Acute Stress Disorder  

Introduction

Acute stress disorder (ASD) features severe acute stress reactions (ASRs) that occur between 3 days to 1 mo after exposure to a traumatic event (direct exposure or indirectly experienced). ¹²³⁴

Synonyms

ASD

ASR

ICD-10CM CODES
F43.0	Acute stress reaction
F43.11	Post-traumatic stress disorder, acute
DSM-5 CODE
308.3	Other acute reactions to stress

Epidemiology & Demographics

Prevalence

The prevalence of ASD varies according to the nature of the traumatic event. Prevalence is estimated at less than 20% in cases that do not involve a personal assault (e.g., motor vehicle accidents, traumatic brain injury, severe burns, etc.), 14% for war-related trauma, ⁵ and at 20% to 50% in cases of interpersonal trauma (e.g., sexual assault, witnessing a mass shooting). ⁶

Predominant Gender

ASD occurs more frequently in females compared with males. Rate of incidence among individuals who do not identify on the gender binary is unclear.

Predominant Age

ASD can be diagnosed at all ages. Children tend to manifest symptoms differently than adults (e.g., frightening dreams that do not directly reflect the trauma). Young children may not report fear at the time of the trauma or when reexperiencing the trauma.

Genetics

Differential function of the serotonin transporter may mediate differential responses to trauma. The 5-HTTLPR may constitute a genetic candidate region. Higher rates of ASD among women may be attributable to higher rates of violence against women and sex-linked neurobiological differences in the stress response.

Risk Factors

Greater perceived severity of the trauma (i.e., catastrophic interpretations of the event, exaggerated appraisals of future harm, hopelessness), high levels of negative affect, avoidant coping style, history of prior trauma, lack of social support, premorbid psychiatric condition (e.g., preexisting anxiety or depressive disorders).

PHYSICAL FINDINGS & CLINICAL PRESENTATION

DSM-5 criteria are met when the following criteria are satisfied:

• •Exposure to actual or threatened serious injury, death, or sexual violation in one or more of the following ways:
  • 1.Experiencing a traumatic event
  • 2.Witnessing a traumatic event as it occurred
  • 3.Learning that a traumatic event occurred to a family member or close friend
  • 4.Repeated or extreme exposure to the details of a traumatic event
• •Presence of nine or more of the following symptoms from any of the following five categories: (1) intrusion, (2) negative mood, (3) dissociation, (4) avoidance, and (5) arousal:
  • 1.Recurrent, distressing, involuntary memories of the trauma (intrusion)
  • 2.Recurrent distressing dreams relating to the trauma (intrusion)
  • 3.Flashbacks to the event, in which the individual feels/acts as if the event is recurring (intrusion)
  • 4.Intense or prolonged psychological distress or physiological reaction in response to cues that are reminiscent of the trauma (intrusion)
  • 5.Continual inability to experience positive emotions (negative mood)
  • 6.Altered sense of reality (dissociation)
  • 7.Inability to recall components of the trauma (dissociation)
  • 8.Avoidance of memories, thoughts, or feelings associated with the event (avoidance)
  • 9.Avoidance of external reminders of the event (avoidance)
  • 10.Sleep disturbance (arousal)
  • 11.Irritability and anger outbursts (arousal)
  • 12.Hypervigilance (arousal)
  • 13.Difficulties concentrating (arousal)
  • 14.Exaggerated startle response (arousal)
• •Symptoms typically begin immediately after the trauma and must persist for at least 3 days, and up to 1 mo, following exposure to trauma. If symptoms persist for longer than 1 mo, a diagnosis of posttraumatic stress disorder (PTSD) may be considered.
• •Exposure to trauma must result in clinically significant impairment in functioning.
• •Symptoms must not be attributable to a medical condition or substance use and cannot be better explained by brief psychotic disorder.

ETIOLOGY

Factors predicting the development of ASD have not been established; however, multiple theoretical models have been proposed. Dissociative models propose that individuals minimize the emotional consequences of trauma by restricting awareness of the event to reduce fear. Cognitive perspectives propose that intentional cognitive processes (e.g., avoidance, distraction, dysfunctional appraisals, attribution of responsibility) result in pathological reactions to trauma. Biological theories focus on the immediate effects of trauma on neuronal function, including cortisol, catecholamines, glucocorticoids, serotonin, and endogenous opioids as mediating factors of the trauma response.

DIFFERENTIAL DIAGNOSIS

• •Adjustment disorder
• •Panic disorder
• •PTSD
• •Obsessive-compulsive disorder
• •Dissociative identity disorder
• •Dissociative amnesia
• •Depersonalization-derealization disorder
• •Psychotic disorders
• •Traumatic brain injury

WORKUP

Diagnosis is made based on individual interviews, including a history of past trauma, age at the time of the trauma, and duration of the trauma. Structured clinical interviews may be used and supplemented with standardized self-report measures. It should be noted that dissociative symptoms may prevent individuals from remembering components of the trauma, as well as remembering feelings of fear, helplessness, or horror. Clinicians often seek collateral data from other sources (e.g., family, close friends, medical providers, therapists) in diagnosing this disorder. Structured measurements such as the Stanford Acute Stress Reaction Questionnaire, Acute Stress Disorder Interview, or Acute Stress Disorder Scale, which is most useful for severity assessment, are also used by clinicians to assist with diagnosis and treatment evaluation.

LABORATORY TESTS

None indicated

IMAGING STUDIES

None indicated

TREATMENT

• •Early treatment should focus on establishing a therapeutic alliance and acknowledging negative emotions (i.e., fear) of future exposure to traumatic agents. ⁷
• •Resilience-focused psychosocial interventions may focus on better tolerating the distress of trauma-related memories, identifying triggers associated with traumatic events to reduce emotional reactivity or reexperiencing trauma, reducing trauma-related avoidance and sleep disturbances and nightmares, increasing social support, decreasing behaviors that interfere with daily life, limiting generalization of the danger experienced, and altering maladaptive attributions and appraisals.
• •Early behavioral and educational interventions demonstrate small to moderate effects for reducing symptoms of psychological trauma.
• •In cases of trauma related to experiences of interpersonal violence, safety planning is necessary for individuals who remain in unsafe situations or relationships.
• •Pharmacological treatment is typically reserved for individuals who have already received psychotherapy. There are few controlled pharmacological treatment trials for ASD.
• •There are currently no medications approved by the FDA for treatment of ASD. Clinicians may consider FDA-approved medications for PTSD, such as sertraline and paroxetine.

NONPHARMACOLOGIC THERAPY

• •Cognitive behavioral therapy (CBT)
• •Cognitive processing therapy (CPT)
• •Relaxation and mindfulness

ACUTE GENERAL Treatment

• •Acute medication may be necessary when the individual is dangerous, agitated, or psychotic. In emergencies, short-acting benzodiazepines or neuroleptics with minimal side effects may be effective.
• •Antiadrenergic agents, such as β-blockers, may be useful for treatment of arousal.
• •Brief, short-term treatment using benzodiazepines (i.e., clonazepam, alprazolam, temazepam) may be useful for treating arousal, insomnia, and anxiety. It should be noted that prolonged use of benzodiazepines has been associated with increased risk of long-term PTSD symptoms.
• •Prazosin is recommended for treatment of nightmares.
• •Selective serotonin reuptake inhibitors (SSRIs) and other antidepressants may be useful for reexperiencing symptoms, avoidance, and hyperarousal.

COMPLEMENTARY & ALTERNATIVE MEDICINE

• •Patients may find activities that increase relaxation (e.g., yoga, meditative approaches including relaxation response breathing techniques, mindfulness, and progressive muscle relaxation) useful.
• •Eye movement desensitization and reprocessing (EMDR) has shown promise in alleviating symptoms in patients diagnosed with ASD with evidence accumulating; however, future research is needed to further understand the relationship between the effects of EMDR treatment and the natural recovery from traumatic stress.

DISPOSITION

Treatment should be delivered in the least restrictive environment that can ensure patient safety. Most patients with ASD can be managed in an outpatient setting. Partial or inpatient hospitalization may be necessary for crisis management and may be considered for patients who have comorbid psychiatric/medical diagnoses; who are experiencing suicidal or homicidal ideation, plans, or intention; or who are severely ill.

REFERRAL

Patients are to be treated by a mental health clinician.

PEARLS & CONSIDERATIONS

COMMENTS

• •Although some individuals with ASD go on to develop PTSD, many with ASD do not. Available data at this time suggest that ASD criteria are not adequate for identifying individuals at risk for developing PTSD.
• •There is evidence to suggest that the identification of subtypes of ASD, as well as a focus on high levels of arousal symptoms, could lead to better predictability of subsequent diagnoses of PTSD.
• •Recent research suggests that individual differences in emotion regulation predict COVID-19 acute distress. ⁸
• •When assessing trauma responses among culturally diverse individuals, culturally sensitive instruments should be used, as well as practicing cultural humility when administering instruments. ⁹
• •Research suggests that trauma patients who are discharged from their hospital stay prior to 72 hr should be rescreened after discharge. ¹⁰

PREVENTION

Critical incident stress debriefing (CISD) after a trauma is typically administered in one 1- to 3-hr group session within 72 hr of the trauma, with the goals of allowing survivors to “vent.” Systematic reviews have suggested that single-session individual psychological debriefing is not an effective intervention. ¹¹¹²¹³ As a result, its use has steadily declined. Psychological first aid (PFA) is designed to improve outcomes after trauma by fostering safety, calmness, social connectedness, and optimism. A randomized controlled trial showed that group PFA was more effective in lowering negative affect postintervention and more effective in increasing positive affect both at postintervention and at a 30-min delay relative to the group conversation condition. ¹⁴

PATIENT & FAMILY EDUCATION

U.S. Department of Veterans Affairs, Health Care, PTSD: National Center for PTSD, Providers, Treatment, Acute Stress Disorder ( www.ptsd.va.gov/professional/treat/essentials/acute_stress_disorder.asp )

RELATED CONTENT

Posttraumatic Stress Disorder (Related Key Topic)

REFERENCES

1.Armour C., Hansen M.: Assessing DSM-5 latent subtypes of acute stress disorder dissociative or intrusive? . Psychiatry Res 2014; 225: pp. 476-483.

2.Bryant R.A., et al.: A review of acute stress disorder in DSM-5 . Depress Anxiety 2011; 28: pp. 802-817.

3.Bryant R.A., et al.: Acute and chronic posttraumatic stress symptoms in the emergence of posttraumatic stress disorder: a network analysis . JAMA Psychiatry 2017; 74: pp. 135-142.

4.Bryant R.A.: Acute stress disorder . Curr Opin Psychol 2017; 14: pp. 127-131.

5.Geoffrion S., et al.: Systematic review and meta-analysis on acute stress disorder: rates following different types of traumatic events . Trauma, Violence, & Abuse 2022; 23: pp. 213-223.

6.Gradus J.L.: Prevalence and prognosis of stress disorders: a review of the epidemiologic literature . Clin Epidemiol 2017; 9: pp. 251-260.

7.Tol W.A., et al.: Management of acute stress, PTSD, and bereavement: WHO recommendations . JAMA 2013; 310: pp. 477-478.

8.Tyra A.T., et al.: Individual differences in emotion regulation prospectively predict early COVID-19 related acute stress . J Anxiety Disord 2021; 81: pp. 102411.

9.Patel A.R., et al.: Beyond the DSM-5 diagnoses: a cross-cultural approach to assessing trauma reactions . Focus 2021; 19 (2): pp. 197-203.

10.Veenis A.C., et al.: Acute stress disorder in trauma patients discharged in 72 hours or less . Injury 2022;

11.Roberts N.P., et al.: Early psychological intervention following recent trauma: a systematic review and meta-analysis . Eur J Psychotraumatol 2019; 10: pp. 10-25.

12.Roberts N.P., et al.: Multiple session early psychological interventions for the prevention of post-traumatic stress disorder . Cochrane Database Syst Rev 2019; 8: pp. CD006869.

13.Twigg S.: Clinical event debriefing: a review of approaches and objectives . Curr Opin Pediatr 2020; 32: pp. 337-342.