Acute Stress Disorder

The Diagnosis Before PTSD

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PTSD is a severe mental health condition that stems from exposure to a traumatic event, such as combat, sexual assault, motor vehicle accident, or natural disaster. Its symptoms include nightmares, flashbacks, insomnia, irritability, concentration difficulties and feelings of alienation. In order to receive a diagnosis of PTSD, a patient must experience a sufficient number of symptoms across four general criteria. The symptoms must be significantly distressful or cause functional distress, such as interfering with a person’s career or personal relationships. The symptoms must have lasted at least one month before a person can be diagnosed with PTSD.

However, symptoms can often manifest within hours of a trauma. What does that mean in terms of a possible mental health diagnosis for the person living with the after-effects of the trauma? If the person is clearly suffering, what exactly are they suffering from if it’s too early to diagnose PTSD?

The answer is likely acute stress disorder (ASD), which can be diagnosed as soon as the third day after trauma exposure.

How Acute Stress Disorder is Diagnosed

Like PTSD, acute stress disorder requires that a person either directly or indirectly experience a trauma, such as exposure to actual or threatened death; serious injury; or sexual violation. There are four categories of exposure: directly experiencing the trauma; witnessing, in person, traumatic events that happen to other people; learning that a family member or close friend was involved in a traumatic event without personally witnessing it; or repeated exposure to details of a traumatic event, usually in the course of employment.

However, while PTSD has specific criteria across four different categories of symptoms, and a specific number of symptoms that need to be experienced within each category, there is simply a minimum number of general symptoms that a person presenting with possible ASD must have in order to be diagnosed. There are fourteen symptoms listed for ASD; a person over age six must have nine of them. Like PTSD, the diagnostic criteria for ASD in children under age six is somewhat different.

The possible symptoms are as follows:

  1. Recurrent, involuntary and intrusive distressing memories of the traumatic event.
  2. Recurrent, distressing dreams in which the content and/or the affect of the dream is related to the event.
  3. Dissociative reactions (flashbacks) in which the person feels or acts as if the traumatic event were recurring.
  4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  5. Persistent inability to experience positive emotions.
  6. An altered sense of the reality of one’s surroundings or one’s self, such as being in a daze; feeling as if time were slowing down; or seeing one’s self from another’s perspective.
  7. Inability to remember an important aspect of the traumatic event, typically due to dissociative amnesia.
  8. Efforts to avoid distressing memories, thoughts or feelings about, or closely associated with, the traumatic event.
  9. 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.
  1. Sleep disturbances such as difficulty falling or staying asleep; or restless sleep.
  2. Irritable behavior 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.

Many of the symptoms of ASD are exactly the same as the symptoms listed in Criteria B through E of the PTSD entry in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, there are some differences, especially the focus on dissociative symptoms within the ASD diagnosis. This represents a holdover of the diagnostic criteria for ASD found in the DSM-IV-TR (the previous edition). That version was heavily focused on episodes of dissociation, listing five distinct dissociative symptoms, of which a patient had to present with a minimum of three.

The Purpose of Diagnosing ASD

Originally, the purpose of diagnosing a person with ASD was to more accurately predict those who would go on to develop PTSD. However, while the majority of patients who are diagnosed with ASD do go on to develop PTSD, it cannot be said that most PTSD patients initially present with ASD. Rather, most people who are eventually diagnosed with PTSD do not initially present with ASD.

There are several reasons for this lack of bi-directional correlation. The DSM-IV-TR overly focused on dissociation, based on the incorrect assumption that dissociative responses to trauma were crucial to predicting future psychopathology. This reliance on dissociation as a predictor resulted in the failure to focus on acute arousal at the time of trauma, which some studies indicate may actually be the critical connection between experiencing trauma and developing PTSD. Finally, and most significantly, additional research into the relationship between ASD and PTSD revealed that the development of PTSD is far more complicated and multivariate than originally assumed. Development of PTSD is non-linear. Some studies have identified four distinct symptom trajectories: a resilient group, with few symptoms at any point; a recovery group, which initially expresses a significant number of symptoms that gradually fade; a delayed-reaction group, which presents with few symptoms at the beginning but eventually presents with multiple significant symptoms; and a chronic distress group, which consistently presents with high symptom levels.

While ASD is no longer used as a predictor of a future diagnosis of PTSD, it is still important to address the symptoms as soon as they appear. Short-term intervention for immediate reactions to trauma in and of itself is a worthwhile aim as it can help alleviate stress that would otherwise be debilitating.

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  • Bryant RA, Creamer M, et al. A Multisite Study of the Capacity of Acute Stress Disorder Diagnosis to Predict Posttraumatic Stress Disorder. Journal of Clinical Psychiatry. 2008 Jun;69(6):923-9.
  • Bryant RA1, Friedman MJ, et al. A review of acute stress disorder in DSM-5. Depression and Anxiety. 2011 Sep;28(9):802-17.