What Kind of Stress?

Over the last pandemic year, I have heard countless stories of people who have lost their jobs, had to move, lost a loved one to COVID-19, or just felt that their entire world had been upended by the restrictions and lockdown that this time in the world has foisted on all of us. These folks are invariably stressed, sometimes to their breaking points. They are not functioning well. They are irritable and depressed and anxious. They can’t eat and they barely sleep. They have little desire to do anything and have lost the joy they used to feel for almost everything. They come to see me, tell me their stories, and then tell me what they think the problem is and what I need to treat them for.

“I have PTSD,” they tell me, sure that this is the diagnosis that this pandemic has saddled them with, and equally sure that a medication or two will fix things and get them on the fast road to recovery and mental health again. But wait, is it really PTSD, or is that simply the diagnosis that most people know is associated with trauma, therefore must be the one they are suffering from?

I would like to talk to you this week about two kinds of stress reactions that are very easily confused. Most of the information that I am about to share with you can be found in UpToDate, a medical resource that pulls together the latest research and knowledge on a wide variety of topics and illnesses.

The first disorder is ASD, or Acute Stress Disorder. ASD is an acute stress reaction that occurs within one month of the traumatic event that causes it. Prevalence for this disorder is between 5-20%. What kinds of trauma can lead to ASD? Thirteen per cent of those who have severe motor vehicle accidents will have it, as will 16% of assault victims and, most horribly notable for all of us over the last month or two, 33% of those who witness mass shootings. Risk factors for developing ASD include being female, having various pre-existing mental health or physical illnesses, having a history of a previous trauma, and being exposed to a more severe trauma in the first place. The trauma experienced by someone may lead to a very transient reaction and no ASD, with a very swift return to normal. On the other hand, it may lead to ASD, then within a month also return to normal, pre-trauma life. One group, however, may go on to develop PTSD, or Post Traumatic Stress Disorder. As we shall see shortly, these folks may suffer long term effects that are life changing.

What are the symptoms of ASD? Re-experiencing the traumatic event is common, as is anxiety. Nightmares and vivid dreams may affect sleep. Recurring thoughts and increasing feelings of fear may arise. There is sometimes hypervigilance guarding against further threats. One might avoid people, places or things that remind of the trauma, and emotional numbing with flat features sets in. Dissociation from others, isolation and social avoidance complete the picture of someone who is feeling terrible but has an extremely hard time communicating this or sharing it with others, even those they are the closest to.

The good news? Most people who experience traumatic events of various kinds will have a brief period of symptoms and adjustment, and then will adapt and go back to their previous level of functioning within days to weeks. In some studies, it has been shown that 40-80% of people with ASD will go on to develop PTSD. The bright side of that is of course that almost half will not.

How is the diagnosis of ASD made? Quite simply, one must have several necessary symptoms. The first is exposure to the trauma, either directly, as a witness, or being told of the danger or injury to a loved one, for example. Intrusive symptoms can include dreams, memories and flashbacks. Mood becomes negative. There may be dissociative episodes. Avoidance tries to prevent recurrent trauma. Finally, arousal leads to decreased sleep, irritability, and an increased startle reflex. ASD may begin immediately after a trauma, but is usually best diagnosed three days or more afterwards.

What about PTSD? How is it different? It is diagnosed after four weeks of symptoms following the traumatic event. Two of the most likely types of events to lead to PTSD include sexual trauma at 33% (which may include childhood sexual abuse, rape, or domestic violence) and interpersonal traumatic 30% (which might include the death of your spouse or the serious illness of a child). Lifetime prevalence of PTSD may be as high as 6-9%. In one sample of 5692 adults in the United States, 83% had been exposed to severe traumatic events, but only 8.3% had developed lifetime symptoms of PTSD. Some very specific groups like native Americans and refugees from other countries with endemic abuse and stress are at higher risk for PTSD. Gender, age, educational level, history of previous abuse and poor social support may also lead to a higher risk of developing PTSD. Women are four times more likely to suffer from PTSD than men. A higher severity of symptoms at one month seems to be predictive of more serious PTSD symptoms at six months and onward.

Diagnosis of PTSD is similar to ASD, in that exposure to a traumatic event is necessary, intrusive symptoms such as re-experiencing and flashbacks are often present, and avoidance is present. Depression, decreased interest in activities, guilt, and disconnection from others are often seen. People feel on edge, reckless and irritable, and they tend to engage in risky behavior or make poor decisions. There may more serious depersonalization or derealization, or even amnesia for parts of the traumatic event.

PTSD tends to be a chronic disorder in many. One third recover at one year follow up, but another one third might still have symptoms ten years after the trauma. Some studies have shown that those with PTSD have poor social supports, increasing disability and inability to complete higher educational goals,

Now, what does all of this mean for the dozens if not hundreds of patients who have told me that they have “PTSD” because they feel traumatized and anxious due to pandemic? The very good news is that the vast majority of us will have initial anxiety when traumatized in this way, but most of us will recover in a very short time. We anticipate getting back to our pre-COVID lives one day, and we very much look forward to that. Those who go on to develop more serious anxiety symptoms and the other associated symptoms of PTSD should of course seek treatment as needed for what can turn into a chronic and debilitating illness.