Treatment of Acute Stress Reaction
For a patient experiencing acute stress reaction, provide psychological first aid with reassurance and supportive communication, avoid psychological debriefing, and do NOT use benzodiazepines or routine pharmacotherapy—reserving brief cognitive-behavioral therapy for those who develop persistent symptoms or meet criteria for acute stress disorder. 1, 2
Immediate Management Approach
First-Line Intervention: Psychological First Aid
Ensure the patient's immediate safety and provide calm, supportive communication to reduce anxiety, as this addresses the root cause of acute stress symptoms including hyperventilation and carpopedal spasm. 2, 3
Educate the patient that acute stress reactions and associated physical symptoms (including panic, hyperventilation, carpopedal spasm) are normal responses to stressful situations, not signs of serious mental illness. 2, 3
Instruct deliberate breathing techniques such as breathing through pursed lips or counting breaths to manage hyperventilation-related symptoms. 2
Provide practical assistance and help connect the patient with social support networks, encouraging active use of these resources and self-care strategies. 4, 3
Monitor the patient's mental state in the days following the traumatic event, watching for progression to acute stress disorder or persistent symptoms. 4, 3
Critical Interventions to AVOID
Do NOT perform psychological debriefing or Critical Incident Stress Debriefing (CISD), as these interventions have not been shown to be effective and may potentially worsen outcomes by overwhelming victims and impeding natural recovery. 1, 2, 3
Do NOT use benzodiazepines (such as lorazepam) for acute stress reactions, as they are contraindicated in trauma-related conditions, have high abuse potential, and evidence suggests they worsen outcomes. 1, 5, 6
Avoid routine pharmacotherapy as a preventive intervention after traumatic exposure in the immediate aftermath. 4, 3
When Symptoms Persist or Worsen
Criteria for Acute Stress Disorder
If symptoms persist beyond the immediate reaction and the patient develops features within four weeks of trauma including:
- Intense fear, helplessness, or horror
- Dissociative symptoms
- Reexperiencing the traumatic event
- Avoidance behaviors
- Symptoms severe enough to interfere with psychological or social functioning
Then the patient meets criteria for acute stress disorder and requires specific treatment. 3, 7
Treatment for Acute Stress Disorder
Provide trauma-focused cognitive-behavioral therapy (CBT) with prolonged exposure as the first-line treatment, ideally 5 sessions within 2 weeks of trauma, as this reduces PTSD development from 56-83% in supportive counseling to 8-20% with CBT. 7, 8
Prolonged exposure therapy is the most critical component, with studies showing only 14-15% of patients treated with prolonged exposure developed PTSD at 6-month follow-up compared to 67% with supportive counseling alone. 8
Eye movement desensitization and reprocessing (EMDR) with in-vivo exposure (confronting avoided situations in a graded, systematic manner) may also be provided. 4
Pharmacotherapy Considerations (Use Cautiously)
When to Consider Medication
Short-term pharmacologic intervention may be beneficial only for relieving specific associated symptoms such as severe insomnia, pain, or depression in cases of extreme distress that persists despite psychological first aid. 4, 3
Medications should NOT replace trauma-focused psychological therapy as first-line treatment for acute stress disorder or PTSD. 4
If Medication Is Necessary
Sertraline is the preferred SSRI, initiated at 25 mg daily for one week, then increased to 50 mg daily, with FDA approval specifically for PTSD treatment. 5, 9
Paroxetine is an alternative first-line SSRI, started at 20 mg daily, though it has higher discontinuation syndrome risk than sertraline. 5
Evaluate treatment response after 8 weeks of SSRI therapy if medication is used. 5
Medications to Absolutely Avoid
Never use benzodiazepines (lorazepam, alprazolam, etc.) particularly in patients with substance use history, as they have high abuse potential, can cause severe withdrawal reactions, physical dependence, and evidence shows worsening outcomes in PTSD. 1, 5, 6
Do not use cannabis or cannabis-derived products for acute stress reactions or PTSD treatment. 1, 5
Special Considerations for Comorbid Depression or Anxiety History
Patients with current or family history of anxiety or mood disorders are at increased risk for developing PTSD following acute stress reactions. 3
Trauma-focused psychotherapy should still be initiated first, as evidence from multiple RCTs demonstrates that patients with complex trauma and comorbid mood disorders benefit from trauma-focused treatment without requiring prior stabilization. 5
If comorbid depression is present and medication is considered, sertraline remains the preferred choice as 44% of PTSD patients in sertraline trials had secondary depressive disorder and showed significant improvement on both PTSD and depression measures. 5
Psychotherapy and pharmacotherapy can be initiated concurrently without waiting for a stabilization phase, as emotion dysregulation improves with trauma-focused treatment rather than requiring pre-treatment stabilization. 5
Common Pitfalls to Avoid
Avoid dismissive attitudes, as acute stress reactions can be genuinely distressing even when symptoms are self-limited. 2
Do not overemphasize fear and anxiety through excessive discussion, as this may undermine the patient's ability to cope and function, particularly when traumatic events are ongoing. 1
Recognize that denial, repression, and isolation—typically considered counter-productive in clinical settings—may actually be functional coping mechanisms in the immediate aftermath of trauma for the general population. 1
Do not assume all patients need formal intervention, as most of the public does well on their own with basic psychological first aid and social support. 1