Acute Stress Disorder

Acute stress disorder (ASD) is a common acute posttraumatic syndrome, which is strongly associated with the later development of Posttraumatic Stress Disorder. Acute stress disorder represents both an acute pathological reaction to trauma and the role of dissociative phenomena in both short-term and long-term reactions to trauma. ^[1]

Acute Stress Disorder was introduced into DSM-IV to describe acute stress reactions (ASRs) that occur in the initial month after exposure to a traumatic event and before the possibility of diagnosing Posttraumatic Stress Disorder, and to identify trauma survivors in the acute phase who are high risk for Posttraumatic Stress Disorder. ^[2][3]

DSM-5 (Diagnostic and Statistical Manual of Mental DisordersPublished by the American Psychiatric Association as the standard classification of mental disorders used by US mental health professionals. It consists of diagnostic classification, the diagnostic criteria sets, and descriptive text. The DSM-II listed multiple personality disorder as a symptom of hysterical neurosis, dissociative type. The DSM-III (1980) moved Multiple Personality Disorder from a symptom to its own disorder. The DSM-IV changed the name to dissociative identity disorder (1994) and the DSM-5 (May 2013) updated the listing to current standards. {{Rp|384}})

DSM-5 code 308.3 (F43.0)

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) occurred to a close family memory or close friend.
3. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).

B. Presence of nine or more of the following symptoms from any of the five categories of intrusion, negative mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}}, dissociation, avoidance, and arousal, beginning or worsening after the traumatic even(s) occurred:"

IntrusionParts of the [[personality]] influence each other, whether they are aware of others or not. Any part may intrude on, and influence the experience of the part that is functioning in daily life, without taking full control of functioning. {{Rp|27}} In dissociative identity disorder and other disorders, dissociative symptoms are felt when one dissociated state intrudes into the experience of another. Intrusions occur in perceptions, ideas, wishes, needs, movements and behaviors. {{Rp|18}} In partial dissociation, amnesia is not present. {{Rp|228}} Symptoms

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s).
3. Dissociative reactions in which the individual feels or acts as if the traumatic event(s) 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(s).

Negative Mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}}

1. Persistent inability to experience positive emotions.

Dissociative Symptoms

1. An altered sense of the reality of one's surroundings or oneself.
2. Inability to remember an important aspect of the traumatic events(s).

Avoidance Symptoms

1. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

1. Sleep disturbance.
2. Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects.
3. Hypervigilance"Excessive attention to and focus on all internal and external stimuli."{{Rp|26} A pattern presenting with fight or flight reactions is common in individuals with unprocessed trauma memories. {{Rp|217}} A PTSD symptom. Hypervigilance is an arousal symptom within PTSD and acute stress disorder..
4. Problems with concentration.
5. Exaggerated startle response.

C. Duration of the disturbance is 3 days to 1 month after trauma exposure."

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance, or other medical condition and is not better explained by brief psychoticA person experiencing psychosis, or a characteristic of psychosis. {{Rp|24}} disorder. ^[4]:149-151

Dissociative symptoms and the link to Posttraumatic Stress Disorder

The previous version of the DSM manual, known as the DSM-IV-TR,^[5]:471-472 described the dissociative symptoms from criteria B, using more concise technical terms. The dissociative and intrusive symptoms are described as follows.

DSM-5	DSM-IV-TR equivalent	Type of symptom / Alternate terms
Dissociative reactions - the individual feels or acts as if the traumatic event(s) were recurring	recurrent images, illusionsIllusions are distortions of real images or sensations, however hallucinations are not based on things which are not real. Illusions have many different causes include being substance related, or caused by a disorder such as Schizophrenia or PTSD (reexperiencing the truma). {{Rp|168,260}}, flashback episodes of the trauma, or a sense of reliving the experience	Dissociative intrusionsParts of the [[personality]] influence each other, whether they are aware of others or not. Any part may intrude on, and influence the experience of the part that is functioning in daily life, without taking full control of functioning. {{Rp|27}} In dissociative identity disorder and other disorders, dissociative symptoms are felt when one dissociated state intrudes into the experience of another. Intrusions occur in perceptions, ideas, wishes, needs, movements and behaviors. {{Rp|18}} In partial dissociation, amnesia is not present. {{Rp|228}}: hallucinationsThe DSM-IV-TR psychiatric manual defined hallucinations as a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations are common both in schizophrenia and dissociative identity disorder. {{Rp|525}}Hallucinations can be auditory (voices, noises or other sounds), voices commenting on the person's behavior or thoughts, voices conversing, somatic or tactile (peculiar physical sensations), olfactory (unusual smells), visual (shapes or people that are not present). {{Rp|45}}Visual hallucinations are the most common type of hallucination and are often in geometric forms and figures {{Rp|127}} Illusions are similar to visual hallucinations but are based on real images or sensations., flashbacks
An altered sense of the reality of one's surroundings	Reduction in awareness of his/her surroundings, e.g. "being in a daze"	Dissociative: derealization or trance
Persistent inability to experience positive emotions	sense of numbing, detachmentCharacterized by distant interpersonal relationships and lack of emotional involvement {{Rp|24}}, or absence of emotional responsiveness, depersonalization	Dissociative: depersonalisation, mood: depression
An altered sense of the reality of ... oneself	depersonalisation	Dissociative: depersonalisation
Inability to remember an important aspect of the trauma	dissociative amnesia (i.e., inability to recall an important aspect of the trauma)	Dissociative: amnesiaMemory loss. {{See also| amnesia}}
Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s)	recurrent dreams (related to the trauma)	Dissociative intrusions: nightmares, night terrors
Recurrent, involuntary, and intrusive distressing memories of the trauma	Recurrent thoughts (related to the trauma)	Dissociative intrusions
Psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the trauma	Distress on exposure to reminders of the traumatic event	Dissociative intrusions: in response to triggers
Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma. Efforts to avoid external reminders	Marked avoidance of stimuli that arouse recollections of trauma (thoughts, feelings, conversations, activities, places, people)	Avoidance
Hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, irritable behavior and angry outbursts	Marked symptoms of anxiety or increased arousal (difficulty sleeping, irritability, poor concentration, hypervigilance"Excessive attention to and focus on all internal and external stimuli."{{Rp|26} A pattern presenting with fight or flight reactions is common in individuals with unprocessed trauma memories. {{Rp|217}} A PTSD symptom. Hypervigilance is an arousal symptom within PTSD and acute stress disorder."Excessive attention to and focus on all internal and external stimuli."{{Rp|26} A pattern presenting with fight or flight reactions is common in individuals with unprocessed trauma memories. {{Rp|217}} A PTSD symptom. Hypervigilance is an arousal symptom within PTSD and acute stress disorder., exaggerated startle response, motor restlessness)	Arousal

Diagnosing Acute Stress Disorder (ASD)

The Acute Stress Disorder Structured Interview (ASDI) is a structured clinical interview for diagnosing Acute Stress Disorder, and is based on the DSM-IV criteria. The Acute Stress Disorder Scale (ASDS) is a self-report measure of ASD symptoms. ^[6] It measures four clusters of symptoms: dissociation, re-experiencing, avoidance and arousal. The Stanford Acute Stress Reaction Questionnaire (SASRQ) is a similar self-report measure for Acute Stress Disorder. ^{[6] [7]} Acute Stress Disorder: A handbook of theory, assessment, and treatment (Bryant and Harvey, 2000) gives the ASDI and ASDS criteria in detail in the Appendix. ^[8]

Acute Stress Reaction in the ICD10

This is coded as F43.0 in the ICD-10, and referred to as Acute stress reaction. The description is:

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of "daze" with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor - F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered. ^[9]

References

1. ^ Cardeña, E., & Carlson, E. (2011). Acute stress disorder revisited. Annual review of clinical psychology, 7, 245-267
2. ^ Bryant, Richard A., et al. "A review of acute stress disorder in DSM‐5." Depression and anxiety 28.9 (2011): 802-817. Accessed 12 Jun, 2013 from http://focus.psychiatryonline.org/article.aspx?articleID=178213&RelatedNewsArticles=true
3. ^ Stahl, Stephen M., and Bret A. Moore, eds. Routledge, 2013
4. ^ American Psychiatric Association, =9780890425565 (2013). . APA.
5. ^ American Psychiatric Association, (2000). . APA..
6. ^ a b Bryant, R.A., Harvey, A.G., Dang, S., & Sackville, T. (1998). Assessing Acute Stress Disorder: Psychometric properties of a structured clinical interview. Psychological Assessment, 10, 215-220.
7. ^ Bryant, R. A., Moulds, M. L., & Guthrie, R. M. (2000).Acute Stress Disorder Scale: a self-report measure of acute stress disorder. Psychological Assessment, 12(1), 61.
8. ^ Bryant, R.A., & Harvey, A.G. (2000). Washington, D.C.: American Psychological Association.
9. ^ World Health Organization, "International Classification of Diseases 10", 2010. Accessed Jun 12, 2013 from http://apps.who.int/classifications/icd10/browse/2010/en#/F43.0