event, we're going to have a reaction — could be trouble sleeping or completing simple daily activities, waking up with nightmares, or feeling on edge that someone's going to attack," says Jennifer M. Schofield, L.I.C.S.W., M.S.W., a social worker at Mayo Clinic's campus in Rochester, Minnesota. "It's normal to have a response after trauma, but if the symptoms significantly impair one's ability to fulfill life roles, seeking help is vital."

Patients who've undergone trauma may show signs of ASR from two days to one month after the event. ASR may result from an event the patient directly experienced, witnessed or even heard about from a family member or close friend who was involved. This is particularly true for parents of pediatric trauma patients.

"There is no correlation between the severity of the injury and one's potential for acute stress reaction or even long-term post-traumatic stress disorder," says Denise B. Klinkner, M.D., M.Ed., Mayo Clinic level 1 pediatric trauma medical director. "We strive to provide resources to patients and their families, as the impact lasts well beyond their hospitalization."

Schofield also notes ASR may arise in first responders or other providers involved with trauma patients, known as secondary trauma. Not everyone who experiences a traumatic event will develop ASR, as each person experiences trauma differently.

Currently, health care providers encourage thinking of a patient as a whole person — caring for physical as well as mental and emotional health, according to Schofield. The primary distinction between ASR and post-traumatic stress disorder (PTSD) is time: Up to one month of symptoms related to a traumatic event is classified as ASR, while over one month of symptoms is classified as PTSD. ASR is the acute period, while PTSD has similar, more-prolonged symptoms.

How trauma providers can help

Schofield offers the following suggestions to trauma providers to help patients through potential ASR:

Screening

All trauma providers, even those unacquainted with ASR diagnostic criteria, can do basic screening by asking a patient and the patient's support people questions immediately following a traumatic event or if the patient later returns to the hospital, such as:

  • How are you doing?
  • How are you holding up?
  • How is your eating? Sleeping? Mood?

Depending on the conversation with the patient, Schofield suggests further formal screening or referral to a social worker, counselor or therapist.

In addition, Schofield recommends reviewing the diagnostic criteria for acute stress disorder in DSM–5, for awareness of the symptoms that may affect trauma patients.

Psychoeducation

Anyone who experiences trauma may be at risk of ASR, and those with trauma-avoidant coping mechanisms or mental health issues may face higher risk levels. Thus, it's important to communicate this risk and inform patients who've experienced trauma and their families about ASR. Though this education may occur at any point, starting the conversation early, while the patient is still in the hospital, is beneficial. Communicate to patients and the patient's support people what's normal and when to ask for support. ASR education is especially important when patients return to their primary care or local physicians for follow-up visits, says Dr. Klinkner.

"Talking openly about the impact trauma has on an individual's mental health and daily functioning helps both patients and their support systems to be able to identify signs and seek support for early intervention," says Schofield, who recommends advising the patient's support system to look out for ASR symptoms such as changes in mood, different sleeping patterns or other behaviors out of the norm for the patient.

Support

Patients experiencing ASR need additional support, ideally with professional care, but at minimum from family and friends with whom the patient can talk about symptoms and the trauma he or she experienced. A support group may be helpful. Patients may need counseling to help process the trauma, address particular symptoms and learn coping strategies.

Trauma professionals can help patients who need support by providing a link: alerting a family member that the patient may need to talk about the trauma or bringing in or referring the patient to a social worker, therapist or other psychology professional. Along with making these support connections for patients, providers can explain to patients that getting help is the best thing they can do for themselves and for those around them.

"In my experience, patients have expectations of themselves, thinking, 'I should be able to manage this.' At times they may minimize their distress," says Schofield. "I would want patients to know that if they are hesitant to get help, getting help is never weak; it is empowering them in their recovery. An example I use is, 'If you would treat a headache with acetaminophen, why wouldn't you get support for psychological stress?'"

Self-care

Schofield also recommends that professionals take care of themselves first so that they are able to best care for their patients. She explains that many caring professionals experience compassion fatigue. "The saying holds true. You need to put on your oxygen mask first to be able to help others," she says.

For more information

Trauma- and stressor-related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM–5. 5th ed. American Psychiatric Association; 2013.

International Repository for Information Sharing. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. World Health Organization.