Acute Stress Disorder

Lindsay M. Orchowski, PH.D.
Daniel W. Oesterle, B.S.

Basic Information

Definition

Acute stress disorder (ASD) features severe acute stress reactions (ASRs) that occur between 3 days to 1 month after exposure to a traumatic event.

Synonyms

ICD-10CM CODES
F43.0	Acute stress reaction
F43.11	Post-traumatic stress disorder, acute
DSM-5 CODES
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 and at 20% to 50% in cases of interpersonal trauma (e.g., sexual assault, witnessing a mass shooting).

Predominant Age

ASD can be diagnosed at all ages. Children tend to manifest symptoms differently (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.

Predominant Sex

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

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

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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 mental disorder (e.g., preexisting anxiety or depressive disorders)

Physical Findings & Clinical Presentation

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

A.
Exposure to actual or threatened serious injury, death, or sexual violation in one or more of the following ways:
1. ○
  
  Personally 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
B.
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)
C.

Symptoms typically begin immediately after the trauma and must persist for at least 3 days, and up to 1 month, following exposure to trauma. If symptoms persist for longer than 1 month, a diagnosis of posttraumatic stress disorder (PTSD) may be considered.
D.

Exposure to trauma must result in clinically significant impairment in functioning.
E.

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.

Diagnosis

Differential Diagnosis

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Adjustment disorder
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Panic disorder
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Dissociative disorders
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PTSD
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Obsessive-compulsive disorder
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Psychotic disorders
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Traumatic brain injury

Workup

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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.

Laboratory Tests

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None indicated

Imaging Studies

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None indicated

Treatment

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Early treatment should focus on establishing a therapeutic alliance and acknowledging negative emotions (i.e., fear) of future exposure to traumatic agents.
•

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.
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Early behavioral and educational interventions demonstrate small to moderate effects for reducing symptoms of psychological trauma.
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In cases of trauma related to experiences of interpersonal violence, safety planning is necessary for individuals who remain in unsafe situations or relationships.
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Pharmacological treatment is typically reserved for individuals who have already received psychotherapy. There are few controlled pharmacological treatment trials for ASD.
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There are currently no medications approved by the FDA for treatment of ASD. Clinicians may consider FDA-approved medications for PTSD, such as paroxetine and sertraline.

Nonpharmacologic Therapy

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Cognitive behavioral therapy
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Prolonged exposure
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Cognitive processing therapy
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Relaxation and mindfulness

Acute General Rx

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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.
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Antiadrenergic agents, such as beta-blockers, may be useful for treatment of arousal.
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Brief, short-term treatment using benzodiazepines (i.e., alprazolam, clonazepam, Temazepam) may be useful for treating arousal, insomnia, and anxiety. It should be noted that prolonged use of benzodiazepines has been associated with higher rates of PTSD.
•

Prazosin is recommended for treatment of nightmares.
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SSRIs and other antidepressants may be useful for re-experiencing symptoms, avoidance, and hyperarousal.

Complementary & Alternative Medicine

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Patients may find activities that increase relaxation (i.e., yoga, mindfulness, meditation) useful.
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Eye movement desensitization and reprocessing (EMDR) has shown promise in alleviating symptoms in patients diagnosed with ASD; 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 treated by a mental health clinician.

Pearls & Considerations

Comments

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Although many individuals with ASD go on to develop PTSD, many with ASD do not go on to develop PTSD. Available data at this time suggest that ASD criteria are not adequate for identifying individuals at risk for developing PTSD.
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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.

Prevention

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Critical incident stress debriefing (CISD) after a trauma is typically administered in one 2- to 3-hour group session within 72 hours of the trauma, with the goals of allowing survivors to “vent.” There is some evidence that CISD does not prevent PTSD and may contribute to poor recovery. Psychological first aid (PFA) is designed to improve outcomes after trauma by fostering safety, calmness, social connectedness, and optimism. Although PFA has received some empirical support, questions remain regarding the optimal format of administration.

Patient & Family Education

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National Center for PTSD, Public Section, Information on Trauma and PTSD for Veterans, the General Public and Families: Acute Stress Disorder. (http://www.ptsd.va.gov/professional/treatment/early/acute-stress-disorder.asp)

Ferri – Acute Stress Disorder