Acute Stress Disorder

All people experience traumatic events in their lives. All people lose loved ones, 1 in 4 women experience rape or attempted rape during their lifetime, and 1 million children are abused or neglected each year. In 2000, one quarter of a million Americans were raped or sexually assaulted, three quarters of a million were robbed, and half a million were assaulted. Millions of children are bullied in school, 7% of men and 22% of women are assaulted by an intimate partner, and 3 million people a year are involved in car accidents.

Most Americans were shocked by the loss of thousands of lives in the terrorist attack on the World Trade Center. Natural disasters such as Hurricane Katrina and the earthquake in Haiti can unexpectedly take thousands of lives. Victims of such disasters, along with those who love them, are vulnerable to considerable emotional turmoil and a variety of symptoms after a traumatic event and the loss of loved ones.

Typically, emotional responses to disaster develop in the following 4 phases:

• Impact phase - Individuals often feel stunned during the first few days; in the first week, disbelief, numbness, fear, and possibly confusion to the point of disorganization occur

• Crisis phase - After the initial impact has been absorbed, individuals can experience a number of feelings; they may alternate between denial and intrusive symptoms with hyperarousal; they may experience somatic symptoms (eg, fatigue, dizziness, headaches, and nausea), as well as anger, irritability, apathy, and social withdrawal; or they may be angry with caregivers who fail to solve problems or who are unable to respond in a fully organized way in the chaos of the crisis

• Resolution phase - Grief, guilt, and depression are often prominent during the first year as individuals continue to cope with their losses

• Reconstruction phase - Reappraisal, assignment of meaning, and integration of the event into a new self-concept occur

Only a minority of victims of traumatic events have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or posttraumatic stress disorder (PTSD).

Diagnostic criteria (DSM-5)

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lists 5 specific diagnostic criteria for ASD. ^[1]

The first criterion is exposure to actual or threatened death, serious injury, or sexual violation in 1 (or more) of the following ways:

• Directly experiencing the traumatic events(s)

• Witnessing, in person, the event(s) happening to others

• Learning that the 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)

• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains or police officers repeatedly exposed to details of child abuse)

The second criterion is the presence of at least 9 of 14 symptoms from any of 5 categories—intrusion, negative mood, dissociation, avoidance, and arousal—beginning or worsening after the traumatic event(s) occurred.

Intrusion symptoms include the following:

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); children may engage in repetitive play during which themes or aspects of the traumatic event(s) are expressed

• Recurrent distressing dreams in which the content or affect of the dream is related to the event(s); children may experience frightening dreams without recognizable content

• Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring

• Intense or prolonged psychological distress or marked physiologic reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

Negative mood consists of the following:

• Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings)

Dissociative symptoms include the following:

• Altered sense of the reality of one’s surroundings or oneself (eg, seeing oneself from another’s perspective, being in a daze, or feeling that time is slowing)

• Inability to remember an important aspect of the traumatic event(s), typically resulting from dissociative amnesia and not from other factors (eg, head injury, alcohol or drugs)

Avoidance symptoms include the following:

• Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

• Efforts to avoid external reminders (eg, people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Arousal symptoms include the following:

• Sleep disturbance (eg, difficulty falling or staying asleep or restlessness during sleep)

• Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects

• Hypervigilance

• Problems with concentration

• Exaggerated startle response

The third DSM-5 diagnostic criterion for ASD is that the duration of the disturbance is 3 days to 1 month after trauma exposure. Although symptoms may begin immediately after a traumatic event, they must last at least 3 days for a diagnosis of ASD to be made.

The fourth criterion is that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The fifth and final criterion is that the disturbance cannot be attributed to the physiologic effects of a substance (eg, a medication or alcohol) or another medical condition (eg, mild traumatic brain injury) and cannot be better explained by a diagnosis of brief psychotic disorder.

ASD may progress to PTSD after 1 month, but it may also be a transient condition that resolves within 1 month of exposure to traumatic event(s) and does not lead to PTSD. ^[1] In about 50% of people who eventually develop PTSD, the initial presenting condition was ASD. Symptoms of ASD may worsen over the initial month can occur, often as a consequence of ongoing stressors or additional traumatic events.

Factors increasing the risk of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in someone suffering a sufficient precipitating event include the following:

• Loss of a loved one in the event

• Significant injury from the event

• Witnessing of horrendous images

• Dissociation at the time of the traumatic event

• Development of serious depressive symptoms within 1 week that last for 1 month or longer

• Numbness, depersonalization, a sense of reliving the trauma, and motor restlessness after the event

• Preexisting psychiatric problems

• Previous trauma

• Loss of home or community

• Extended exposure to danger

• Toxic exposure

• Absent social supports, or social supports who were also traumatized and thus are incapable of adequate emotional availability

According to the DSM-5, ^[1] the frequency with which acute stress disorder (ASD) develops in individuals exposed to traumatic events depends on both the nature of the event and the context in which it is assessed. Within and outside the United States, ASD tends to occur at the following rates:

• 20-50% of cases follow interpersonal traumatic events (eg, assault, rape, and witnessing a mass shooting)

• 13-21% of motor vehicle accidents

• 14% of mild traumatic brain injuries

• 19% of assaults

• 10% of severe burns

• 6-12% of industrial accidents

The following are useful websites for patient and family education:

• Duke University Health Services, Bereavement, Coping After a Traumatic Death

• The University of Iowa, Coping with Death, Grief, and Loss

• Helpguide.org, Coping with Grief and Loss: Guide to Grieving and Bereavement

For other patient education resources, see the Mental Health Center, as well as Grief and Bereavement and Posttraumatic Stress Disorder (PTSD).