Acute Stress Disorder

Key points

• Acute stress disorder (ASD) describes acute stress reactions lasting from three days to four weeks after a traumatic event; reactions lasting longer than four weeks can meet the criteria for post-traumatic stress disorder (PTSD).
• The diagnosis is clinical: there is no validated laboratory or imaging test.
• Trauma-focused cognitive behavioral therapy (CBT) is the treatment of choice, and exposure therapy is the standard of care.
• There is no high-quality evidence for any medication in ASD; most drug recommendations are drawn from PTSD research.
• Routine debriefing in the first 72 hours is discouraged because it has not been shown to prevent PTSD.

Overview

This StatPearls chapter reviews the causes, diagnosis, treatment and prognosis of acute stress disorder. ASD was introduced in DSM-IV in 1994; with DSM-5 in 2013 it moved to the new trauma and stressor-related disorders category, and dissociative symptoms are no longer required for the diagnosis. The main takeaway is that trauma-focused CBT, together with safety, support and follow-up, is the first-line approach, while medication has a limited role.

Diagnostic criteria

As summarized in the chapter, DSM-5 requires exposure to a traumatic event plus more than eight symptoms from five categories: intrusion (recurrent distressing memories, dreams, flashbacks), negative mood, dissociation, avoidance and arousal (sleep problems, irritability, hypervigilance, distractibility, unusually strong reactions to sudden events). Symptoms must last between three days and four weeks, cause significant functional impairment and not be due to substances or another medical condition such as traumatic brain injury. Validated questionnaires exist: a checklist for children aged 2 to 18 years that takes about ten minutes, and the Acute Stress Disorder Scale for adults.

Frequency and risk factors

Survey studies suggest that 20% to 90% of the general population experience at least one extreme stressful event. Reported ASD prevalence varies widely: 24.0% to 24.6% less than one week after injury and 11.7% to 40.6% at one to two weeks; a 2018 meta-analysis of road traffic accident survivors found a pooled prevalence of 15.81%. Risk factors, largely extrapolated from PTSD, include female gender, previous trauma and psychiatric history before the event; trauma severity, assault, rape and physical injury during it; and pain severity, ICU stay, brain injury and later life stress afterwards.

Management

General measures include ensuring the patient is safe, emotional and practical support, regular follow-up for six months after a significant traumatic event, and assessment of suicidality at every visit. Trauma-focused CBT can reduce the risk of developing PTSD and can be delivered in person, by phone or online. Serotonin reuptake inhibitors and propranolol showed little evidence of efficacy for preventing or treating ASD. For PTSD, fluoxetine, sertraline, paroxetine and venlafaxine have the strongest evidence and are first-line, benzodiazepines are not recommended, and prazosin has shown efficacy for sleep disturbance.

Prognosis

ASD is strongly associated with later PTSD. According to DSM-5, PTSD remits within three months in about half of patients, while at least one-third remain symptomatic for more than two years. Patients with ASD are 24 times more likely to die by suicide, and one study found all-cause mortality twice as high in patients diagnosed with a stress disorder. Persistent avoidance can lead to job loss, financial hardship and relationship problems.

Frequently asked questions

How is acute stress disorder different from PTSD?

The difference is mainly duration: ASD covers symptoms from three days to four weeks after the trauma, while symptoms lasting beyond four weeks can meet PTSD criteria.

Is medication needed for acute stress disorder?

Not as first-line treatment: the chapter recommends trauma-focused CBT, as there is no high-quality evidence for any drug in ASD.

Does debriefing right after the trauma help?

Studies have not shown that debriefing in the first 72 hours prevents PTSD, so it is discouraged as a routine intervention.

Source

Fanai M, Khan MAB. Acute Stress Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; last updated July 10, 2023. PMID: 32809650. Distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 licence (CC BY-NC-ND 4.0). This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.