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Acute stress disorder
Diagnosis and Prognosis

Definition

Acute stress disorder is a typical pattern of anxiety, dissociative and other symptoms that occur within 1 month of exposure to an extremely traumatic event.

Diagnostic criteria

DSM-IV diagnostic criteria

The DSM-IV criteria for acute stress disorder are divided into eight parts.
Criterion A

The person must have been exposed to a traumatic event and both of the following must be fulfilled:

  • the person experienced, witnessed or was confronted with an event that involved death or serious injury (actual or threatened) or a threat to the physical integrity of himself or herself or of others;
  • the person responded with intense fear, helplessness or horror.
Criterion B

The person must have had at least three of the following symptoms either during the traumatic event or after it:

  • a subjective sense of numbing, detachment or lack of emotional responsiveness;
  • reduced awareness of the surroundings;
  • derealization;
  • depersonalization;
  • dissociative amnesia about the event.
Criterion C

The person must persistently re-experience the traumatic event in at least one of the following ways:

  • recurrent images, thoughts, dreams, illusions, flashbacks of the event;
  • a sense of reliving the event;
  • distress when exposed to reminders of the event.
Criterion D

The person must markedly avoid stimuli that cause recollections of the traumatic event (e.g. people, places, conversations, activities, thoughts, feelings).

Criterion E

The person must have marked symptoms of anxiety or increased arousal.

Criterion F

The person must have significant distress or functional impairment as a result of the disturbance, or have difficulty in pursuing a necessary task (e.g. telling family members about the traumatic event) as a result of the disturbance.

Criterion G

The disturbance must last for at least 2 days and not for longer than 4 weeks. It must occur within 4 weeks of the traumatic event.

Criterion H

The disturbance must not be due to the effects of a substance or a general medical disorder. It must not be better accounted for by a brief psychotic disorder, and it must not be an exacerbation of a pre-existing axis I or axis II disorder.

Signs and symptoms

The event that triggers an acute stress disorder must be a significantly stressful one in that it must involve actual or threatened death or serious injury or a threat to the physical integrity of the patient or others. The traumatic event may be experienced directly, witnessed or learned about.

Directly experienced events that may trigger an acute stress disorder include:

  • physical attack or mugging;
  • sexual assault;
  • being kidnapped or taken hostage;
  • being subject to a terrorist attack;
  • torture;
  • being a prisoner or war or in a concentration camp;
  • natural or artificial disasters (e.g. earthquake, collapse of a bridge);
  • severe transport accidents;
  • being bitten by a poisonous snake or insect;
  • being diagnosed with a life-threatening illness.
Witnessed and learned-about events that may trigger an acute stress disorder include:
  • observing a violent or unnatural death in another person;
  • unexpectedly seeing a dead body or body parts;
  • a serious accident or unexpected death of a family member or close friend;
  • learning that a family member or close friend has a life-threatening disease.
In the acute phase (during the traumatic event and for a few hours afterwards), patients with acute stress disorder experience may to report:
  • emotional shock;
  • paradoxical calm;
  • psychic numbing;
  • denial (including denial of or amnesia for the traumatic event);
  • motor `freezing' or restlessness;
  • insomnia;
  • hypervigilance, which may increase to panic and flight;
  • irritability;
  • pervasive anxiety;
  • unprovoked aggression;
  • impaired cognition.
Later, patients with acute stress disorder may have:
  • marked behavioral changes;
  • somatization;
  • dissociation;
  • delirium;
  • intrusive memories, `reliving' the traumatic event, flashbacks;
  • avoidance of reminders of traumatic event;
  • guilt and shame, which may be accompanied by depression.
Complications

Possible complications of acute stress disorder include:

  • social or occupational disability;
  • decompensation leading to major depression, psychosis or anxiety disorder;
  • delayed wound healing: disturbed behavior from acute stress disorder may complicate recovery from physical injuries;
  • suicide.
Symptoms that persist beyond 1 month may indicate the development of post-traumatic stress disorder.
Differential diagnosis

The differential diagnosis of acute stress disorder includes:

  • a normal response to a stressful or traumatic event;
  • other anxiety disorders;
  • post-traumatic stress disorder;
  • a mental disorder due to head trauma or another general medical condition, including confounding medical illnesses or injuries resulting from the traumatic event;
  • exacerbation of other, pre-existing mental disorders caused by a traumatic event;
  • malingering, particularly if there is a chance of financial reward or increased eligibility to benefits as a result of the traumatic event.
References

Diagnostic and Statistical Manual of Mental Disorders, 4th ed Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association 2000; 469-471.

Anxiety Disorders

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