Acute Stress Disorder

Primer

Acute Stress Disorder (acute stress reaction, psychological shock) is a mental disorder that arises in response to experiencing or witnessing a traumatic event that induces a strong emotional response within the individual. Common traumas include combat/war in males, assault/rape in females, torture, natural disasters, and serious accidents. Acute stress disorder is a “precursor” diagnosis to Posttraumatic Stress Disorder (PTSD), as symptoms last less than 1 month.

Epidemiology
  • Acute stress disorder and posttraumatic stress disorders have a lifetime prevalence of 7%, and up to 30% in US Vietnam veterans.[1]
Prognosis
Comorbidity
Risk Factors

DSM-5 Diagnostic Criteria

Criterion A (Exposure)

Exposure to actual or threatened death, serious injury, or sexual violence in at least 1 of the following ways:

  1. Directly experiencing the traumatic event(s).
  2. Witnessing, in person, the event(s) as it occurred to others.
  3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  4. 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: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
Criterion B

Presence of at least 9 of the following symptoms from any of the five categories of (1) intrusion, (2) negative mood, (3) dissociation, (4) avoidance, and (5) arousal, beginning or worsening after the traumatic event(s) occurred:

1. Intrusion Symptoms
  1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
  2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). In children, there may be frightening dreams without recognizable content.
  3. Dissociative reactions (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.) In children, trauma-specific reenactment may occur in play.
  4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
2. Negative Mood
  1. Persistent inability to experience positive emotions (e.g. - inability to experience happiness, satisfaction, or loving feelings)
3. Avoidance Symptoms
  1. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  2. 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)
4. Arousal Symptoms
  1. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)
  2. Irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
  3. Hypervigilance
  4. Problems with concentration
  5. Exaggerated startle response
5. Dissociative Symptoms
  1. 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)
  2. 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)
Criterion C

Duration of the disturbance (symptoms in Criterion B) is 3 days to 1month 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.
Criterion D

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion 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.

Specifiers

Episode Specifier

Severity Specifier

Specify if:

Signs and Symptoms

Screening and Rating Scales

Pathophysiology

Differential Diagnosis

PTSD

PTSD can develop after ASD, but it can also also develop even if ASD does noccur. PTSD can only be diagnosed if the symptoms have lasted longer than 1 month.

Investigations

Physical Exam

Treatment

Psychotherapy

Pharmacotherapy

Guidelines

Acute and Post-Traumatic Stress Disorder Guidelines

Guideline Location Year PDF Website
Canadian Clinical Practice Guidelines Canada 2014 - Link
National Institute for Health and Care Excellence (NICE) UK 2018 - Link
American Psychiatric Association (APA) USA 2004, 2009 - • Guideline (2004)
• Guideline Watch (2009)
• Quick Reference
Veterans Affairs (VA) and Department of Defense (DoD) USA 2017 - Link

Resources

For Patients
For Providers
Articles
Research

References

1) Reisman, M. (2016). PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next. Pharmacy and Therapeutics, 41(10), 623.