Psychiatry · Year 3 · from Psychiatry
Case 2: Acute Stress Disorder
Patient Demographics
- Age: 28 years old
- Sex: Female
- Occupation: Bank teller
Chief Complaint
"I was held at gunpoint during a robbery 2 weeks ago. I can't stop shaking. I can't go back to work."
History of Present Illness
The patient presents to the emergency department 2 weeks after experiencing a bank robbery at her workplace. A masked gunman entered the bank, pointed a weapon at her face, and demanded she fill a bag with cash. She was held at gunpoint for approximately 5 minutes, during which she believed she would be killed. Since the event, she has been unable to return to work. She experiences frequent intrusive images of the gun pointed at her face and the robber's eyes. She has had nightmares about the robbery every night. She describes episodes where she feels like the robbery is happening again (flashbacks), during which she feels disconnected from her body. She has been avoiding the news, driving past banks, and any crime shows on TV. She is unable to feel happiness and feels emotionally numb, as if "everything is muted." She is jumpy and startles at minor sounds. She has difficulty falling asleep and concentrating. She has not left her apartment in a week and has been calling in sick to work. She is worried she will lose her job but cannot imagine returning to the bank.
Mental Status Examination
Appearance: Young woman, appears frightened, tearful, tremulous
Behavior: Hypervigilant, startles when phone rings in office, requests door remain open
Speech: Soft, trembling voice
Mood: "Terrified" and "numb"
Affect: Anxious, fearful, blunted, tearful
Thought Process: Linear but occasionally loses track due to intrusive thoughts
Thought Content:
- Intrusive images of robbery
- Fear of returning to work
- No suicidal or homicidal ideation
- No delusions
Perceptions: Flashbacks (dissociative), no hallucinations
Cognition: Alert, oriented, concentration impaired
Insight: Good
Judgment: Fair - seeking help
Psychiatric Workup
Screening Tools:
- Acute Stress Disorder Scale (ASDS): 74 (clinical range >56)
- PCL-5: 54 (high, though PTSD diagnosis requires >1 month duration)
- PHQ-9: 12 (moderate)
Timeline:
- Trauma occurred 2 weeks ago
- Symptoms began within days of event
- Duration: 2 weeks (within 3 days to 1 month window for ASD)
Diagnosis
Acute Stress Disorder (F43.0)
DSM-5 Criteria:
- Exposure to actual/threatened death (gunpoint) - present
- 9+ symptoms from five categories present after trauma:
Intrusion symptoms:
- Intrusive memories - present
- Distressing dreams - present
- Flashbacks - present
- Distress at reminders - present
Negative mood:
- Inability to experience positive emotions - present
Dissociative symptoms:
- Altered sense of reality (derealization) - present
- Inability to remember aspect of trauma - not reported
Avoidance symptoms:
- Avoidance of memories/thoughts - present
- Avoidance of external reminders - present
Arousal symptoms:
- Sleep disturbance - present
- Hypervigilance - present
- Exaggerated startle - present
- Concentration problems - present
- Duration 3 days to 1 month: Present (2 weeks)
- Causes significant distress/impairment: Present (cannot work)
Treatment Plan
Immediate Support:
- Normalize acute stress reactions (common response to trauma)
- Psychoeducation about expected symptom course
- Provide information about ASD and potential for PTSD
Pharmacotherapy:
- Consider short-term sleep aid: trazodone 50-100 mg QHS
- Avoid benzodiazepines (may increase PTSD risk)
- SSRI not typically started immediately but consider if symptoms persist
Trauma-Focused CBT (First-line for ASD):
- Brief intervention (4-5 sessions) shown to prevent PTSD development
- Components:
- Psychoeducation about trauma responses
- Anxiety management/relaxation training
- Imaginal exposure to trauma memory
- In-vivo exposure to avoided situations
- Cognitive restructuring
Practical Support:
- Letter for employer requesting medical leave
- Discuss workplace accommodations when ready to return
- Different position (not teller window)
- Gradual return schedule
- Victim services/crime victim compensation information
Safety Planning:
- No current suicidal ideation
- Provide crisis resources (988)
- Social support activation (family, friends)
Prognosis:
- With early intervention, many ASD patients do not develop PTSD
- Early trauma-focused CBT reduces PTSD development by ~50%
- Without treatment, ~50% of ASD patients develop PTSD
Follow-up:
- Twice weekly trauma-focused CBT for 2-3 weeks
- Re-evaluate at 1 month; if symptoms persist, diagnose PTSD and adjust treatment