Acute stress disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

Pharmacologic medical therapies for acute stress disorder include beta blockers, alpha adrenergic agents, benzodiazepines and/or SSRIs.

Medical Therapy

Basic principles of intervention after emotional trauma include the following:

Reduce stress by all possible means

Ensure that survivors have a safe environment

Promote contact with loved ones and other sources of support

Support self-esteem; help patients understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology

Help survivors focus on immediate needs, such as rest, food, shelter, social supports, or a sense of belonging to a community

Promote coping mechanisms

Help patients reframe any destructive cognitions

Administer medication (eg, beta-blockers, alpha agonists, benzodiazepines, or nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal

Avoid increasing stress - Avoid prompting discussion of issues that cannot be resolved; avoid abreaction in groups and the resulting contagion effect; respect defenses, and do not force reality on people who cannot handle it yet; keep in mind that debriefing may be harmful

Discuss the experience with patients who want to talk about it, and avoid pressuring those who do not wish to discuss it

Identify persons at high risk - Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, or toxins)

Have faith in the normal healing processes

• The use of medications to decrease arousal and insomnia may have a long-term impact in the treatment of acute stress disorder (ASD). Pharmacologic agents that may be helpful in acute stress disorder include beta-adrenergic blocking agents, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, alpha adrenergic agonists, and sedating antihistamines.

Medications to decrease arousal and insomnia have a long-term impact on acute stress disorder

Alpha adrenergic agents and beta blockers limit hyperarousal. An atypical neuroleptic or mood stabilizer may be needed for an extreme aggression, agitation, dissociation, or psychosis

SSRIs may be helpful in dealing with the symptoms such as depression, anxiety, withdrawal, and avoidance and can be effective in longer-term treatment

Benzodiazepines, can be helpful in the initial stages, by there ability to limit hyperarousal and ability to foster sleep; however, continuous administration of benzodiazepines may interfere with readaptation and grieving. Longer-acting agents are beneficial when follow-up treatment is in short supply and medication is administered at the emergency site

Comorbid conditions such as attention deficit hyperactivity disorder (ADHD) should be treated. Reduction in atleast one disabling symptom such as insomnia or hyperarousal may have a powerful positive impact on the individual’s ability to re-compensate.

The mechanism of action and common features of various pharmacological agents that may be helpful in acute stress disorder is shown below in a tabular form:

Drug class	Drug Action	Examples	Features
Beta-Adrenergic blocking agents	Beta blockers inhibit inotropic, chronotropic, and vasodilatory responses to beta adrenergic stimulation	Propranolol	Propranolol may be useful for the treatment of hyperarousal
Selective Serotonin Reuptake Inhibtors	SSRIs are the first-line agents for managing anxiety, depression, avoidance behaviors, and intrusive recollections SSRIs inhibit central nervous system (CNS) neuronal uptake of serotonin (5HT) They have a week effect on norepinephrine and dopamine neuronal reuptake	Escitalopram	Escitalopram i sthe S-enantiomer of citalopram Escitalopram has a faster onset of depression relief, usually 1-2 weeks in comparison with other antidepressants
		Sertraline	Sertraline selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine
		Citalopram	Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane Citalopram is the least activating of the SSRIs and is particularly useful in acute stress disorder The incidence of adverse effects especially sexual is less with citalopram than with other SSRIs
Benzodiazepines	Benzodiazepines bind to specific receptors on the gamma amino- butyric acid (GABA) receptor complex, thereby increasing the affinity of (GABA) for its receptor They also increase the frequency of chlorine channel opening in response to GABA binding GABA receptors are chlorine channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization They have sedative-hypnotic and anxiolytic effect	Clonazepam	Clonazepam is a long-acting benzodiazepine that increases presynaptic GABA inhibtion and reduces the monosynaptic and polysynaptic reflexes
		Diazepam	Diazepam depresses all levels of the CNS such as limbic and reticular formations, by increasing activity of GABA
		Lorazepam	Lorazepam is a sedative-hypnotic with short onset of effect and a relatively long half-life By increasing the action of GABA, lorazepam may depress all levels of the CNS, including limbic and reticular formations It is important to monitor the patient's blood pressure after administering a dose and to adjust the dose as necessary
Alpha Adrenergic Receptors	The centrally acting alpha2 adrenergic agonists clonidine and guanfacine have been used to treat children with attention deficit hyperactivity disorder (ADHD) Inhibition of norepinephrine in the brain may be its mechanism of action	Clonidine	Clonidine affects alpha1, alpha2, and alpha3-adrenergic receptors It is frequently given to children but is not approved by the US Food and Drug Administration (FDA) for any psychiatric uses in children It is available in tablets and in transdermal skin patches
		Guanfacine	Guanfacine has an action similar to that of clonidine but has a longer half-life and is less sedating It is more selective alpha agonist, affecting only alpha2-adrenergic receptors Guanfacine is not recommended for children younger than 12 years
Antihistamines	Older, sedating antihistamines such as diphenhydramine are often prescribed as sedatives because of their CNS- depressing properties	Diphenhydramine	Diphenhydramine is available as nonprescription preparations containing 25 mg of diphenhydramine in liquid, chewable, and capsule forms

References