Acute Stress Disorder DSM-5 308.3 (F43.0)
DSM-5 category: Trauma and Stressor-Related Disorders
Introduction
The DSM-5 describes acute stress disorder as the development of specific fear behaviors that last from 3 days to 1 month after a traumatic event. These symptoms always occur after the patient has experienced or witnessed death or threat of death, serious injury or sexual assault. Examples of traumatic events from the DSM-5 include physical attack, physical abuse, mugging, active combat, sexual violence, natural disaster and serious accidents. Acute stress disorder can also result from hearing about the violent or accidental trauma of a loved one, or repeated exposure to traumatic events (American Psychiatric Association, 2013). Outcomes of acute stress disorder are best when the victim has access to immediate crisis management therapy. When crisis intervention is unavailable, acceptance and commitment therapy is an effective therapeutic intervention.
Symptoms of Acute Stress Disorder
Individuals with acute stress disorder experience intrusive thoughts or memories of the traumatic event. Distressing dreams about the trauma and general sleep disturbances are also common. The patient may also experience flashbacks or distress when exposed to triggers of the traumatic event. Conversely, the patient may “block out” or be unable to remember parts or the entire traumatic event. Many patients avoid external reminders, such as places or people related to the traumatic event. In addition to these intrusive symptoms, patients experience a negative mood. They may feel depressed, anxious, angry or guilty and unable to feel happy. Additionally, the patient may have unrealistic feelings or beliefs about the event. For example, believing that a plane crash could have been prevented had the patient done something differently. Hyper vigilance, problems with concentration and exaggerated startle response are also common. Additionally, the DSM-5 explains that physical symptoms, such as headaches, dizziness and sensitivity to light or sound may occur, even without injury (American Psychiatric Association, 2013).
Acute Stress Disorder in Children
The DSM-5 explains that in children, symptoms of acute stress disorder may manifest through play, where themes related to the trauma may emerge. Additionally, children may experience nightmares, often with no memory of the content (American Psychiatric Association, 2013). Children also tend to experience physical symptoms such as nausea, vomiting, headaches and vague pain. Emotional symptoms include nervousness, fear, clinging to caregivers, irritability and withdrawn mood (Foa, 2009). Children may also be poorly behaved, whiny or demand more attention than usual (American Psychiatric Association, 2013).
Social Consequences of Acute Stress Disorder
Acute stress disorder affects every area of the patient’s life. The DSM-5 explains that the depressive mood associated with acute stress disorder can cause patients to have difficulty feeling joy, happiness satisfaction or sexual arousal. This can create problems in romantic relationships. Avoidance behaviors may lead to being late for work and appointments, or missing them altogether. Nightmares and sleep problems can further mood problems and lead to being less focused and pervasively tired. Impulsive and reckless behaviors, such as gambling, substance abuse and dangerous driving may occur (American Psychiatric Association, 2013). Substance use after experiencing trauma is extremely common. In some cases, alcohol or drug abuse may persist after the designated time period for acute stress disorder (Stein and Moriarty, 2013).
Prevalence of Acute Stress Disorder
The prevalence of acute stress disorder is difficult to determine because response to trauma can vary depending on the nature of the event. The DSM-5 estimates that prevalence among those who experiences an interpersonal traumatic event, such as mugging or sexual assault is as high as 50%. The prevalence for other traumatic and catastrophic events is less than 20% (American Psychiatric Association, 2013)
Distinction Between Acute Stress Disorder and Post Traumatic Stress Syndrome
The symptoms of acute stress disorder are very similar to the symptoms of post traumatic stress disorder (PTSD). The most important diagnostic distinction between the two disorders is that acute stress disorder persists for a period of one month or less after a traumatic event. PTSD symptoms can persist for months or years (Foa, 2009). The DSM-5 estimates that half of patients experiencing PTSD initially presented with acute stress disorder (American Psychiatric Association, 2013).
Another important distinction between acute stress disorder and PTSD is the diagnostic emphasis of dissociative symptoms present in acute stress disorder. Dissociative symptoms, such as feeling detached from an experience, feeling numb, or being unable to remember traumatic events are believed to impede the victim’s ability to deal with the problem, even when treated shortly after the trauma. These symptoms are a predictor of PTSD because the victim may experience symptoms more severely once dissociative symptoms cease (Bryant, et al., 2011).
Treatment of Acute Stress Disorder
The primary treatment goal of acute stress disorder is to prevent the disorder from developing into PSTD, which is chronic and involves long-term social and occupational impairment. Debriefing or crisis therapy is one method of quickly treating acute stress disorder. The goals of crisis therapy are to promote a sense of safety after a trauma, calm the victim, promote a sense of self-efficacy, encourage community or victim connectedness, and instill a sense of hope. Debriefing can be done in a variety of ways. When an entire community is affected by a catastrophe, such as a school shooting or natural disaster, group therapy is helpful. During individual therapy, victims of trauma can share their personal narrative related to the traumatic event and quickly develop coping skills (Foa, 2009).
When crisis therapy is unavailable or does not effectively eliminate acute stress disorder, acceptance and commitment therapy is a method of psychotherapy that promotes the use of mindfulness to accept the traumatic event. Mindfulness describes the act of living in the present moment. Most symptoms of acute stress disorder keep the victim’s thoughts and feelings in the moment of the trauma rather than present circumstances or future possibilities. Mindfulness also promotes a sense of acceptance. Patients are coached to recognize and accept the pain associated with their traumatic experience (Walser and Westrup, 2007). Once symptoms of acute stress disorder are managed, patients must learn to use stress management and reduction techniques to prevent PTSD from developing at a later time. Common components of stress management and reduction include thought stopping, relaxation breathing, assertiveness training, behavior rehearsal and psycho-education (Simpson and Moriarty, 2013).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bryant, R.A., Friedman, M.J., Spiegal, D., Ursano, R. & Strain, J. (2011) A review of acute stress disorder in DSM-5 Depression and Anxiety. 28 (9): 802-817
Foa, E.B. (2009) Effective treatments for PTSD : practice guidelines from the International Society for Traumatic Stress Studies. New York : Guilford Press.
Simpson, J. & Moriarty, G.L. (2013).Multimodal Treatment of Acute Psychiatric Illness : A Guide for Hospital Diversion. New York : Columbia University Press.
Walser, R.D. & Westrup, D. (2007). Acceptance & commitment therapy for the treatment of post-traumatic stress disorder & trauma-related problems : a practitioner's guide to using mindfulness & acceptance strategies. Oakland, Calif. : New Harbinger Publications.
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