Acute Stress Disorder (ASD) is a classified trauma & stressor related disorder that is also referred to as Posttraumatic Stress (PTS), or Acute Stress Reaction . ASD was only introduced within the DSM IV, so it’s a relatively new diagnosis and not often seen. Approximately half of people who eventually develop Posttraumatic Stress Disorder (PTSD), present with ASD.
Risk & Prognostic Factors
Temperamental: Risk factors include prior mental disorder, high levels of negative affectivity (neuroticism), greater perceived severity of the traumatic event, and an avoidant coping style. Catastrophic appraisals of the traumatic experience, often characterized by exaggerated appraisals of future harm, guilt, or hopelessness, are strongly predictive of ASD.
Environmental: First and foremost, an individual must be exposed to a traumatic event to be at risk for ASD. Risk factors for the disorder include a history or prior trauma.
Genetic and Psychological: Females are at greater risk for developing ASD. Elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure increases the risk for developing ASD.
The essential feature of ASD is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events.
Traumatic events experienced directly include, but not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g. sexual violence, physical attack, active combat, mugging, childhood physical and / or sexual violence, being kidnapped, being taken hostage, terrorist attack, torture), natural or human-made disasters (e.g., earthquake, hurricane, airplane crash), and severe accident (e.g., severe motor vehicle, industrial accident). For children, sexually traumatic events may include inappropriate sexual experiences without violence or injury.
A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g.,waking during surgery, anaphylactic shock). Stressful events that do not possess the severe and traumatic components of events encompassed by Criterion A may lead to an adjustment disorder but not ASD.
Witnessed events include, but not limited to, observing threatened or serious injury, unnatural death, physical or sexual violence inflicted on another individual as a result of violent assault, severe domestic violence, severe accident, war, and disaster; it may also include witnessing a medical catastrophe (e.g., a life-threatening hemorrhage) involving one’s child. Events experienced indirectly through learning about the eevent are limited to close relatives or close friends. Death due to natural causes does not qualify. Such events must have been violent or accidental and include violent personal assault, suicide, serious accident, or serious injury.
Diagnostic Criteria for 308.3 (F43.0) Acute Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
- Directly experiencing the traumatic event(s).
- Witnessing, in person, the event(s) as it occurred to others.
- Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) occurred.
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
- Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
- An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
- Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
- Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
- Problems with concentration.
- Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.
Adjustment disorders: In adjustment disorders, the stressor can be of any severity rather than the severity and type required by Criterion A of ASD. The diagnosis of an adjustment disorder is used when the response to a Criterion A event does not meet the criteria for ASD (or other specific disorder) and when the symptom pattern of ASD occurs in response to a stressor that does not meet Criterion A for exposure to actual or threatened death, serious injury, or sexual violence (e.g., spouse leaving, being fired). Depressive or anger responses in an adjustment disorder may involve rumination about the traumatic event, as opposed to involuntary and intrusive distressing memories in ASD.
Panic disorder: Spontaneous panic attacks are very common in ASD. However, panic disorder is diagnosed only if panic attacks are unexpected and there is anxiety about future attacks or maladaptive changes in behavior associated with fear of dire consequences of the attacks.
Dissociative disorders: Severe dissociative responses (in the absence of characteristic ASD symptoms) may be diagnosed as derealization / depersonalization disorder. If severe amnesia of the trauma persists in the absence of characteristic ASD symptoms, the diagnosis of dissociative amnesia may be included.
Posttraumatic stress disorder: ASD is distinguished from PTSD because the symptom pattern in ASD must occur within 1 month of the traumatic event and resolve within that 1 month period. If the symptoms persist for more than 1 month and meet criteria for PTSD, the diagnosis is changed from ASD to PTSD.
Obsessive-Compulsive Disorder (OCD): In OCD there are recurrent intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive thoughts are not related to an experienced traumatic event, compulsions are usually present, and other symptoms of ASD are typically absent.
Psychotic disorders: Flashbacks in ASD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, other psychotic disorders, depressive or bipolar disorder with psychotic features, a delirium, substance / medication-induced disorders, and psychotic disorders due to another medical condition. ASD flashbacks are distinguished from these other perceptual disturbances by being directly related to the traumatic experience and by occurring in the absence of other psychotic or substance-induced features.
Traumatic Brain Injury (TBI): When a brain injury occurs in the context of a traumatic event (e.g., traumatic accident, bomb blast, acceleration / deceleration trauma), symptoms of ASD may appear. An event causing head trauma may also constitute a psychological traumatic event, and TBI related neurocognitive symptoms are not mutually exclusive and may occur concurrently. Symptoms previously termed post-concussive (e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits) can occur in brain-injured and non-brain injured populations, including individuals with ASD. Because symptoms of ASD and TBI overlap, differential diagnosis between them may be possible based on the presence of symptoms that are distinctive to each presentation. Whereas reexperiencing and avoidance are characteristic of ASD and not the effects of TBI, persistent disorientation and confusion are more specific to TBI than to ASD. Furthermore, differential is aided by the fact that symptoms of ASD persist for up to only 1 month following trauma exposure.
ASD is treated similarly to PTSD, in that the first line of defence is psychotherapy combined with possible medication, depending on severity. The two highest rating therapies for ASD are Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR), combined with exposure therapy. Either of the first two will satisfy the traumatic aspects, though both require an exposure therapy process, in conjunction, towards the associated fear aspects.
In both US and non-US populations, ASD tend to be identified in less than 20% of cases following traumatic events that do not involve interpersonal assault; 13% – 21% of motor vehicle accidents, 14% of mild traumatic brain injury, 19% of assault, 10% of severe burns, and 6% – 12% of industrial accidents. Higher rates are reported (20% – 50%) following interpersonal traumatic events, including assault, rape, and witnessing a mass shooting.