Acute stress disorder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Acute stress disorder is defined as the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events.^[1] The exact pathogenesis of acute stress disorder is not fully understood. It is thought that acute stress disorder is caused by either sympathetic nervous system, both directly and indirectly through the release od adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands, or hypothalamic-pituitary-adrenal axis.^[2] Acute stress disorder may be caused by either experiencing, witnessing, or being confronted with one or more traumatic events.^[3][4][5][6] The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. Females are more commonly affected with acute stress disorder than males.^{[7][8][9][10][11][12]} Common risk factors in the development of acute stress disorder are temperamental, environment, and genetic and physiological.^{[13][14][15][16][17]} If left untreated, 50% of patients with acute stress disorder may progress to develop post traumatic stress disorder. Common complications of acute stress disorder include interference with sleep, energy levels, and capacity to attend to tasks, generalized withdrawal, and progression to post traumatic stress disorder. Prognosis is generally good, and the majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). The diagnosis of acute stress disorder is based on the DSM-5 diagnostic criteria, which include criterion A i.e the exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways such as directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occurred to others, learning that the event(s) occured to a close family member or close friend, and experiencing repeated or extreme exposure to aversive details of the traumatic event(s), criterion B i.e presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred, criterion C i.e duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure, criterion D i.e the disturbance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning, and criterion E i.e the disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.^[18] Symptoms of acute stress disorder include dissociative symptoms, symptoms of reexperiencing the traumatic event, avoidence symptoms, symptoms of anxiety or increased arousal, symptoms of distress, chaotic and impulsive behavior, and post-concussive symptoms. The optimal therapy for acute stress disorder includes cognitive-behavioral therapy and pharmacotherapy. The mainstay of therapy for acute stress disorder is cognitive-behavioral therapy.^{[19][20][21][22][23][24]} Pharmacologic medical therapies for acute stress disorder include beta blockers, alpha adrenergic agents, benzodiazepines and/or SSRIs.

Acute stress disorder was originally made known during world wars 1 and 2, where soldiers exhibited signs of stress up to 1 month after a traumatic event.^[25]

There is no classification system established for acute stress disorder.

The exact pathogenesis of acute stress disorder is not fully understood. It is thought that acute stress disorder is caused by either sympathetic nervous system, both directly and indirectly through the release of adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands, or hypothalamic-pituitary-adrenal axis.^[2]

Acute stress disorder may be caused by either experiencing, witnessing, or being confronted with one or more traumatic events.^{[26][27][28][29]}

Acute stress disorder must be differentiated from other diseases that closely mimic a range of acute stress disorder symptoms, including depersonalization, derealization, reduced awareness, and dissociative amnesia or from disorders that doesn’t meet criteria for acute stress disorder such as post traumatic stress disorder, obsessive-compulsive disorder, anxiety disorders, depression, dissociative disorders, panic disorder, adjustment disorder, effects of analgesic medications, medical conditions involving coma or impaired awareness, effects of substance abuse, traumatic brain injury (TBI), exacerbation of a preexisting mental condition, brief psychotic episode, and psychotic disorders.

The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. Females are more commonly affected with acute stress disorder than males.^{[7][8][9][10][11][30]}

Common risk factors in the development of acute stress disorder are temperamental, environment, and genetic and physiological.^{[13][14][15][16][17]}

According to the United States Preventive Services Task Force, screening for acute stress disorder is not recommended.^[31]

If left untreated, 50% of patients with acute stress disorder may progress to develop post traumatic stress disorder. Common complications of acute stress disorder include interference with sleep, energy levels, and capacity to attend to tasks, generalized withdrawal, and progression to post traumatic stress disorder. Prognosis is generally good, and the majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). Of individuals who have cognitive-behavioral therapy (CBT) shortly after frightening events, only about 10% to 20% develop PTSD.

The diagnosis of acute stress disorder is based on the DSM-5 diagnostic criteria, which include criterion A i.e the exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways such as directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occured to others, learning that the event(s) occured toa close family member or close friend, and experiencing repeated or extreme exposure to aversive details of the traumatic event(s), criterion B i.e presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred, criterion C i.e duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure, criterion D i.e the disturbance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning, and criterion E i.e the disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g.,mild traumatic brain injury) and is not better explained by brief psychotic disorder.^[18]

Symptoms of acute stress disorder include dissociative symptoms, symptoms of reexperiencing the traumatic event, avoidence symptoms, symptoms of anxiety or increased arousal, symptoms of distress, chaotic and impulsive behavior, and post-concussive symptoms.

Patients with acute stress disorder usually appear disheveled and unclean and may show the effects of dehydration and failure to care for themselves. Mental status examination of patients with acute stress disorder is usually remarkable for anxious, sad, irritable, apathetic, emotionally labile, angry, or calm, individuals may feel helpless, be confused, be in a state of disbelief, have markedly impaired concentration, have lowered self-esteem, or be driven to search for the deceased, patients may have visual or auditory hallucinations that the deceased person is present; feelings of unreality, flashbacks, numbness, and denial may occur, confusion in combination with preoccupation with those they have lost may be present that impair an individuals’ judgment and insight, and suicidal thoughts occur in as many as approximately 54% of survivors and may continue up to 6 months after the death; thoughts or plans of homicide may be present.

There are no diagnostic lab findings associated with acute stress disorder.

There are no chest x ray findings associated with acute stress disorder.

There are no CT scan findings associated with acute stress disorder.

There are no MRI findings associated with acute stress disorder.

There are no other imaging findings associated with acute stress disorder.

There are no other diagnostic studies associated with acute stress disorder.

Pharmacologic medical therapies for acute stress disorder include beta blockers, alpha adrenergic agents, benzodiazepines and/or SSRIs.

The optimal therapy for acute stress disorder includes cognitive-behavioral therapy and pharmacotherapy. The mainstay of therapy for acute stress disorder is cognitive-behavioral therapy.^{[19][20][21][22][23][24]}

Effective measures for the primary prevention of acute stress disorder include getting medical treatment with a few hours of experiencing a traumatic event and counseling and preparation training in military personnel.

There are no secondary preventive measures available for acute stress disorder.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2] Yashasvi Aryaputra[3]

Acute stress disorder was originally made known during world wars 1 and 2, where soldiers exhibited signs of stress up to 1 month after a traumatic event.

The term “acute stress disorder” was originally coined during world wars 1 and 2, where soldiers experienced short term stress as a result of traumatic events. It was not until 1994 that the DSM-IV officially included acute stress disorder.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

There is no classification system established for acute stress disorder.

There is no classification system established for acute stress disorder.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2] Yashasvi Aryaputra[3]

The exact pathogenesis of acute stress disorder is not fully understood. It is thought that acute stress disorder is caused by either sympathetic nervous system, both directly and indirectly through the release of adrenaline and to a lesser extent noradrenaline from the medulla of the adrenal glands, or hypothalamic-pituitary-adrenal axis.

• When triggered by a stimuli, the body has a natural “fight-or-flight” response
• In response to such stimuli, the body can release either adrenaline or noradrenaline, which result in physiological responses such as increased heart rate, constricted blood vessels, and increased breathing
• The locus ceruleus “fires” neurons in a very minimal manner when an individual is in a calm state
• The locus ceruleus “fires” neurons at a much faster and more intense rate if a stimulus seems threatening
• The “fight-or-flight” response we feel is a result of our sympathetic nervous system, which raises our pulse and causes anxiety
• Another response, called the “rest-and-digest” response, is a result of the parasympathetic nervous system, which reduces heart rate, and can potentially cause loss of consciousness
• The parasympathetic nervous system increases digestion by stimulating the digestive system and urinary system^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Acute stress disorder may be caused by either experiencing, witnessing, or being confronted with one or more traumatic events.^[1][2][3][4]

Traumatic events that can cause acute stress disorder include the following:^[5][6][7][8]

• Directly experiencing the traumatic event,
• Witnessing the traumatic event
• Being confronted with one or more traumatic events

Approximately 6 to 33 percent of people who experience a traumatic event develop ASD. This rate varies based on the nature of the traumatic situation

Traumatic event	Type of traumatic event	Example of traumatic event
Traumatic events experienced directly, but not limited to	Exposure to war as a combatant or civilian
	Threatened or actual violent personal assault	Sexual violence, physical attack , active combat, mugging, childhood physical and/or sexual violence, being kidnapped being taken hostage, terrorist attack, torture For children, sexually traumatic events may include inappropriate sexual experiences without violence or injury
	Natural or humanmade disasters	Earthquake, airplane crash, hurricane
	Medical incidents	Sudden, catastrophic events such as waking during surgery, anaphylactic shock A severe life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event
	Severe accident	Severe motor vehicle, industrial accident
Traumatic events witnessed, but not limited to	Observing threatened or serious injury
	Unnatural death
	Physical or sexual violence inflicted on another individual as a result of violent assault
	Severe domestic violence
	Severe accident
	War
	Disaster
	Witnessing a medical catastrophe involving one’s child	A life-threatening haemorrhage
Being confronted with one or more traumatic events
Traumatic events experienced indirectly through learning about the event are limited to close relatives or close friends	Events must have been violent or accidental Death due to natural causes does not qualify When the stressor is interpersonal or intentional ( e.g, torture, rape), the disorder may be especially severe The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase	violent personal assault, suicide , serious accident, or serious injury
Experiencing repeated or extreme exposure to aversive details of the traumatic events	Child abuse, death	First responders collecting human remains, police officers repeatedly exposed to details of child abuse

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Acute stress disorder must be differentiated from other diseases that closely mimic a range of acute stress disorder symptoms, including depersonalization, derealization, reduced awareness, and dissociative amnesia or from disorders that doesn’t meet criteria for acute stress disorder such as post traumatic stress disorder, obsessive-compulsive disorder, anxiety disorders, depression, dissociative disorders, panic disorder, adjustment disorder, effects of analgesic medications, medical conditions involving coma or impaired awareness, effects of substance abuse, traumatic brain injury (TBI), exacerbation of a preexisting mental condition, brief psychotic episode, and psychotic disorders.

Acute stress disorder must be differentiated from the following disorders:^{[1][2][3][4][5]}

• Post traumatic stress disorder
• Obsessive-compulsive disorder
• Anxiety disorders
• Depression
• Dissociative disorders
• Panic disorder
• Adjustment disorder
• Effects of analgesic medications
• Medical conditions involving coma or impaired awareness
• Effects of substance abuse
• Traumatic brain injury (TBI)
• Exacerbation of a preexisting mental condition
• Brief psychotic episode
• Psychotic disorders

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. Females are more commonly affected with acute stress disorder than males.^{[1][2][3][4][5][6]}

The point prevalence of acute stress disorder (ASD) following trauma exposure has been estimated at between 5 and 20 percent. According to the DSM-5, the frequency with which acute stress disorder develops in individuals exposed to traumatic events depends on the following features:

• The context in which the event is assessed
• The nature of the event
• Within and outside the United States, acute stress disorder tends to occur at the following rates:^{[1][2][3][4][5][7]}
  • 6-12% of industrial accidents
  • 10% of severe burns
  • 13-21% of motor vehicle accidents
  • 14% of mild traumatic brain injuries
  • 19% of assaults
  • 20-50% of cases follow interpersonal traumatic events (eg, assault, rape, and witnessing a mass shooting)

• Females are more commonly affected with acute stress disorder than males.^[8]
• Acute stress disorder is more prevalent among females than among males. It is hypothesized that sex-linked neurobiological differences in stress response may contribute to females’ increased risk for acute stress disorder. The increased risk for the acute stress disorder in females may be attributable in part to a greater likelihood of exposure to the traumatic events with a high conditional risk for acute stress disorder, such as rape and other interpersonal violence (domestic violence etc.).^[9]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Common risk factors in the development of acute stress disorder are temperamental, environment, and genetic and physiological.^{[1][2][3][4][5]}

Risk factors for acute stress disorder include the following:^{[1][2][3][4][5]}

Risk factors	Description
Temperamental	Prior mental disorder High levels of negative affectivity (neuroticism) Greater perceived severity of the traumatic event An avoidant coping style Catastrophic appraisals of the traumatic experience, often characterized by exaggerated assessment of future harm, guilt, or hopelessness, are strongly predictive of acute stress disorder
Environment	History of prior trauma Absent social support
Genetic and physiological	Females are at greater risk for developing acute stress disorder Elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure increases the risk for developing acute stress disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

According to the United States Preventive Services Task Force, screening for acute stress disorder is not recommended.^[1]

According to the United States Preventive Services Task Force, screening for acute stress disorder is not recommended.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

If left untreated, 50% of patients with acute stress disorder may progress to develop post traumatic stress disorder. Common complications of acute stress disorder include interference with sleep, energy levels, and capacity to attend to tasks, generalized withdrawal, and progression to post traumatic stress disorder. Prognosis is generally good, and the majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). Of individuals who have cognitive-behavioral therapy (CBT) shortly after frightening events, only about 10% to 20% develop PTSD.

• In the initial days and weeks after a traumatic event, trauma survivors typically display symptoms of marked distress, but then the majority of people tend to adapt, and these symptoms remit.
• Persons may develop an acute stress reaction, within minutes of a traumatic event. Acute stress reaction is a transient condition involving a broad array of signs and symptoms, including anxiety, depression, fatigue, difficulties with memory and concentration, hyperarousal, and social withdrawal. These occur at the same time as or within a few minutes of the traumatic event, and in majority of cases disappear within hours or days. Patients with traumatic stress often present with general symptoms, such as gastrointestinal disorders, headaches, rheumatic pain, skin disorders, cardiovascular symptoms, difficulty sleeping, or psychological problems such as anxiety and depression.^[1]
• Acute stress disorder cannot be diagnosed until 3 days after a traumatic event. Although acute stress disorder may progress to posttraumatic stress disorder (PTSD) after 1 month, it may also be a transient stress response that remits within 1 month of trauma exposure and does not result in post traumatic stress disorder (PTSD). Approximately half of individuals who eventually develop post traumatic stress disorder (PTSD) initially present with acute stress disorder. Symptom worsening during the initial month can occur, due to ongoing life stressors or further traumatic events.^[2]
• The forms of reexperiencing can vary across development. Young children may report frightening dreams without content that clearly reflects aspects of the trauma, unlike adults and adolescents. Children age 6 years and younger are more likely than older children to express reexperiencing symptoms through play that refers symbolically to the trauma. Young children also do not necessarily manifest fearful reactions at the time of the exposure to the trauma or even during reexperiencing. In young children who are traumatized, parents typically report a range of emotional expressions, such as shame, anger, or withdrawal, and even excessively bright positive affect.
• The intent of the ASD diagnosis is to facilitate identification and treatment of acute stress responses. Treatment of ASD can have a significant benefit of limiting subsequent posttraumatic stress disorder (PTSD).

Acute Stress Disorder may interfere with sleep, energy levels, and capacity to attend to tasks. This disorder can result in generalized withdrawal from many threatening situations (e.g., medical appointments, absenteeism from work). Half of the individuals who develop Post-traumatic Stress Disorder initially present with Acute Stress Disorder. Individuals may be indifferent to maintaining their health and safety. There is a possibility of progression to posttraumatic stress disorder. Feelings of despair can be severe enough to qualify as a major depressive episode.

The majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). Of individuals who have cognitive-behavioral therapy (CBT) shortly after frightening events, only about 10% to 20% develop PTSD. Decreased functioning following previous stresses, lack of a support system, substance abuse, and the coexistence of other psychiatric disturbances can negatively affect the outcome of the disorder. Approximately between 40 and 80 percent of those with ASD develop subsequent PTSD; that is, half or more of people with ASD do not experience chronic PTSD. Only approximately 30 to 60 percent of those who eventually develop PTSD meet criteria for acute stress disorder (ASD) in the acute phase, indicating that most people who develop PTSD are not detected by the diagnosis.^{[3][4] [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]}

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