Acute Stress Disorder (ASD) Diagnosis: An Essential Guide for Clinicians

Introduction

Acute Stress Disorder (ASD) emerged as a distinct diagnostic entity in 1994 with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This classification was introduced to address the needs of individuals experiencing acute trauma who, in the early stages of their condition, were often excluded from insurance coverage. Furthermore, it aimed to identify individuals at risk of developing post-traumatic stress disorder (PTSD) and facilitate timely interventions.

ASD is characterized by acute stress reactions (ASRs) that manifest between three days and four weeks following a traumatic event. When ASR symptoms persist beyond four weeks, the diagnosis may shift to post-traumatic stress disorder (PTSD). The establishment of ASD sought to accurately categorize ASRs that were previously overlooked or misdiagnosed as adjustment disorders. Notably, the DSM-5, while retaining dissociative symptoms as a diagnostic criterion, removed the requirement for their presence for an ASD diagnosis.

The DSM-5, published in 2013, significantly reorganized diagnostic categories, moving ASD from anxiety disorders to the newly defined category of trauma and stressor-related disorders. This change underscored the unique nature of ASD. A key distinction from DSM-IV is the elimination of dissociative symptoms as a mandatory criterion for ASD diagnosis in DSM-5.

This article provides a comprehensive overview of acute stress disorder, encompassing its etiology, epidemiology, pathophysiology, diagnostic procedures, management strategies, prognosis, and the crucial role of interprofessional collaboration in optimizing patient outcomes.

Etiology of Acute Stress Disorder

Survey data indicates that a significant proportion of the general population, ranging from 20% to 90%, will encounter at least one severely stressful event during their lifetime. Despite this high exposure rate, only a smaller percentage, between 1.3% and 11.2%, progress to develop acute stress disorder (ASD) and potentially long-term conditions like PTSD.

Risk Factors for ASD

Research on specific risk factors for ASD development following trauma remains limited. However, given the close relationship between ASD and PTSD, risk factors identified for PTSD are likely relevant to ASD as well. Drawing on meta-analyses by Ozer et al. and Brewin et al., Sareen J. categorized these risk factors into pretrauma, peritrauma, and posttrauma categories:

1. Pretrauma Factors:
   • Female sex
   • Intellectual disability
   • Lower educational attainment
   • Prior history of traumatic experiences
   • Pre-existing psychiatric disorders
   • Personality disorders
   • Genetic predispositions
2. Peritrauma Factors:
   • Severity of the traumatic event
   • Experiences of assault
   • Rape
   • Physical injury sustained during the trauma
3. Posttrauma Factors:
   • Initial diagnosis of Acute Stress Disorder (ASD)
   • Elevated heart rate (tachycardia)
   • Lower socioeconomic status
   • Severity of physical pain post-trauma
   • Intensive Care Unit (ICU) admission
   • Traumatic brain injury (TBI)
   • Presence of dissociative symptoms
   • Physical disability resulting from the trauma
   • Subsequent stressful life events

Epidemiology of ASD

Although Acute Stress Disorder (ASD) was formally recognized in DSM-IV two decades ago, epidemiological data, particularly regarding its prevalence in the general population, remains scarce. While ASD is distinguished from PTSD as a separate diagnosis, the primary differentiating factor is the duration of ASR symptoms, which complicates precise prevalence measurements for ASD. Reported ASD prevalence varies widely depending on the study methodology and the nature of the traumatic event studied. Studies conducted less than one week post-injury have reported prevalence rates ranging from 24.0% to 24.6%, while studies conducted 1 to 2 weeks post-injury show a range of 11.7% to 40.6%.

Epidemiological investigations in specific populations provide further insights. A 2018 meta-analysis by Wenjie Dai et al., focusing on ASD prevalence after road traffic accidents, reported a pooled prevalence of 15.81% (95% CI: 8.27-25.14%) across thirteen studies in eight countries, encompassing 2989 accident survivors. These findings highlight the importance of recognizing and addressing early ASR symptoms. Among children (aged 7 to 17 years) presenting to emergency rooms after trauma, ASD prevalence was found to be 14.2% within two weeks, while PTSD prevalence at nine weeks was 9.6%. In postpartum research, mothers of preterm infants exhibited significantly higher rates of ASD compared to mothers of term infants (14.9% versus 0%, 95% CI: 2.16; 617.61, OR: 36.5).

Pathophysiology of Acute Stress Disorder

The precise mechanisms that determine why some individuals recover from traumatic events while others develop acute stress disorder (ASD) are not fully understood. Current models explaining responses to trauma largely center on “fear conditioning,” a form of Pavlovian learning. In fear conditioning, a traumatic stimulus (e.g., an explosion) becomes associated with a neutral stimulus (e.g., a specific smell) or context (e.g., nighttime). Subsequently, exposure to the neutral stimulus or context alone can trigger fear responses, even without the presence of the original traumatic stimulus.

Adaptive recovery in most individuals involves “extinction learning,” a gradual reduction in fear responses to the traumatic stimulus over time. Failure of this extinction mechanism can lead to the persistent re-experiencing of fearful symptoms characteristic of ASD and PTSD.

Functional magnetic resonance imaging (fMRI) studies in PTSD patients have revealed altered brain activity patterns, including hypoactivity in the frontal cortex and hyperactivity in the temporal cortex, suggesting a link between PTSD and neural function. More recent research has indicated hyperactivation in the superior prefrontal and cingulate cortex and medial posterior precuneus in PTSD patients.

History and Physical Examination for ASD Diagnosis

The American Psychiatric Association’s DSM-5 outlines specific diagnostic criteria for acute stress disorder (ASD):

• Criterion A: Exposure to a Traumatic Event: The individual must have been exposed to actual or threatened death, serious injury, or sexual violence, experienced directly, witnessed in person, learned occurred to a close family member or close friend, or experienced repeated or extreme exposure to aversive details of traumatic events.

• Criterion B: Presence of Intrusion, Negative Mood, Dissociative, Avoidance, and Arousal Symptoms: The individual must exhibit at least eight symptoms from the following categories:

  1. Intrusion Symptoms:
     • Recurrent, involuntary, and intrusive distressing memories of the traumatic event. In children, this may manifest as repetitive play in which themes or aspects of the traumatic event(s) are expressed.
     • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). In children, there may be frightening dreams without recognizable content.
     • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.
     • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
     • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  2. Negative Mood:
     • Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings).
  3. Dissociative Symptoms:
     • An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
     • Inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia and not due to other factors such as head injury, alcohol, or drugs).
  4. Avoidance Symptoms:
     • Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
     • 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(s).
  5. Arousal Symptoms:
     • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
     • Irritable behavior and angry outbursts (typically with little or no provocation), expressed as verbal or physical aggression toward people or objects.
     • Hypervigilance.
     • Problems with concentration.
     • Exaggerated startle response.

• Criterion C, D, and E: Duration and Clinical Significance: Symptoms must last from 3 days to 1 month after trauma exposure, cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, and not be attributable to the physiological effects of a substance or another medical condition.

Evaluation and Diagnostic Tools for ASD

Acute stress disorder (ASD) is primarily diagnosed clinically, based on a comprehensive history and physical examination, despite potential physiological manifestations and fMRI abnormalities. Currently, there are no specific laboratory or radiographic tests to definitively diagnose ASD. Careful behavioral observation and attentive listening to the patient’s narrative are crucial components of the evaluation process. It’s important to recognize that many patients may not fully express their feelings and experiences in an initial evaluation session, necessitating follow-up appointments for a complete assessment.

Validated psychometric questionnaires are available to aid in ASD evaluation for both children and adults. The Child Stress Reaction Checklist (CSRS) is a brief, 10-minute tool designed to assess symptoms of ASD and PTSD in children aged 2 to 18 years. For adults, the Acute Stress Disorder Scale (ASDS) is a specifically designed self-report questionnaire for ASD assessment.

Treatment and Management Strategies for ASD

General Management Measures

• Patient Safety: Ensuring the patient’s immediate safety post-trauma and providing information on accessing emergency assistance, including food and shelter.
• Emotional Support: Providing emotional comfort through social networks like friends and family. Healthcare providers can offer additional support by explaining ASD prognosis, course, and coping mechanisms.
• Practical Support: Assisting patients with practical needs in the aftermath of trauma, such as police reporting, healthcare access, work leave arrangements, and navigating health insurance. For trauma-related disabilities, coordinating multimodal medical support is essential.
• Follow-up Care: Regular follow-up visits (for up to six months) are recommended for individuals who have experienced significant traumatic events to monitor for symptom development and provide ongoing support.
• Suicide Risk Assessment: Routine assessment for suicidality is crucial at each patient encounter, particularly for those with pre-existing suicide risk factors or comorbid psychiatric conditions like depression.

Psychotherapy

Trauma-focused Cognitive Behavioral Therapy (CBT) is the recommended psychotherapy approach for acute stress disorder (ASD). CBT interventions have demonstrated efficacy in reducing the risk of subsequent PTSD development. This evidence-based treatment can be delivered through various modalities, including internet-based platforms, in-person sessions, or telephone consultations. Trauma-focused CBT addresses trauma psychology education, symptom management techniques, identification and modification of cognitive distortions, and exposure therapy. Exposure therapy, a core CBT component, involves controlled exposure to trauma-related stimuli to facilitate fear extinction, mirroring the natural recovery process discussed in pathophysiology. Exposure therapy is considered the standard of care for both ASD and PTSD. While temporary symptom exacerbation is possible, it is not more frequent than with other treatment approaches. Psychological debriefing, involving detailed recounting of the trauma and associated feelings within the first 72 hours, is widely practiced but has not shown to be effective in PTSD prevention and is generally discouraged for routine ASD management. Crisis intervention methods focusing on adaptive coping strategies and discouraging maladaptive behaviors like alcohol use are also important.

Pharmacotherapy

Currently, robust evidence supporting pharmacotherapy for acute stress disorder (ASD) is lacking. Serotonin reuptake inhibitors (SRIs) and propranolol have been investigated for ASD prevention and treatment, but evidence of efficacy is limited. Pharmacotherapy recommendations for ASD are largely extrapolated from PTSD research, given the clinical similarities and greater availability of randomized controlled trials (RCTs) in PTSD. Pharmacological interventions in PTSD have shown more effectiveness in alleviating mood symptoms compared to core PTSD symptoms like intrusive memories and avoidance behaviors.

Other Treatment Modalities

Electroconvulsive therapy (ECT) has shown potential benefits for PTSD patients with co-occurring depression, effectively reducing symptoms of both conditions. The memory disruption associated with ECT is hypothesized to be therapeutically beneficial in severe PTSD cases. Clinical trials evaluating mood stabilizers (e.g., topiramate, tiagabine) in PTSD are limited, with studies showing either no benefit over placebo or small effect sizes. Case reports suggest that lamotrigine and gabapentin may be effective for PTSD-related nightmares and flashbacks, but further research is needed to confirm these findings.

Symptom-Specific Treatments

Symptom-specific pharmacological treatments may be considered to address specific ASD symptoms, such as sleep disturbances or anxiety, while awaiting the effects of psychotherapy. However, these are generally considered adjunctive to primary trauma-focused interventions.

Differential Diagnosis of ASD

The differential diagnosis for acute stress disorder (ASD) includes conditions with overlapping symptom profiles:

• Post-traumatic Stress Disorder (PTSD): Distinguished by symptom duration exceeding one month.
• Adjustment Disorder: Symptom presentation does not meet full ASD criteria.
• Brief Psychotic Disorder: Also characterized by symptom duration less than one month and stress-related onset, but psychotic symptoms are typically more generalized and less severe than in ASD.
• Organic Disorders: Including mild traumatic brain injury (TBI), which can be challenging to differentiate neurologically, and brain tumors, which may present with focal neurological deficits or headaches.
• Mood Disorders: Such as major depressive disorder, where the predominant features are low mood and depressive symptoms, rather than trauma-related symptom clusters.

Pertinent Studies and Ongoing Research

While psychotherapy remains the primary treatment for PTSD/ASD, its efficacy is not consistently high, leading to chronic illness in some individuals. This underscores the need for exploring novel therapeutic approaches. Psychedelics, such as ketamine, psilocybin, and 3,4-methylenedioxymethamphetamine (MDMA), are emerging as promising agents in PTSD treatment research. The FDA has granted breakthrough therapy designations to both MDMA and psilocybin for PTSD and depression treatment. MDMA-assisted psychotherapy is currently under investigation and may be considered for FDA approval in the near future.

Treatment Planning for ASD

For patients diagnosed with acute stress disorder (ASD), trauma-focused cognitive behavioral therapy is the first-line treatment approach, as oral pharmacotherapies have shown limited primary benefit in ASD. Pharmacological studies have primarily focused on secondary prevention of PTSD rather than direct ASD treatment. However, oral medications are established as effective in managing PTSD symptoms, and treatment strategies are often adapted for ASD management based on PTSD evidence.

Adult Pharmacotherapy Options

• Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs like sertraline, paroxetine, and fluoxetine are used in PTSD treatment, with sertraline and paroxetine being FDA-approved for this indication. Example dosing regimens are provided in the original article for fluoxetine and paroxetine.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine extended-release has demonstrated effectiveness in PTSD treatment. Example dosing information is available in the original article.
• Second-Generation Antipsychotics (SGAs): Risperidone and quetiapine have evidence for use as adjunctive therapy in PTSD, particularly for managing specific symptom clusters or comorbid conditions.
• Alpha-1 Selective Adrenergic Blockers: Prazosin, an antihypertensive medication, is used to address sleep disturbances, particularly nightmares, in PTSD and ASD, often as monotherapy or in combination with an SRI.

Toxicity, Adverse Effects, and Management

SRI Side Effects: SRIs carry potential side effects including long QT syndrome, SIADH, hyponatremia, increased suicide risk (especially in children and adolescents), seizures, bleeding risk, sexual dysfunction, gastrointestinal issues, and serotonin syndrome. Prescription and monitoring by qualified professionals are essential. Sexual dysfunction is a common side effect, and management strategies including dose adjustment, medication switching, or augmentation with bupropion may be considered under medical guidance. Abrupt SRI discontinuation can lead to withdrawal symptoms, necessitating gradual tapering. SRIs should be avoided in patients with bipolar disorder due to the risk of inducing mania.

SGA Side Effects: SGAs can cause long QT syndrome, metabolic syndrome (particularly with olanzapine and clozapine), anticholinergic effects, and extrapyramidal symptoms (EPS). EPS, though less common with SGAs than first-generation antipsychotics, can manifest as acute dystonia, akathisia, parkinsonism, and tardive dyskinesia. Risperidone can cause hyperprolactinemia, and clozapine carries a risk of dose-related seizures and neutropenia, requiring regular neutrophil count monitoring.

Prazosin Side Effects: Prazosin may cause first-dose orthostatic hypotension, dizziness, fatigue, and headache. Caution is advised in patients with hepatic impairment.

Prognosis of ASD

Acute stress disorder (ASD) is a significant predictor of later PTSD development. Abnormal fMRI findings in the acute phase are associated with increased PTSD symptom severity over time. DSM-5 data indicates that approximately half of PTSD patients achieve remission within three months. Longer-term pharmacotherapy (6 months to 1 year or more) is often recommended to minimize relapse risk. While most PTSD patients recover within a few years, a substantial proportion (at least one-third) remain symptomatic for over two years and are at increased risk of substance abuse.

Individuals with ASD have a significantly elevated risk of suicide attempts (24 times higher) and all-cause mortality (two times higher) compared to those without ASD. Avoidance behaviors related to trauma reminders can persist and lead to functional impairments, including job loss, financial difficulties, and social relationship disruptions, further complicating emotional well-being.

Complications of ASD

Acute stress disorder (ASD) can increase the risk of developing various psychiatric complications:

• Mood Disorders: Including depressive disorders (with or without suicidal ideation), anxiety disorders, and panic disorder.
• Substance Use Disorders: Including alcohol use disorder and illicit drug dependence.

Deterrence and Patient Education

Patient education plays a crucial role in stress disorder management. It is important to educate patients that strong emotional responses to trauma are common and typically resolve within days to weeks, not becoming chronic conditions in most cases. Patients should be advised to avoid trauma-related triggers (e.g., media), prioritize social support and family time, and practice patience with the recovery process. Active patient participation in treatment planning, therapy choices, and understanding potential treatment side effects is essential for informed decision-making and treatment adherence.

Enhancing Healthcare Team Outcomes through Interprofessional Collaboration

Interprofessional communication and social services are vital in managing acute stress disorder (ASD). Given the increased risks of suicide and mortality associated with ASD, and the potential for progression to chronic PTSD, a collaborative, interprofessional care approach is essential. This team may include professionals from emergency medicine, psychiatry, orthopedics, neurosurgery, psychology, nursing, pharmacy, and social work. Each discipline contributes specialized expertise to the comprehensive care plan, emphasizing open communication and shared decision-making.

Interprofessional teamwork, facilitated by mutual respect for team member roles and efficient communication strategies, is increasingly recognized as crucial, particularly within the context of affordable care initiatives promoting improved care coordination. Social workers play a key role in providing mental health services, referrals, care coordination, and ongoing follow-up, particularly for patients with complex mental health and substance use comorbidities.

By effectively utilizing an interprofessional model in ASD treatment, involving diverse specialties and disciplines, patient outcomes can be significantly improved, while mitigating the potential for adverse events and relapse.

Review Questions

(Note: Review questions are not included as per instructions to only include title and content)

References

(Note: References are included as in the original article)

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Disclosure: Mehdi Fanai declares no relevant financial relationships with ineligible companies.

Disclosure: Moien AB Khan declares no relevant financial relationships with ineligible companies.