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ACUTE STRESS DISORDER (ASD)

AS A DIAGNOTIC ENTITY

The diagnostic criteria, as listed in DSM-IV, are:

 ACUTE STRESS DISORDER (from DSM-IV, American Psychiatric Association)

         (A) The person has been exposed to a traumatic event in which both of the following were present

(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

(2) The person's response to the traumatic event involved intense fear, helplessness, or horror.

 (B) Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

(1) A subjective sense of numbing, detachment, or absence of emotional responsiveness.

(2) A reduction in awareness of his or her surrounding (e.g., "being in a daze").

(3) Derealization.

(4) Depersonalization.

(5) Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).

(C) The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

(D) Marked avoidance of stimuli that arouse recollections of the trauma (e.g. thoughts, feelings, conversations, activities, places or people).

(E) Marked symptoms of anxiety or increased arousal (e.g. difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, and motor restlessness).

(F) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

(G) The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

(H) The disturbance is not due to the direct physiological effects of a substance or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

HOW HELPFUL IS THE DSM-IV DEFINITION OF

ACUTE STRESS DISORDER?

Harvey & Bryant (2002), who have done other nice research on peritraumatic variables and PTSD, as well as on early treatment following trauma, have completed a comprehensive review of the diagnosis of ASD that is highly recommended.  This review is the most comprehensive and complete discussion of the literature on ASD of which I am aware.

The following is a summary of some of Harvey & Bryant’s points.

Acute Stress Disorder as a diagnosis was introduced in 1994, with the publication of DSM-IV.  The intention of the diagnosis was to describe initial trauma reactions that would predict chronic PTSD.

The description is theory driven, and had relatively little empirical support when it was introduced.

ASD as a Predictor of Later PTSD:

The diagnosis of ASD seems to have a mix of strengths and shortcomings as a predictor of later PTSD:

Ø       ASD appears to be a fairly strong predictor of PTSD in studies published to date.  (72%-83% of people with ASD develop PTSD at 6 months posttrauma, and 63-80% have PTSD at 2 years posttrauma)

Ø       However, a large number of people who did not meet criteria for ASD went on to develop PTSD.  Studies have varied considerably, with a range of 27% to 63% of people with PTSD never having met criteria for PTSD

o        Therefore, the diagnosis of ASD may be too narrow as a predictor of PTSD (e.g., good specificity, but poor sensitivity)

o        Looking at specific symptoms for their positive predictive power (i.e., the presence of the Sx predicts the likely presence of PTSD later) and negative predictive power (i.e., the absence of the Sx predicts the later absence of PTSD), the following findings emerged:

§         Dissociation was the strongest positive predictor

§         The symptoms with a combination of the strongest positive and negative predictive power included emotional numbing, depersonalization, a sense of reliving the trauma, avoidance of trauma related thoughts or talking about the trauma.

§         Fear, helplessness, irritability, and hypervigilance had weak positive predictive power and strong negative predictive power.  In other words, their presence did not predict the later presence of PTSD, but their absence meant that later developing PTSD was unlikely.

§         With the exception of reliving (in people without brain injuries) and motor restlessness (for people with brain injuries), negative predictors (predicting the absence of PTSD) were stronger than positive predictors. 

Ø       The absence of ASD symptoms was better at predicting the absence of PTSD than the presence of ASD was at predicting the later presence of PTSD

o        A combination of three arousal and three dissociative symptoms and adding the symptoms of emotional numbing would maximize sensitivity and specificity.

o        Based on available research, the diagnosis of ASD does not appear to be more helpful than PTSD-minus-duration-criteria in predicting later PTSD.

The role of dissociation in the diagnosis of ASD:

Much of the theory, also, pertained to findings on dissociation correlating with the later presence of PTSD.  Regrettably, the DSM-IV diagnosis of dissociation does not distinguish between peritraumatic dissociation and acute dissociation (that occurring in the weeks following a trauma), which might differ in their functions and effects.

Ø       Theory and findings regarding peritraumatic dissociations (i.e., dissociation occurring at the time of the trauma):

o        Individuals may use dissociation to decrease awareness of and cognitive exposure to traumas and, in doing so, decrease the likelihood of being overwhelmed by fear or loss of control

o        dissociation may prevent traumatic memories and emotions from being integrated and resolved

o        dissociation may be a parasympathetic reaction to intense fear or arousal

As noted elsewhere in this outline, numerous studies have found that dissociation at the time of a trauma is highly predictive of later PTSD.  However . . .

Ø       It was not a better predictor than measures of general symptom intensity. 

Ø       The majority of people who meet ASD criteria except for dissociation later meet criteria for PTSD

Ø       The Dissociative Experience Scale, which has been used in many studies of dissociation and PTSD, may be more associated with gross pathology than with specific symptoms of dissociation.

Ø       Although dissociation may mediate the later appearance of PTSD, the relationship may be complex

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