Kratak sadrzaj: Stres je odgovor organizma na izla-

AKUTNI STRESNI ganje stresnim faktorima, ion moze izazvati razlicite

psihopatoloske manifestacije. Psihopatoloski pore-
POREMECAJ rnecaji koji su direktno vremenski i uzrocno poveza-
I POSTTRAUMATSKI ni sa stresom su akutni stresni porernecaj (ASP) i
posttraumatski stresni porernecaj (PISP). Ozbiljnost
STRESNI POREMECAJ traumatskog dogadaja je kao faktor rizika znacajnija
UPOREDNIPREGLED od ukupnog broja tih dogadaja. Prevalenca PTSP-a
varira zavisno od studije i krece se od 1% nakon raz-
licitih trauma do 36% nakon ratnog iskustva. Postoji
Blagoje Kuljic 1 sest grupa simptoma koji se registruju u okviru ASP-
Ljubica Leposavii a i/ili PISP-a: disocijativni, nametanje, izbegavanje,
Srdan Milovanovic 2 anksioznost i hiperekscitabilnost, disfunkcionalnost
i kompulzivna reekspozicija traumi. Najznacajnija ra-
]ovan Maric 2 zlika u dijagnostickim kriterijumima za ASP izrnedu
ICD-IO i DSM-IV je u disocijativnim simptomima na
kojima insistira DSM-IV. U skladu sa DSM-IV ASP
simptomi traju od 2 dana do 4 nedelje. Za razliku od
toga, po ICD-IO simptomi mogu trajati i sarno 8 ca-
soya da bi se postavila ova dijagnoza. Sto se rice
PTSP-a, nema bitnih razlika u dijagnostickim kriteri-
jumima izmedu ove dye klasifikacije. ASP i PISP su
dye vremenski zavisne dijagnosticke kategorije koje
su u bliskoj vezi po svojim klinickim karakteristika-
rna. Trajanje simptoma u vremenu od mesec dana je
tacka gde prestaje ASP i pocinje PISP. Disocijativni
simptomi su .prisutni u ASP-u i oni se gube tokom
vremena tako da nisu prisutni kod PISP-a kao dijag-
nosticki kriterijum. Terapija ASP-a je bazirana na psi-
hoterapiji (ventilacija i abreagovanje). Bazicni prin-
cipi u ovoj terapiji su kratkotrajnost, hitnost, nepo-
srednost, povrsinski metodi intervencije i povratak
na puni nivo premorbidnog funkcionisanja. Terapija
PISP-a takode ukljucuje psihoterapiju (suport, eks-
1 lnstitut za neuropsihijatrijske bolesti planacija i destigmatizacija). Farmakoterapija se ko-
Dr. Laza Lazarevic, Beograd risti zavisno i usmereno na prisutnu psihopatologiju
2 Klinicki centar Srbije, Kljucne reii: akutni stresni poremecaj, posttraumat-
Institut za psihijatriju, Beograd ski stresni porernecaj, stres.

Stres predstavlja odgovor organizma, na iz- stresa se registruju razne anksiozno depre- ,.
lozenost stresnim faktorima, i moze biti sivne dekompenzacije, psihosomatske bo- ~
uzrok raznih psihopatoloskih ispoljavanja. lesti iii on moze biti uvod u zloupotrebu g
U psiholoskom smislu stresni faktori su psihoaktivnih supstanci. Akutni stres moze ;:
situacije koje osoba percipira kao ekstrem- biti uzrok reaktivnih psihoza iii okidac za N

ne ivan svoje kontrole tj. bez mogucnosti egzacerbaciju endogenih psihoza. Ipak, psi- :E
~
znacajnijeg upliva na tok tih dogadaja. Stres hopatoloska ispoljavanja koja su vremenski C,)

po trajanju rnoze bit akutan iii hronican sto i direktno uzrocno posledicno vezana za @
takode utice na njegov ishod na psihickom akutni stres, su akutni stresni poremecaj i
planu. Kao krajnji efekat kod hronicnog posttraumatski stresni poremecaj.
 Akutna stresna reakcija (akutni stresni po-
rernecaj) (ASP) predstavlja neposredan i
kratkotrajan odgovor na stresogenu situa-
ciju a manifestuje se simptomima anksi-
oznosti (kao odgovor na preteen opas-
nost) iii simptomima depresivnosti (kao
odgovor na neposredan gubitak). Pri to-
me, se simptomi anksioznosti i depresiv-
nosti mogu pojavljivati istovremeno jer
stresogeni dogadaj cesto podrazumeva
udruzenu opasnost i gubitak.
Posttraumatski stresni (PTSP) poremecaj
je specifican sindrom koji je posledica
teske traume i podrazumeva prolongiran,
patoloski odgovor na intenzivan traumats-
ki dogadaj (poput prirodnih katastrofa,
ratova, saobracajnih nesreca, seksualnog
nasilja i slicno) koji nije u opsegu uobica-
jenog nacina zivota. Poremecaj karakterisu
tri grupe simptoma: 1) simptomi ponov-
nog dozivljavanja traume; 2) simptomi
izbegavanja situacije koji su u vezi sa trau-
mom i simptomi generalizovane otuplje-
nosti i 3) simptomi prenadrazenosti.
Obzirom na njihovu blisku povezanost po
etioloskom faktoru (stres), mnoge slicno-
sti u klinickoj slici kao i neposredni kon-
takt vremenskom kontinuumu, dacemo
uporedni pregled karakteristika ovih dveju
dijagnostickih entiteta.
FAKTORI RIZIKA ZA
ISPOLjAVANjE POREMECAjA
POVEZANIH SA STRESOM
Step en izlozenosti kao i tezina samog trau-
matskog dogadaja je u vezi sa tezinom
simptoma PTSP-a i ASP-a mada postoje i is-
S jima nalazi u sopstvenim rukama i da to
o
o
trazivaci koji negiraju tu povezanost ( 1, 2).
~ Radena su ispitivanja koliku ulogu u
N
N predikciji simptoma posttraumatskog stre-
sa ima sarna tezina dogadaja. Tako se doslo
do rezultata da generalno gledano ratno is-
kustvo, nasilje i saobracajne nesrece pred-
stavljaju najtraurnaticnija iskustva kod
2
muskaraca, Kod zena su fizicki napad iii
prisusvo takvom napadu kao i povredivan-
je, smrt bliskih osoba i saobracajne nesrece
opisani kao najtraumaticniji. (3).
Kao faktor rizika za razvoj PTSP je u mno-
gim studijama oznacena zivotna istorija sa
visestrukim traumaticnim dogadajima. (4,
5). Osoba koja je u svojoj zivotnoj istoriji
imala veci broj ovih dogadaja, je na neki
nacin senzitizovana na naknadne traume,
jer se kod nje razvija osecaj da je zivot pun
teskoca i gubitaka, kao i da je van sopstvene
kontrole. Takode su bitni i zivotni dogadaji
nakon traume, jer se ova senzitivnost i u
osnovi negativna i uznemirujuca percepcija
zivota sve vise produbljuje. Statisticke ana-
lize su pokazale da tip dogadaja ima vecu
prediktivnu vrenost nego sto je njihov uku-
pni broj.
Emocionalni odgovor na traumaticne doga-
daje odreduju individualna specificna reak-
tivnost i interpretativnost. Neuroticna di-
menzija licnosti utice na odbrambene me-
hanizme i reaktivnost (6). Trait anksioz-
nost, kao jedan aspekt neuroticizma je sta-
bilna osobina, i kao i depresivnost uzroku-
je pojavu poremecaja vezanih za stres (7).
Nizi koeficijent inteligencije je takode zna-
cajno povezan sa razvojem PTSP-a (8).
Pozitivna emocionalna stabilnost i sarno-
pouzdanje su oznaceni kao centralni Li
uspesnoj integraciji traumatskih dogadaja
(9). Emocionalna ekspresivnost je uslov-
ljena nekim neuronalnim karakteristikama,
individualnim temperamentom, uverenji-
rna i kulturalno je modulisana (10). Uvere-
nje da se kontrola nad zivotnim dogada-
nije negde u spoljasnjem svetu (lokus ken-
trole) je takode protektivni faktor (1 I) .
Mnogobrojna su istrazivanja 0 prevalenci-
ji PTSP-a i ASP-a u opstoj populaciji, i 0
faktorima rizika za njihovu pojavu. Medu-
tim, postoje i istrazivanja koja ispituju da
li postoje i neki faktori rizika koji uslov-
ljavaju uopste povecanu izlozenost nekim
stresnim situacijama, pa se usled toga na-
knadno javlja i PTSP. Doslo se do zaklju-
caka da socijalne karakteristike, neuroti-
cizam kao i genetska predispozicija uticu
na stepen izlozenosti stresnim zivotnim
dogadajima (12). Studije sa ispitanicima
koji su prosli kroz traumaticna iskustva
tipa: objekt kriminalnog ataka, traumatske
i saobracajne nesrece, ukazuju da su fak-
tori rizika za uopste izlozenost ovakvim
dogadajima pol, rasa, stepen edukacije,
crte licnosti kao i pozitivna porodicna ana-
mneza psihijatrijskih porernecaja (13). Ta-
ko na primer ekstroverzija direktno preci-
pitira vecu izlozenost rizicnim ponasanji-
ma, a takode i pripadnost nizim socijalnim
slojevima uslovljava kretanje u sredini ko-
ja sobom nosi vece rizike (14). Osobe ko-
je su u braku su manje izlozene traumat-
skim iskustvima (15).
EPIDEMIOLOGIjA
U opstoj populaciji je PTSP registrovan
kao cest poremecaj. Postoje razni statis-
ticki podaci, tako na primer Kessler i sar.
za zivotnu prevalencu u opstoj populaciji
navode cifru od 5% za zene i 10% za mus-
karce. Oni takode navode da je zivotna
prevalenca za izlozenost traumatskim is-
kustvima tj. nesrecama 25% za muskarce i
13% za zene (16).
Prevalenca PTSP-a varira zavisno od studi-
ja i od vrste trauma koje su ispitivane. Ta-
ko na primer Malt navodi incidencu od 1%
kod razlicitih trauma, dok Mayou navodi
cifru od 11 % nakon saobracajnih nesreca,
dok Blanchard navodi 49% 4 meseca na-
kon saobracajne nesrece (17- 19). Bowles
i sar. nalaze ucestalost ASP-a od 10% kod
zena nakon spontanog abortusa (20).
ETIOLOGIjA
Ispitivanja aktivnosti autonomnog nervnog
sistema kao i adrenergicke transmisije su
centralna u literaturi 0 posttraumatskom
stres poremecaju (PTSP). Kod ispitanika sa
PTSP-om jasno je pokazan povisen nivo
krvnog pritiska i srcane frekvencije kao i
promene elektromiogramu i aktivnosti
znojnih zlezda. (21). Nalaz je potvrden ka-
ko u mirovanju tako i pri provokativnim
testovima-prisecanju na traumu. [edan od
glavnih postulata za PTSP govori 0 auto-
nomnoj hiperaktivnosti. Ova povecana raz-
drazljivost je pracena anksioznoscu ali i
besom i depresijom. Upravo pomenute
emocije upucuju pojedine autore na zaklju-
cak da PTSP treba dijagnostikovati kao za-
sebnu kategoriju a ne kao anksiozni pore-
mecaj.
Ispitivanja nivoa adrenalina i noradrenalina
u plazmi i urinu govore uniformno 0 njiho-
vom izrazenijem povisenju pri, ponovnom
izlagan]u stresu u odnosu na kontrolu, dok
rezultati iz faze mirovanja pokazuju kako
povisene tako i normalne vrednosti. To po-
tvrduju i studije koje su registrovale po-
visen nivo MHPG nakon davanja johimbina
(22).
[edna od glavnih karakteristika PTSP-a je
porernecaj sna. Medutim, istrazivanja 0
strukturi i karakteristikama spavanja su
dala jako raznolike rezultate, tako da nije
mogao biti izveden neki precizan i unifor-
man zaklj ucak,
Neuroendokrine studije daju nalaze 0 hi- 1"
perkortizolemiji kod akutnog izlaganja tra- <of)
8
umatskom stresnom faktoru (23). Kao po- s
sledica ovoga rnoze doci do ostecenja hi- ~
pokampusa, sto opet dovodi do neuropsi- N
holoskih deficita u vidu ostecenja memo- ~
rije (24). Dugotrajno izlaganje stresnim ~
faktorima dovodi do snizenja 24 casovne ~
ekskrecije kortizola i preterane supresije
plazmatskog kortizola nakon deksameta- 3
 zonskog supresornog testa (25). Postoje
podaci u literaturi koji govore i 0 povecanju
nivoa kortizola. Objasnjenje za ovu razno-
likost moze biti u razlicitim oblicima PTSP-
a kao i razlicitim fazama koje obuhvataju
kako stabilizaciju simptoma tako i akutne
egzacerbacije.
Takode se notira uticaj i drugih neurotrans-
mitera i neuromodulatora na PTSp, kao sto
su na primer serotonin i opioidi (26).
SIMPTOMI POREMECAJA
POVEZANIH SA STRESOM
Disocijacija
Freud je opisao da u slucajevima ekstremne
opasnosti dolazi do disocijacije tako sto se
osoba udaljava, odvaja od same sebe i stav-
lja se u poziciju da je ona neko drugi ko po-
smatra sa strane taj dogada], a sve u cilju da
bi se eliminisao strah od smrti koji izaziva
sarna situacija. I u novijim studijama je opi-
sivan sled dogadaja: trauma-disocijacija-
posttraumatski sindromi (21).
Disocijativni simptomi su osecaj ukoceno-
sti - inhibiranosti, osecaj otupelosti cula,
dezorganizacija i sporost u misljenju i do-
nosenju odluka nakon nesrece, osamu-
cenost i zbunjenost, derealizacija, deperso-
nalizacija, dozivljaj kroz san, tranzinen-
tne halucinacije i sumanutosti nakon trau-
maticnog iskustva, amnezija i drugi pore-
mecaji pamcenja (28-30).
Anksioznost
7 i hiperekscitabilnost
I
r<')
8 Simptomi anksioznosti cesto traju nede-
o ju osobu od njenog trenutnog okruzenja
~ ljama nakon samog dogadaja. Nju poveca-
vaju i drugi naknadni dogadaji koji nisu di-
52- rektno vezani za nesrecu,
~
t) Strah, poremecaji sna, iritabilnost (tesko-
Z ce u kontroli emocija sa povremenim na-
r.Ll
glim emotivnim praznjenjima i osecajern
4
da ih prisustvo drugih ljudi i kontakt sa
njima iritira), problemi sa koncentracijom,
pojacana vigilnost i preterani OdgOVOf na
stimuluse predstavljaju vidove ispoljava-
nja povecane anksioznosti (31,32).
Ovi simptomi su cesto udruzeni 'sa poja-
can om aktivnoscu autonomnog n~rvnog
sistema. Tako se na primer kod ratnih vet-
erana sa PTSP-om registruje pojacana
srcana frekvencija i sistolni arterijski priti-
sak u mirovanju, kao i veci skok srcane
frekvence nakon izlaganja stimulusima ve-
zanim za ratno iskustvo (33).
Kod hiperekscitabilnosti dolazi do kontinu-
irane anticipacije opasnosti. Svaka rnoguca
opasnost se generalizuje, i potom se cove-
kovo neposredno okruzenje i ceo svet do-
zivljava kao jako nesigurno mesto. Kon-
stantna percepcija opasnosti pokrece meha-
nizme somatske reakcije na stres, a to do-
vodi do toga da se ove somatske senzacije
vise ne mogu percipirati kao signal opasno-
sti onda kada za to zaista bude potrebe i ne
pokrecu na akciju. Pacijenti sa PTSP-om ne
mogu vise realno protumaciti poruke koje
odasilje autonomni nervni sistem, i stoga
ni proceniti svoje emotivno stanje sto se
moze definisati kao aleksitimija.
Nametanje
Zrtve traurnaticnih dogadaja cesto imaju
samonamecuca i uznemirujuca prisecanja
na taj dogadaj, Ova prisecanja naviru u ra-
zlicitim formama, ukljucujuci nezeljcne,
sarnonamecuce misli, kosrnarne snove,
vizuelu i druge senzore obmane, zivopisne
slike (flashback) koje u potpunosti odvaja-
(31-34). Takve epizode su cesto izazvane
odredenim situacionim okidacirna (zvuci,
mirisi, mesta, aktivnosti) , ili mislima i
osecanjima koji su povezani sa traumom.
Osoba se moze osecati kao da se trau-
matski dogadaj ponovo odvija. Ta priseca-
nja na traumu deluju na osobu kao emo-
cionalno snazna, vrlo realna, zivopisna i
precizna. Od ovih je prisecanja nemoguce
pobeci, koliko se god trudili.
Izbegavanje
Nakon nesrece dolazi i do druge grupe
simptoma-izbegavanja, koji obuhvata iz-
begavanje misli, razgovora, osoba, aktiv-
nosti iii situacija koje bi mogle podsetiti
na traumu (35).
Osabe sa ovim poremecajem izbegavaju
stimuluse vezane za traumu, obzirom na to
da su ani jako uznemirujuci. Oni ne izbe-
gavaju sarno aktivnosti, rnesta i ljude koji
podsecaju na traumu, nego i razgovor a
njoj kao i same misli koje bi mogle oziveti
ta secanja, takode mogu imati problema da
se prisete ili reprodukuju secanja na do-
gadaj. Zanimljivo je da se ovo ne secanje za
dogadaje oko traume javlja kod istih ljudi
koji imaju i intruzivne flashback epizode.
Simptomi izbegavanja sa ponasanjern koje
ih prati, dovode do problema u socijalnom
funkcionisanju te se oboleli cesto izoluju
od drugih u svoj usamljenicki prostor i ak-
tivnosti gde se osecaju sigurno. Cesto na-
vade da se osecaju ernocionalno distanci-
rani od svojih bliznjih, porodice i prijatelja,
da su im osecanja otupela, ukocena, gube
interes za neke ranije aktivnosti, a buduc-
nost im se cini neprijatna i bez nade, ako
uopste i razrnisljaju 0 njoj. Planovi i ciljevi
u zivotu, koje su ranije imali bivaju zane-
mareni.
Simptomi iz grupe izbegavanja mogu ima-
ti razne oblike. Oni se registruju i u vidu
upotrebe i zloupotrebe psihoaktivnih sup-
stanci da bi se ublazila zabrinutost i uzne-
mirenost, ili u vidu disocijacije kako bi se
tim mehanizmom uspomene drzale van
dornasaja svesnog. Za ljude sa ovim pore-
mecajima vazi pravilo ne osecati nista je
bolje nego osecati se uznemirenim.
Disfunkcionalnost
U Lindemann-ovoj studiji 0 akutnom stre-
su iz 1944. godine, navedeno je da se nakon
traume javlja porernecaj iii cak slom nor-
malnih obrazaca socijalnog funkcionisanja,
gde je registrovana povecana zavisnost od
drugih osoba. Dolazi do gubitka sposob-
nosti za pokretanje i odrzavanje organizo-
vanih obrazaca akcije. Nasuprot tome, kod
psihotraumatizovanih nakon popustanja
brane u Buffalo Creek-u je registrovana izo-
lacija i osecaj otudenosti (36).
Nakon nesrece se cesto javlja zloupotreba
psihoaktivnih supstanci sto takode znacaj-
no utice na buduce funkcionisanje. Tako je
kod polovine ucesnika u pruzanju zdrav-
stvene zastite prilikom velikog pozara u
Australiji doslo do pojave problema funkci-
onisanja u vidu promene apetita, sna, pove-
canog pusenja, upotrebe alkohola (37).
Kompulzivna reekspozicija
Postoji grupa simptoma koja nije pomenu-
ta u klasifikacijama ICD-IO i DSM-IV: To je
set obrazaca ponasanja koji ustvari pred-
stavljaju kompulzivnu reekspoziciju situa-
cijama koje podsecaju na originalnu trau-
mu. Freud je smatrao da je cilj ovakvog po-
nasanja da se ovlada traumaticna situacija
(38). Medutim, klinicka iskustva po navo-
dima van der Kolk-a pokazuju da do toga
ipak retko dolazi. Postoji nekoliko varijete-
ta ovog ponasanja. Prvi je zlostavljanje dru-
gih. Nairne, u mnogim studijama je doka-
zane da je veliki broj agresivnih krimina- l'
laca fizicki i seksualno zlostavljano u de- ~
tinjstvu (39). Drugi oblik je samodestruk- g
~
tivnost. Veliki je stepen povezanosti seksu- N
N
alnog zlostavljanja u detinjstvu sa suicidal-
nim pokusajima, samopovredivanjem i sa- 5E
~
moizgladnjivanjem (40). Treca varijanta je o
Z
reviktimizacija. Iedna grupa istrazivanja U-l
nalazi da zrtve silovanja mogu biti ponovo
silovane (41), deca koja su bila seksualno 5
 zlostavljana se ukljucuju u prostituciju
(42), bivsi ratnici se ponovo javljaju za od-
lazak u rat kao placenici Hi se prikljucuju
policiji.
KLASIFlKACI]A POREMECAJA
POVEZANIH SA STRESOM
Po desetoj reviziji Medunarodne klasifika-
cije bolesti (ICD-IO) (43), Svetske zdrav-
stvene organizacije, stresni poremecaji su
ukljuceni u kategoriju F40-F48 Neurot-
ski, sa stresom povezani i somatoformni
poremecaji, Oni su izdvojeni kao podka-
tegorija F 43 Reakcije na tezak stres i po-
rernecaji prilagodavanja.
F 43.0 Akutna stresna reakcija
F 43.1 Posttraumatski stresni porernecaj
F 43.2 Poremecaji prilagodavanja
F 43.20 Kratkotrajna depresivna reakcija
F 43.21 Prolongirana depresivna reakci-
ja
F 43.22 Mesovita anksiozna i depresivna
reakcija
F 43.23 Sa dominirajuiim poremeiajem
drugih emocija
F 43.24 Sa dominirajucim porernecajem
ponasanja
F 43.25 Sa mesovitirn porernecajem emo-
cija i ponasanja
F 43.28 Drugi specifikovani dominira-
juci simptomi
F 43.80 Druge reakcije na tezak stres
'<t'
I
rr, F 43.90 Reakcije na tezak stres, nespeci-
oo fikovane
o nekog drugog.
~
;::jPo klasifikaciji Americkog udruzenja psihi-
SS' jatara DSM IV (44), ASP i PTSP su svrsta-
~ ni u grupu Anksiozni porernecaji.
CJ
Z 1. Posttraumatski stresni poremecaj 309.81.
u..J
2. Akutni stresni poremecaj 308.3.
6
DI]AGNOSTICKI KRITERI]UMI
POREMECAJA POVEZANIH
SA STRESOM
Akutna stresna reakcija
ICD-IO
Postojanje neposredne i jasne vremenske
povezanosti izmedu dejstva jakog stresa i
pocetka simptoma; pocetak je obicno u in-
tervalu od nekoliko minuta, ukoliko nije
trenutan uz to, simptomi: a) pokazuju me-
sovitu i obicno promenljivu sliku, uz inici-
jalno stanje zgranutosti: mogu biti pri-
sutni depresija, anksioznost, bes, ocaj,
preterana aktivnost ili povlacenje ali ni je-
dan simptom ne dominira dugo; b) gube
se brzo, najvise nekoliko sati u onim slu-
cajevima gde je uklanjanje iz stresne si-
tuacije moguce. U slucajevima produze-
nog stresa, ili onog koji se po svojoj priro-
di ne moze preobratiti, simptomi se sman-
juju obicno posle 24 do 48 sati i obicno su
minimalni nakon tri dana. Pod akutnom
stresnom reakcijom ukljucuju se i dijag-
nosticki entiteti: a) akutna krizna reakcija;
b) borbeni zamor; c) krizno stanje; d) psi-
hicki sok.
DSM-IV
A. Osoba je bila izlozena traumatskom do-
gadaju pri cemu su tacne obe sledece
tvrdnje.
1. Osoba je dozivela, prisustvovala iii bila
suocena sa jednim ili vise dogadaja koji
su podrazumevali stvarnu ili pretecu
smrt iii tesku fizicku povredu iii pretnju
telesnom integritetu same osobe ili
2. Reakcija te osobe je podrazumevala in-
tenzivan strah, bespomocnost i uzas.
B. Tokom traumatskog dogadaja, ili nakon
njega, osoba je imala tri ili vise od na-
vedenih disocijativnih simptoma:
1. Subjektivni osecaj otupelosti, odsutnos-
ti, ili gubitak emocionalne reaktivnosti.
2. Smanjen interes za dogadan]a iz okoline
(biti kao osamucen).
3. Derealizacija.
4. Depersonalizacija.
5. Disocijativna amnezija (nemogucnost
prisecanja vaznih aspekata trume).
C. Simptomi ponovnog prezivljavanja tra-
ume (neophodno je postojanje najma-
nje jednog od navedenih 5 simptoma):
rekurentne slike, misli, snovi, iluzije,
slikovite predstave, iii osecaj ponovnog
prozivljavanja traume; iii distres prili-
kom izlaganja faktorima koji podsecaju
na traumu.
D. Izbegavanje stimulusa koji su u vezi sa
traumom (aktivnosti, osecanja, razgov-
or, misli, mesta, ljudi).
E. Simptomi anksioznosti Hi prenadraze-
nosti (nesanica, iritabilnost, teskoce u
koncentraciji, hipervigilnost, previse iz-
razena reakcija trzanja, motorni nemir).
F. Ove promene klinicki izazivaju znacajan
distres iii ostecenje u socijalnom, profe-
sionalnom iii ostalim vaznim oblastirna
zivotnog funkcionisanja.
G. Porernecaj traje minimalno dva dana a
maksimalno cetiri nedelje, a pojavljuje
se u okviru od cetiri nedelje nakon tra-
umatskog dogadaja.
Porernecaj nije izazvan direktnim fiziolos-
kim efektom supstance (zloupotrebom psi-
hoaktivnih supstanci), Hi opstim zdrav-
stvenim stanjem, ne odnosi se na kratki
psihoticni poremecaj, i ne predstavlja eg-
zacerbaciju ranije postojeceg po osi I iii osi
II poremecaja,
POSTTRAUMATSKI
STRESNI POREMECAJ
ICD-10
A. Pacijent mora da bude izlozen stres-
nom dogadaju iii situaciji (bilo kratkog,
bilo dugog trajanja) izuzetno jake iii
katastroficne prirode, koji bi mogao da
uzrokuje stres kod gotovo svakog.
B. Simptomi ukljucuju prisecanje iii po-
novno nametljivo dozivljavanje stresora
(flashbacks), u budnom stanju iii u sno-
virna iii dozivljavanje neprijatnog stresa
kada je izlozen priIikama koje podsecaju
na stresor iii koje su udruzene s njim.
C. Pacijent izbegava iii tezi da izbegava
okolnosti koje podsecaju na stresor iii
koje su udruzene s njim, sto nije posto-
jalo pre delovanja stresora.
D. Takode postoji:
nesposobnost secanja, parcijalna iii pot-
puna, nekih vaznih aspekata iz perioda
izlozenosti stresoru;
neprekidni simptomi pojacane psiholo-
ske osetljivosti i uzbudljivosti (koji nisu
postojali pre izlaganja stresoru), a sto
dokazuje prisustvo bilo koja dva od sle-
decih: teskoce uspavljivanja i odrzavanja
sna, razdrazljivost iii izbijanja ljutnje, te-
skoce koncentrisanja, preterana bud-
n~st, trzanje na mali povod.
Kriterijumi B,C i 0 moraju da budu zastu-
pljeni u roku od 6 meseci od stresnog do-
gadaja ili od kraja stresnog perioda (za ne-
ke svrhe, i pocetak odlozen vise od 6 me-
sed moze da bude ukljucen, ali to treba ja-
sno oznaciti).
DSM-IV
A. Osoba je bila izlozena traumatskom
dogadaju pri cernu su tacne obe sledece
tvrdnje.
1. Osoba je dozivela, prisustvovala iii bila
suocena sa jednim iii vise dogadaja koji ~
su podrazumevali stvarnu ili preteen 0'
smrt iii tesku fizicku povredu iii pretnju g
telesnom integritetu same osobe ili ~
nekog drugog. ~
2. Reakcija te osobe je podrazumevala in- ~
tenzivan strah, bespomocnost i uzas. o
Z
B. Simptomi ponovnog prezivljavanja tra- u.l
ume (neophodno je postojanje najma-
nje jednog od navedenih 5 simptoma). 7
 1. Rekurentna, nametljiva i neprijatna se-
canja na traumu, koja ukljucuju preds-
tave (slike), razrnisljanja 0 traumi, misli
i opazanja.
2. Rekurentni i neprijatni snovi koji se od-
nose na traumu.
3. Ponasanja i dozivljavanja kao da se trau-
ma panovo odigrava ( kroz osecaj da se
trauma ponovo prozivljava, iluzije, halu-
cinacije, disocijativna slikovita prozivlja-
vanja traume, ukljucujuci ona prilikom
budenja ili u stanju intoksiciranosti).
4. Intenzivni psiholoski distres prilikom
izlaganja unutrasnjim ili spoljasnjim
stimulusima koji simbolizuju neki as-
pekt traume ili lice na njega.
5. Fizioloska reaktivnost na izlaganje unu-
trasnjirn iii spoljasnjim stimulusima
koji simbolizuju neki aspekt traume iii
lice na njega.
C. Trajno izbegavanje stimulusa koji su u
vezi sa traumom i simptomi generali-
zovane otupljenosti (koji nisu bili pri-
sutni pre traume), u vidu postojanja tri
od svih navedenih simptoma.
1. Izbegavanje razrnisljanja, osecanja iii
razgovora koji se odnose na traumu.
2. Izbegavanje aktivnosti, mesta ili ljudi
koji bude secanja na traumu.
3. Nesposobnost prisecanja znacajnih as-
pekata traume.
4. Izrazito smanjeno interesovanje za uce-
see u znacajnim aktivnostima.
5. Dozivljaj distaciranosti ili otudenosti
od drugih osoba.
6. Smanjen opseg osecanja (na primer, gu-
bljenje pozitivnih osecanja prema dru-
gima).
7. Dozivljaji bezperspektivnosti iii uskra-
0'
8 eerie buducnosti (bez znacajnih oceki-
~ vanja i polaganja nade u profesionalnu
N
N karijeru, brak, decu, i uopste normalno
zivotno dostignuce).
D. Simptomi prenadrazenosti (koji nisu
bili prisutni pre traume), u vidu posto-
janja dva od svih navedenih simptoma.
8
1. Teskoce pri uspavljivanju iii odrzavanju
sna.
2. Razdrazljivost iii izIivi besa.
3. Teskoce u koncentraciji.
4. Hipervigilnost.
5. Previse izrazena reakcija trzanja (upla-
senost na bezazlene stimuluse).
E. Trajanje promena, navedenih pod B, C i
D je duze od mesec dana.
E Ove promene klinicki izazivaju znacajan
distres ili ostecenje u socijalnom, profe-
sionalnom iii ostaIim vaznim oblastima
zivotnog funkcionisanja.
Potrebno je odrediti tip PTSP:
Akutni: trajanje simptoma manje od tri
meseca
Hronicni: trajanje simptoma duze od tri
meseca
Sa odlozenim pocetkorn: simptomi se
pojavljuju najmanje 6 meseci nakon
traumatskog dogadaja
SPECIFICNOSTI KLASIFIKACIjA
ICD-IO / DSM-IV
Akutna reakcija na stres je dijagnaza usta-
novljena 1993. godine u desetoj reviziji Me-
dunarodne klasifikacije bolesti (ICD-I 0),
koju je dala Svetska zdravstvena organizaci-
ja (WHO). Koopman navodi da su ustvari
i normalne reakcije na stres pracene poje-
dinim simptomima iz dijagnostickih krite-
rijuma za ASP (45). Medutim, njihova tezi-
na i ucestalost kao i stepen onesposobljenja
koji se javlja kod individue su u stvari kri-
terijumi na osnovu kojih se postavlja dijag-
noza ASP i time odreduje potreba za kli-
nickom intervencijom. Postaviti dijagnozu
ASP-a u stvari znaci identifikovati visok ni-
vo distresa ili disfunkcionalnosti kod osobe
izlozene traumaticnorn iskustvu.
Americka psihijatrijska asocijacija je 1994
u cetvrtcj reviziji Dijagnostickog i stati-
 stickog prirucnika (DSM-IV) uvela termin
akutni stresni poremecaj. Glavne odred-
nice u DSM-IV su postojanje cetiri kate-
gorije simptoma koji moraju biti prisutni,
a to su disocijativni, anksiozni, repeticija
sadrzaja vezanog za traumu i izbegavanje
sadrzaja koji podsecaju na traumu. Simp-
tomi moraju uticati na socijalno i profesio-
nalno funkcionisanje osobe. Simptomi mo-
raju trajati najmanje dva dana pa do maksi-
malno cetiri nedelje. Razlika u odnosu na
dijagnosticke kriterijume iz ICD-lO, koji
su prethodili ovima u DSM-IY, je u tome
sto je WHO dala kriterijum od 8 casova za
trajanje simptoma ukoliko je stres bio pro-
laznog karaktera a dva dana ako je stres
produzen.
Po Marshall-u, jednu od kljucnih razlika u
dijagnostickim kriterijumima ASP izrnedu
ove dye klasifikacije, cini insistiranje DSM-
IV na disocijativnim simptomima. Medu-
tim, po njemu ovaj kriterijum je diskutabi-
Ian i trebalo bi ga reevaluirati (46). Slicnog
je misljenja i Bryant (47).
Sto se tice PTSP-a, sustinske razlike u di-
jagnostickim kriterijumima izrnedu ove
dye klasifikacije ne postoje.
OONOS ASP-a i PTSP-a
Irnajuci u vidu dijagnosticke kriterijume
za ASP i PTSp' ova dva poremecaja mo-
zemo shvatiti kao zasebne entitete koji
stoje jedan uz drugi posrnatrajuci ih u jed-
nom nedeljivom vremenskom kontinu-
umu. Harvey kod povredenih osoba koje
su ispoljile ASp, registruje PTSP u 80%
nakon dye godine (48).
Vremenska odrednica mesec dana trajanja
simptorna cini granicu gde zavrsava ASP i
.. pocinje PTSP. Takode, disocijativni sirnpto-
mi predstavljaju karakteristiku ASP-a i oni
se vremenom gube tako da nisu prisutni u
vreme kada pocinju da vaze kriterijumi za
PTSP. Bowles i sar. navode kao glavnu raz-
liku izmedu ova dva entiteta upravo vre-
menske odrednice (49).
jasnu vezu izmedu ASP i PTSP-a pokazuje
uslovljenost ovih poremecaja sa ektrern-
nim-traumatskim iskustvom, koje je oki-
dac za oba. Drugu vezu pokazuje individu-
alna predispozicija ka disocijativnom rea-
govanju koje je karakteristika samog ASP-
a a koji je ujedno jak prediktivni faktor za
razvoj PTSP-a. Sklonost ka disocijativnom
reagovanju kod osoba sa ASP-em uslovlja-
va da iskustva vezana za traumu bivaju na
neki nacin sklonjena iz svesnog dela
licnosti, kako bi se ona zastitila od njenih
bolnih sadrzaja. Medutim, buduci da usled
toga sadrzaji vezani za traumu ne bivaju
obradeni i integrisani u licno iskustvo, oni
kasnije probijaju u podrucje svesnog u vi-
du intruzivnih simptoma i time zapocinje
manifestacija simptoma PTSP-a. Postoji ja-
sna vezaizrnedu prisustva ASP-a i kasnijeg
ispoljavanja PTSP-a (50, 51). Tako Solo-
mon i sar navode da je kod lzraelskih voj-
nika pojava psihicke ukocenosti, kao diso-
cijativnog simptoma neposredno nakon
traumaticnog dogadaja jak prediktor kas-
nijeg PTSP-a (52). Dalju potvrdu ovome
daju i retrospektivne studije na Vijetnam-
skim veteranima Marmar (30), kao i na-
kon udara groma u Oakland/Berkley Ko-
opman i sar. (53).
Povezanost izmedu sklonosti ka disocijativ-
nom reagovanju i PTSP-aje utvrdena u stu-
dijama Stutman-a (54) i Spiegel-a (55).
Oni su utvrdili povezanost izmedu PTSP-a '<t'
I
i stepena hipnotizabilnosti koja ukljucuje ~
kapacitet za disocijaciju. Percepcija stepena g
~
ugrozenosti to kom traumaticnog dogadaja N
je takode povezana sa ovim entitetima. N
Nairne, 510 je dogadaj dozivljen traumatic- ~
~
nije to ce osoba pre ispoljiti disocijativne CJ
Z
simptome da bi se zastitila od njega. Ovo ce UJ
dalje, po vee opisanom sledu dogadaja iza-
zvati pojavu PTSP-a. 9
 Problem u dijagnostikovanju ASP-a, po
Koopmanu predstavlja i to sto je ljude stid
priznati da imaju teskoce u prevazilazenju
traume (56). To proizilazi iz toga sto bi se
onda mogla zakljuciti da oni nisu dovoljno
jaki, da su izgubili kontrolu nad situaci-
jam, ili sa druge strane ih moze biti stid da
priznaju postojanje simptoma koji bi mo-
gli ukazati da su mentalno oboleli. Stoga
ASP ostaje cesto ne dijagnostikovan i biva
izgubljeno dragoceno vreme za terapijsku
intervenciju u tom ranom periodu kada bi
trebalo uspesno integrisati traumaticne
memorije. Tek nakon duzeg perioda se pa-
cijent biva upucen psihijatru ili kada se mo-
ze registrovati ne ASP vee PTSp' jer je peri-
od od prvih mesec dana nakon traume od-
makao.
Terapija
Terapija ASP-a se pre svega zasniva na psi-
hoterapijskim tehnikama koje mogu delo-
vati prilicno jednostavno ali su od ogrorn-
nag znacaja, Nairne, primenom ventilacije
i abreagovanja kroz individualni i grupni
rad oslobadamo emotivni naboj vezan za
traumu i predupredujemo pojavu disocija-
tivnih procesa koji bi bili podloga za razvoj
naknadne pojave PTSP-a. U terapiji ASP-a
se moraju postovati osnovni principi hit-
nag i neposrednog pruzanja pomoci, dakle
vremenski i prostorno sto blize nesreci.
Intervencija treba biti povrsinska i pri to-
me insistirati na potpunom oporavku i
ukljucivanju u ranije obaveze.
'TTerapija PTSP-a kao i kod ASP-a podrazu-
~ meva primenu psihoterapije. Potrebno je
o
o
2!-
10
pruziti dugotrajni suport uz prihvatljiva ob-
jasnjenja traume i njenih posledica, cime se
ornogucava pravilno integrisanje secanja na
traumu i staje na put procesima disocijaci-
je. Edukaciju i podrsku treba pruzati kroz
individualni i grupni rad. Potrebno je orga-
nizovati lokalne i nacionalne institucije za
pruzanje pomoci ovim ljudima. Time se po-
spesuje njihovo sto brze i potpunije uklju-
civanje u drustvo i sprecava razvoj socia
ekonomskog propadanja koje se maze javi-
ti. Od tehnika se mogu primenjivati kogni-
tivno bihejvioralne tehnike, implozivna te-
rapija, sistematska desenzitizacija i relaksa-
cioni trening. Hospitalizacije su potrebne u
slucaju pogorsanja koja sobom nose suici-
dalni i homicidalni rizik, te tesku depre-
sivnost i rizican stepen bolesti zavisnosti.
Frmakoterapiju treba primenjivati zavisno
od ispoljene psihopatologije. Kod predorni-
nacije simptoma nametanja preporucuje se
upotreba triciklicnih antidepresiva, MAO
inhibitora kao i beta blokatora. Simptome
izbegavanja (koji su rezistentniji ad simp-
toma nametanja) treba tretirati serotoner-
gicima - arnitriptilinom i fluoksetinom.
Anksioznost i hiperekscitabilnost najbolje
odgovaraju na primenu triciklika, MAO in-
hibitora i benzodiazepina. Da bi se ispoljio
efekat medikamenata kod ovih rezistentnih
simptoma hronicnog PTSP-a potrebno je
sacekati i osam nedelja, a preporucuje se
tretman odrzavanja u trajanju ad barem
godinu dana. U literaturi postoje podaci a
efikasnosti nekih, u ovom slucaju pornoc-
nih psihofarmaka. To su karbarnazepin, val-
proati, litijumove soli, bupropion i kloni-
din.
 Summary: Stress is the answer of organism to expo-
ACUTE STRESS sure to stress factors and is the cause of various psy-
chopathological manifestations. Psychopathological
DISORDER AND consequences that are timely and directly related to
POSTTRAUMATIC stress are acute stress disorder (ASD) and post trau-
matic stress disorder (PTSD). Severity of the trau-
STRESS DISORDER matic event, as a predictiv factor for ASD and PTSD,
COMPARATIVE is more important than the number of events. Preva-
lence of PTSP varires depending on a study, starting
SUMMARY from 1% after various trauma while after combat
experience it can be up to 36%. There are six groups
of symptoms present in ASD or PTSD: dissociative,
Blagoje Kuljit 1 intrusive, avoiding, anxiety and hiperexcitability, dis-
Ljubica Leposavic: funcionallity and compulsory reexposure to trauma.
]ovan Marit2 The main difference in ASD diagnostic criteria
between ICD-IO and DSM-IV classifications is the
Sraan Milovanovit 2 fact that DSM-IV insists in dissociative symptoms.
According DSM-IV, ASD symptoms last for a mini-
mum of2 days and a maximum of 4 weeks. These cri-
teria differ from ICD-IO criteria which require only 8
hours of duration of the symptoms. There is no im-
portant difference between the classifications in diag-
nostic criteria for PTSD. ASD and PTSD are two time
dependent diagnostic categories and they are closely
connected regarding to their clinical features. Durati-
on of the symptoms less than 1 month or more is the
point where ASD finishes and when PTSD starts.
Dissociative symptoms are present in ASD and dimin-
ish with time, and they are absent in PTSD.Treatment
of ASD is based on psychotherapeutical intervention
(ventilation or abreaction). The most important prin-
ciples in the treatment of ASD are brevity, immediacy,
proximity, superficiality and return to full functio-
ning. Therapy of PTSD as well as therapy of ASD in-
cludes psychotherapeutical techniques (support, ex-
I Institute of neuropsihijatrijske bolesti planation and destigmatization). Pharmacotherapy is
Dr, Laza Lazarevic, Belgrade used in according to actual psychopathology.
2 Clinical Centre of Serbia, Key words. acute stress disorder, posttraumatic stress
Institute of Psychiatry, Belgrade disorder, stress.

Stress is like an answer of organism to Final effect of chronic stress could result 1"
exposure to stress factors and is the cause in anxiety, depression or mixed condi- rf')
o
of various psychopathological manifesta- tions, psychosomatic diseases, or it could g
tions. In psychological view stress factors be the entrance into the field of substance t!-
N
are situations that are experienced as ex- abuse. Acute stress could be the main rea- N

treme and beyond the control of the per- son for developing states like brief psy- ~
son and without possibility of influence chotic reactions or it could precede or be a <.)
on circumstances. Stress could be acute or trigger for developing or exacerbation of
z
LLl
chronic condition, which also has an in- endogenous psychosis. However psycho-
fluence on the final psychological result. pathological states that are timely and di- 11
 rectly related to acute stress are acute
stress disorder and post traumatic stress
disorder.
Acute stress reaction (acute stress disor-
der) presents as a consequence with clear
and immediate temporal connection to
stresful event. Dominant are anxiety sym-
ptoms (as an answer to anticipated dan-
ger) or depressive symptoms (as an
answer to direct loss).
Posttraumatic stress disorder is a specific
syndrome due to heavy trauma that arises
pathological response to stressful event or
situation (natural disaster, war, car acci-
dents, rape, etc.). Disorder is character-
ized by three sets of symptoms: 1) symp-
toms of repetitive, intrusive recollection
or re-enactment of the event; 2) sYmP-
toms of avoiding of stimuli that might
arouse recollection of the trauma; 3)
symptoms of autonomic disturbances.
Because of the clear etiological connection
(stress) between these two clinical enti-
ties comparative summary of clinical char-
acteristics is reviewed.
RISK FACTORS FOR
APPEARANCE OF STRESS
RELATED DISORDERS
Degree of exposure as well as severity of
traumatic event is clearly connected to
severity of PTSD and ASD symptoms. Yet
there are investigators that deny that con-
nection 0, 2). Investigations were perfor-
med about the predictions of symptoms
and connection with severity of traumatic
8'o event. Most traumatic experience to men
~ are, generally, combat situations, violence
and car accidents. In women those are di-
:E rect physical assaults or presence during
~ physical assaults, bereavement and car
tE accidents (3). Numerous studies have
shown that risk factor for developing PTSD
12
is a life history of multiple traumatic
events (4, 5). Person that have had in its
life history several traumatic events is in a
way sensitized to traumatic events in the
future, mainly because of sense that life is
hard and full oflosses, and out of control.
More over, events after the trauma are
important, because of the sensi.tivity that is
basically negative followed by the disturb-
ing perception of life. Statistical analysis
has shown that type of event has more
valuable prediction significance than the
number of events. Emotional answer to
traumatic events is specified by individual
specific reactivity and interpretativity (6).
Neurotical dimension of personality deter-
mines defense mechanisms and reactivity.
Trait anxiety as one aspect of the neuroti-
cism is a stable feature and as well as
depressivity causes appearance of disorders
related to stress (7). Lower IQ is also con-
nected to development of PTSP (8).
Emotional stability and self confidence
holds central position in successful inte-
gration of traumatic events (9). Emotional
expresivity is conditioned by some neu-
ronal characteristics, individual tempera-
ment, beliefs and it is culturally influ-
enced (0). Belief that control over life
events is in it's own hands and not some-
where else is also a protective factor (11).
There are numerous investigations about preva-
lence and risk factors for developing PTSP and
ASP in population. However there are studies
that investigate if there are same riskfactors that
condition higher propensity for stress situations,
therefore conditioning development of PTSP. We
can make conclusions based on that studies, that
social characteristics, neuroticism, and genetic
predisposition have impact on the degree of expo-
sure to stressful events (12). Studies with exami-
nees that have had traumatic experience as cri-
minalattack, traumatic event, or traffic accident
refers that risk factors for such events are sex,
race, level of education, personality traits, [ami-
ly history of psychiatric disorders, i.e. extrover-
sion directly precipitates risky behaviours as well
as lower socioeconomic status (13, 14, 15).
EPIDEMIOLOGY
In general PTSP is as common disorder.
Various investigators have proposed sta-
tistical data about epidemiology of PTSp'
for example, Kessler at al, states that life
prevalence for developing PTSD for wo-
men is 5% and 10% for men. Same inve-
stigators state that life prevalence for
exposing to traumatic events for men is
25% and 13% for women (16).
Prevalence of PTSP varies depending on a
study, Malt finds prevalence of 1% after
various trauma while Mayou quote that
11% of injured will develop PTSD after car
accident, for the same situation Blanchard
finds that 49% of injured will 4 months
after accident develop PTSD symptoma-
tology (17-19). Bowles et al finds that
occurence of ASD in 10% of population
after spontaneous abortion (20).
ETIOLOGY
Investigations on activity of autonomic
nervous system and of adrenergic trans-
mission are essential in the literature that
deals with posttraumatic stress disorder
(PTSD). There is a clear connection bet-
ween elevated blood pressure level and
heart rate in people with PTSD, as well as
changes in electromiogram and in activity
of sweat glands (21). This was noted in
rest state and during provocative test - re-
colls of the trauma. One of basic postulates
of PTSD is based on autonomic hyperacti-
vity. Hyperactivity is followed by anxiety,
rage, or depression. Mentioned emotions
are responsible for posing PTSD in a sepa-
rate diagnostic category. It is clear that
patients with PTSD have disturbed sleep
and frequent sleep complaints but defini-
tive role for sleep dysregulation in the pato-
physiology of PTSD is not yet established.
Neuroendocrine studies finds evidences
on high cortisol levels after acute exposu-
re to traumatic stressful event (23). It is
documented that result of chronic stress
is damage of hippocampal neurons that
could result in dysfunction of explicit me-
mory system (24). Long lasting exposure
to stress factors leads to lower 24-hour
urinary cortisol levels however there are
studies that finds elevation of 24 hour
urinary cortisol levels (25). Explanation
for different findings could be the variety
of PTSD as well as different phases that
comprehends both, periods of stabiliza-
tion and periods of exacerbations of symp-
toms. There are implications that other
neurotransmitters and neuromodulators
are in involved in PTSD, i.e. serotonin and
opioids (26).
STRESS RELATED SYMPTOMS
Dissociation
Freud (1959) has suggested that there
may be a psychological tendency to elimi-
nate the fear of death by perceiving our-
selves as detached observers who survive
the treat. Similar to Freud's idea recent
studies describe consequent events: trau-
ma-dissociation-posttraumatic syndromes l'
(27). ~
o
o
Dissociative symptoms are: subjective ~
sense of numbing, detachment, or absence ~
of emotional resposiveness; a reduction in ;g
awareness of one's surroundings; dereal- ~
o
ization; deprersonalization; dissociative ~
amnesia (28-30).
13
 Anxiety and hiperexcitability
Often anxiety symptoms occur and usual-
ly last several weeks after traumatic event.
Anxiety symptoms are usually exaggera-
ted by other events that are not directly
connected to trauma. Anxiety symptoms
are fear, disturbances of sleep, irritability,
(problems in controlling emotions follo-
wed by occasional sudden emotional out-
bursts, sense that presence of other peo-
ple is annoying and irritating), decreased
concentration, hyper vigilance, and over-
activity to stimuli (31, 32).
All mentioned symptoms are often in con-
nection to hyper arousal activity of the au-
tonomic nervous system. (i.e combat vet-
erans that developed PTSD had amplified
heart frequency and systolic heart pres-
sure in steady state, while after exposure
similar to war trauma was registred high-
er jump of heart frequency (33).
During hyperexcitability there is continu-
os anticipation of danger. Every possibility
is being generalized as a treat and after-
wards proximal surroundings and whole
world is being perceived as a very unsafe
place to be. The persistent, irrelevant fir-
ing of warning signals causes pshysical
sensations to lose their functions as sig-
nals of emotional states and, as a conse-
quence, they stop serving as guiding for
action. PTSD suffers can't realistically
decider messages from the autonomic ner-
vous system, consequently they can't
apprehend their emotional state, which is
called alexithymia.
'i'
I
('()
S Disfuncionallity
g Intrusions
~ In Lindemann's research (1944) on acute
People with PTSD usually have peristent
intrusions and memories related to the
trauma. These intrusions of truamatic
event can take many different shapes:
flashbacks, intense emotions, nightmares,
14
and somatic sensations. These events are
usually triggered by specific activators
that are somehow related to trauma (tho-
ughts, smells, places, activities) (31, 34).
Person could claim that reliving experi-
ences are as vivid as when they was when
the trauma first occured.
Avoidance
Avoidance may take different forms, such
as avoidance of stimuli that arouse recol-
lections of the trauma, which includes
thoughts, feelings, activities, conversati-
ons, places, and people (35). Persons also
could have problems in recollecting mem-
ories of trauma. Problems with remem-
bering are characteristic for people that
are suffering from intrusive flashback
episodes. Avoidance symptoms and beha-
viour usually leads to various problems in
social functioning and in professional ma-
ladaptation. Those people loose their
interes in outerworld, they feel distance
form other people, and future seems to be
non-promising. Previous life plans and
motives are neglected.
Other forms of avoiding symptoms may
present in form of ingestion of drug and
alcohol in order to numb awereness of dis-
tressing emotional states. Sometimes
avoidance is manifested through dissocia-
tion by keeping unpleasant experiences
from concious awareness. For people with
PTSD there is a rule: It is better to feel
nothing than to feel irritable and upset.
stress he observed among people who had
undergone trauma a breakdown of normal
patterns of social interaction in which se-
ems to be increased dependency on other
persons. Also, persons can perform lack of
capacity to initate and maintain organized CLASSIFICATION OF STRESS
patterns of activity (36). Another way of RELATED DISORDERS
coping is self-medication with alcohol or
other substances, which can also interfere Stress related disorders are included in
with functioning. About one half of the category F 40 - F 48 Neurotic, stress re-
medical health team providing assistance lated and somatoform disorders, accord-
to Ash Wednesday bushfire surviviors in ing to 10th revision classification of disea-
Australia reported problems with their ses, released byWorld Health Organiza-
own functioning as a result, including ill- tion (43).
nesses, accidents, and changes in eating, F 43.0 Acute Stress Reaction
sleeping, smoking and/or alcohol drinking
(37) . F 43.1 Posttraumatic Stress Disorder
F 43.2 Adjustment disorder
ASD and PTSD are enclosed in the group
Compulsory reexposure to trauma
Anxiety Disorders, according to DSM IV
One set of behaviours that is not men- released by American Psychiatric Associa-
tioned in the diagnostic criteria for PTSD tion (44):
in ICD-10 and DSM-IV is compulsory
300.01 Panic Disorder Without Agorap-
reexposure of some traumatized individu-
hobia
als to situations remiscent of the trauma.
Freud though that the aim of such repeti- 300.21 Panic Disorder With Agorap-
tion is to gain mastery (38), but clinical hobia
experience based on investigations of van 300:22 Agoraphobia Without History of
der Kolks, shows that this rarely happens, Panic Disorder
instead, repetition causes further suffe-
ring for the victims and for the people 300.29 Specific Phobia
around them. This kind of behaviour 300.23 Social Phobia
could manifest itself in a several different
300.3 Obsessive-Compulsive Disorder
ways. First one is doing harm to others.
Numerous studies have documented that 309.81 Posttraumatic Stress Disorder
many violent criminals were physically or 308.3 Acute Stress Disorder
sexually abused as children. (39). Second
way of behaviour is self-destructivness. 300.02 Generalized Anxiety Disorder
Self destructive acts are common in abu- 293.89 Anxiety Disorder Due to ... (Indi-
sed children. Studies consistently find a cate the General Medical Condition)
highly significant relationship between
300.00 Anxiety Disorder Not Otherwise
childhood sexual abuse and various forms 1"
Specified r<">
of self-harm later in life, particulary sui- ao
cide attempts, cutting, and self starvating o
~
(40). Third form of behaviour is revictim- DIAGNOSTIC CRITERIA N
N
ization. Rape victims are more likely to be :E-
ACUTE STRESS DISORDER
raped again. (41), victims of sexual abuse
~
are at high risk of becoming prostitutes o
ICD - 10 Z
(42), ex combat soldiers may become mer- U-l

cenaries or join police teams. There is the existence of direct time corre-
lation between the stress event and the 15
 beginning of symptoms. The symptoms
begin usually immediately or within few
minutes after the traumatic event. The
characteristics of the symptoms are: a)
depression, anxiety, anger, hyperactivity
or isolation but all these symptoms can be
altered and neither of them dominate for a
long time; b) they are not long lasting, and
they diminish within few hours if the
escape from stress situation is possible. In
a case of prolonged stress situation, the
symptoms diminish after 24 or 48 hours,
and they are minimized after 3 days. Acute
stress disorder encloses the diagnosis a)
acute crisis reaction, b) combat fatigue, c)
crisis, d) psychical shock. (43)
DSM-IV
A. The person has been exposed a trau-
matic event in which both of the fol-
lowing were present:
1. The person experienced, witnessed, or
was confronted with an event or events
that involved actual or threatened death
or serious injury, or a threat to the
physical integrity of self or others
2. The person's response involved intense
fear, helplessness, or horror.
B. Either while experiencing or after expe-
riencing the distressing event, the indi-
vidual has three (or more) of the fol-
lowing dissociative symptoms:
1. a subjective sense of numbing, detach-
ment, or absence of emotional respon-
siveness
N
N
C. The traumatic event is persistently re-
experienced in at last one of the follow-
16
ing ways: recurrent images, thoughts,
dreams, illusions, flashback episodes,
or a sense of reliving the experience, or
distress on exposure to reminders of
the traumatic event.
D. Marked avoidance of stimuli that aro-
use recollections of the trauma (tho-
ughts, feelings, or conversations asso-
ciated activities, places or people)
E. Marked symptoms of anxiety or incre-
ased arousal (difficulty sleeping, irri-
tability, difficulty concentrating, hyper-
vigilance, exaggerated startle response,
motor restlessness)
F. The disturbance causes clinically signi-
ficant distress or impairment in social,
occupational, or other important areas
of functioning or impairs the individ-
ual's ability to pursue some necessary
task, such as obtaining necessary assis-
tance or mobilizing personal resources
by telling family members about the
traumatic experience
G. The disturbance lasts for a minimum of
2 days and a maximum of 4 weeks and
occurs within 4 weeks of the traumatic
event
H. The disturbance is not due to the direct
physiological effects of a substance or
general medical condition, is not better
accounted for by Brief Psychotic Disor-
der, and is not merely an exacerbation
of a persisting Axis I or Axis II disor-
der. (44)
POSTTRAUMATIC STRESS
DISORDER
ICD-I0
A. The person has been exposed to a trau-
matic event or situation of extreme or
 catastrophic nature in which can cause
the stress in any person
B. The symptoms include recollections or
reexperience of stressors (flashbacks),
awake or in dreams or distress on expo-
sure to reminders of the traumatic
event.
C. Marked avoidance of stimuli that aro-
use recollections of the trauma (not
present before the trauma)
D. There is also
- Inability to recall an important aspect of
the trauma
- Symptoms of increased psychological
reactivity and arousal (not presented
before the trauma), what is presented
by: difficulty in sleeping, irritability,
poor concentration, hypervigilance,
exaggerated startle response.
Onset of symptoms (criteria B, C and D)
is at first 6 months after the traumatic
event (if the onset of symptoms is at least
6 months after the trauma, this must be
specified). (43)
DSM-IV
A. The person has been exposed a trauma-
tic event in which both of the following
were present:
1. The person experienced, witnessed, or
was confronted with an event or events
that involved actual or threatened death
or serious injury, or a threat to the
physical integrity of self or others
2. The person's response involved intense
fear, helplessness, or horror.
B. The traumatic event is persistently re-
experienced in one (or more) ofthe fol-
lowing ways:
1. recurrent and intrusive distressing rec-
ollections of the event, including ima-
ges, thoughts, or perceptions
2. recurrent distressing dreams of the
event
3. acting or feeling as if the traumatic event
were recurring (includes a sense of reliv-
ing the experience, illusions, hallucina-
tions, and dissociative flashback episo-
des, including those that occur on awa-
kening or when intoxicated).
4. intense psychological distress at expo-
sure to internal or external cues that
symbolize or resemble an aspect of the
traumatic event
5. physiological reactivity on exposure to
internal or external cues that symbolize
or resemble an aspect of the traumatic
event
C. Persistent avoidance of stimuli associ-
ated with the trauma and numbing of
general responsiveness (not present
before the trauma) , as indicated by
three (or more) of the following:
1. efforts to avoid thoughts, feelings, or
conversations associated with the tra-
uma
2. efforts to avoid activities, places or peo-
ple that arouse recollections of the trau-
ma
3. inability to recall an important aspect of
the trauma
4. markedly diminished interest or partic-
ipation in significant activities
5. feeling of detachment or estrangement
from others
6. restricted range of affect
7. sense of a foreshortened future
D. Persistent symptoms of increased aro- ~
usal (not present before the trauma), 5E
as indicated by two (or more) of the ~
following ~
u.J
1. difficulty falling or staying asleep
2. irritability or outburst of anger 17
 3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
E. Duration of the disturbance (symptoms
in Criteria B, C, and D) is more than 1
month
F. The disturbance causes clinically signi-
ficant distress or impairment in social,
occupational, or other important areas
of functioning
Specify if:
Acute: if duration of symptoms is less
than 3 months
Chronic: if duration of symptoms is 3
months or more
Specify if:
With Delayed Onset if onset of symptoms
is at least 6 months after the stressor
(44).
THE COMPARISON BETWEEN
CLASSIFICATIONS ISD-I0
AND DSM-IV
There is no important difference between
the classifications in diagnostic criteria for
PTSD.
Diagnosis Acute Stress Disorder is esta-
blished in 1Oth revision of disease classifi-
cation, released BY WorlD Health Organi-
zation in 1993. Koopman et al. have found
that normal reaction to stress had also
some symptoms presented in ASD (45).
g
o
Frequency and severity of these symptoms
~ as well as disturbance in social and occu-
pational functioning are the main criteria
for ASD diagnosis making. ASD diagnosis
is related to highly present distress and
disfunctionality in persons exposed to
traumatic experience.
18
American Psychiatric Association included
diagnosis of ASD in 4th revision of Diag-
nostic and Statistic Manual of Mental Di-
sorders made in 1994. Diagnostic criteria
include four categories of symptoms: disso-
ciative, anxiety, reexperience and avoiding.
The symptoms influence social and occupa-
tional functioning of the patient. Symp-
toms last for a minimum of 2 days and a
maximum of 4 weeks. These criteria differ
from lCD-IO criteria which require only 8
hours of duration of the symptoms.
The main difference between these two
classifications is in the fact that DSM-lV
insist in dissociative symptoms. According
to Marshall opinion criterion is not so
important and must be reconsidered (46).
Bryant shares the same opinion (47).
THE RELATION BETWEEN
ASDAND PTSD
ASD and PTSD are two time dependent
diagnostic categories and they are closely
connected regarding to their clinical fea-
tures. Harvey found that 80% of ASD pa-
tients develop PTSD two years after the
accident (48).
Duration of the symptoms less than 1
month or more is the point where ASD fi-
nishes and when PTSD starts. Disso-
ciative symptoms are present in ASD and
diminish with time, and they are absent in
PTSD. Bowles pointed to time criteria as
the most important factor in the differe-
ntiation between ASD and PTSD (49).
ASD and PTSD share the same etiological
factor - exposing to traumatic event. Risk
factor for both disorders is susceptibility
to dissociative reactions. Dissociation is a
way to protect conscious part of persona-
lity from trauma. Traumatic experiences
remain unintegrated in personal memo-
ries, but they intrude in consciousness in
the form of intrusive distressing recollec-
tions of the event. This is the beginning of
PTSD symptoms. There is clear connection
between ASD and subsequent PTSD (50,
51). Solomon has found some dissociative
symptoms immediately after traumatic
event and that was strong predictive factor
for development of PTSD (52). The same
findings reported Marmar in Vietnam War
veterans' (30) and Koopman after the
thunderbolt in Oakland/Barkley area (53).
Hypnotizability is correlated with the sus-
ceptibility to dissociation and with PTSD
(Stutman, Spiegel) (54, 55). Individual
perception of the trauma like a life threat-
ening one causes dissociative reaction,
and subsequently PTSD.
The major problem in diagnostic of ASD
among traumatized persons is shame
which they feel if confess the problem
with trauma coping (Koopman) (56). This
confession can mean that they were weak,
that lost control over the situation, and
those symptoms were the signs of a men-
tal illness. Due to these reasons, ASD
remains undiagnosed and the time for
psychiatric intervention in early phase is
lost. When patient decides to consult a
psychiatrist, after a long period of disturb-
ing symptoms, we are not faced with ASD
any more, but with PTSD.
Treatment
Treatment of ASD is based on psychothe-
rapeutical intervention. Ventilation or ab-
reaction of affects and images connected
with the trauma are encouraged, and they
prevent dissociative reactions that are risk
factors for subsequent PTSD. The most im-
portant principles in the treatment of ASD
are brevity, immediacy, proximity, superfi-
ciality and return to full functioning.
Therapy of PTSD as well as therapy of
ASD includes psychotherapeutical techni-
ques. Support, explanation and destigma-
tization of all aspects of trauma and its
consequences provides integration of
traumatic memories and inhibits dissocia-
tion. Both individual and group psycho-
therapy is used in PTSD treatment. There
is a great benefit from local and national
institutions for trauma survivors, because
they help patients' resocialization and pre-
vent isolation and occupational and eco-
nomical problems. Positive effects of cog-
nitive behavioral techniques, implosive
therapy, systematic desensitization and re-
laxation training are well documented.
Hospitalization may be necessary at time
of crisis, during suicidal and homicidal
risk, severe depression and acute drug in-
toxication.
Pharmacotherapy is used according to
actual psychopathology. The intrusive
symptoms respond to tricyclic drugs,
MAO inhibitors and B-blocker drugs. The
avoidant symptoms appear to be less res-
ponsive than the intrusive symptoms,
although some evidence suggests that
serotonergic antidepressants (amitripty-
line, fluoxetine) can help the avoidant sy-
mptoms. Hyperarousal may respond to
MAO inhibitors, tricyclic drugs, azaspi-
rones and benzodiazepines, although tri-
cyclics may not effectively reduce increa-
sed startle responses. At least eight weeks 1" ("()
of treatment may be needed to show drug 0-
a
efficacy in chronic PTSD. Maintenance a
~
treatment should continue at least one ~
year. Other drugs that may help include ~
carbamazepine, valproic acid, lithium, ~
bupropion and clonidine. ~
U..l
19
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