Acute Stress Disorder

Since we are now commemorating the 12th anniversary of the September 11 terrorist attacks, I am releasing a report on one of several cases that I treated for “Acute Stress Disorder” following the 9/11 attacks on the Twin Towers.

The unexpected encounter of a high-magnitude trauma of this nature is likely to overwhelm all lines of psychological defense.

The Twin-Tower attacks on 9/11 directly exposed thousands of New York residents to the horror of a near-death experience. This was associated with a sense of dread and impending doom, and accompanied by the witnessing of mayhem, collective chaos, personal loss or injury, and the dislocation from an environment that had previously been safe and predictable.

Acute Stress Disorder is one of the more serious responses to a shocking violation or near-death experience. It begins within hours or days after a traumatic event, and the victim suffers a combination of “Dissociative” symptoms, as well as the immediate onset of full-blown post-traumatic stress symptoms.

In this victim of Acute Stress Disorder the “dissociation” was so severe that she presented to the Emergency Room at SUNY Downstate in a trance-like state.

This young woman had been walking down the stairwell when she heard a tremendous explosion. She quickened her pace until she smelled fumes and heard screaming. At that point she opened the door from the stairwell that allowed her to stand on a small platform (all that remained of that floor).

Immediately, a burning tire came hurtling down, missing her by inches. As she gazed up, she saw above her the remnants of offices, disconnected from their main landing, like suspended islands. Injured and burning survivors, assured of their pending doom, could be seen screaming in pain and terror.

The woman paused before realizing that their fate was sealed, and then continued down about another 40 floors until reaching the exit. She remained in the chaos at “Ground Zero” for a short time, and then followed a crowd of people walking across the Brooklyn Bridge. Several hours later she arrived home in a “dazed state.”

Her mother brought her to the Emergency Room the following morning. She had paced the floor of her apartment the entire night without sleeping.

On evaluation, what one observed was a young woman who was staring blankly in front of her. She was quietly moaning and sobbing.

She was still totally immersed in the trauma scene as if it were occurring that moment. Not only did she not answer questions, she didn’t even notice my presence in the room. From time to time she would reach or call out to the victims still visible in front of her. On several occasions she raised her hands to shield herself against falling debris. This describes the “dissociative” component of her “Acute Traumatic Stress” Disorder.

This description depicts an extreme form of dissociative reaction, where the victim`s fixation to the scene of the trauma precluded the mind`s ability to spontaneously unfold again.

While some traumatized individuals experience a spontaneous recovery (due to habituation), a minority of survivors continue to experience a disruption in their ability to integrate the flow of consciousness and regain their capacity for full emotional re-engagement into their work and social environments.

This situation usually results in a “shutting down” effect. Psychiatric researchers suspect that the biological underpinning of this phenomenon is a temporary loss of synthetic brain function predominantly involving the Hippocampus and Pre-Frontal Lobes.

These brain cells have the most complex cyto-architecture, were originally described as the “Circuit of Papez” and while appearing like NeoCortex, as they arch with the Hippocampus, deeply into the limbic-emotional brain, but cannot sustain a prolonged period of assault by stress-hormones such as C.R.F. and Cortisol.

A failure to contain such severe emotional arousal inhibits the resilience of this cortical-limbic function, which is normally responsible for generating the trauma narrative, and reducing limbic arousal.

The immediate treatment goal is to re-establish emotional regulation.

Until the trauma-material has been processed, trauma-reminders are likely to evoke in the survivor fear, guilt, or even rage.

In Acute Stress Disorder the victim also has “Intrusive” Symptoms, (in the form of thoughts or images), as well as “Arousal” Symptoms (from a shift of brain functions to that of Sympathetic Overdrive: characterized by marked anxiety, irritability, and disturbance of sleep or concentration, and hyper-vigilance;

When this is also accompanied by the impulse to take “flight”, – run away from (“avoid”) anything (even thoughts) that reminds the victim of the experience, then this fulfills the criteria for the diagnosis of Acute Stress Disorder.

If the symptoms recounted above for Acute Stress Disorder persist beyond four weeks, then professional intervention is required, since the individual has then evolved into the more persistent condition of post-traumatic stress disorder.

Tags: 9/11, ACTH, caretaking following disasters, Dentate Nucleus, Glucocorticoid, Hippocampus, James Papez, Neocortex, Prefrontal, PTSD