Acute Stress Disorder

Stephen E. Ghazikhanian, M.D., Anne E. Ruble, M.D., M.P.H.

DEFINITION

  • Trauma-related disorder lasting 3 days to 1 month after exposure to a traumatic event (threatened death, serious injury, or sexual violence), characterized by intrusive memories, avoidance of associated stimuli, negative mood, hyperarousal, and/or dissociative symptoms that impair daily functioning. [1]

EPIDEMIOLOGY

  • Prevalence: occurs in 19-50% of victims or witnesses of trauma involving interpersonal assault (e.g., rape, witnessing a shooting[2][3][4][5]), < 20% following trauma without interpersonal assault (e.g. motor vehicle accidents[6], traumatic brain injury[7], severe burns[8])
  • Risk factors[9][10][11]: preexisting psychiatric illness, prior trauma, female gender, high neuroticism, poor social supports, avoidant coping
  • Symptom profile can vary across cultures, particularly as it relates to dissociative symptoms, nightmares, avoidance, and somatic symptoms (e.g., ataque de nervios among Latin Americans).[12][13]

DIAGNOSIS

Clinical Presentation

  • Instrusion Symptoms: Psychological distress from recurrent and intrusive reminders of the trauma including memories, nightmares, flashbacks, and/or internal/external cues that symbolize/represent the trauma
  • Negative Mood: Inability to experience positive emotions; often have negative emotions (e.g., fear, sadness, anger, guilt, shame)
  • Dissociative Symptoms: experiencing altered sense of reality or oneself; inability to remember significant aspect of the trauma (i.e., dissociative amnesia)
  • Avoidance Symptoms: avoid distressing thoughts, memories, feelings, or other external reminders (e.g., people, places, things) of trauma of reminders of trauma, which can induce emotional numbing as well as heightened reactivity
  • Arousal Symptoms: sleep disturbance, increased irritability and anger outbursts, hypervigilance, poor concentration, exaggerated startle response.
  • Other Associated Features: catastrophic thinking[14][15], excessive guilt (particularly as it relates to trauma)[16][17], panic attacks[18][19], impulsive behaviors (e.g., reckless driving), postconcussive symptoms even in those without brain injury[20][21]

Tests and Procedures

  • Acute stress disorder (ASD) is a clinical diagnosis based on history and physical without a diagnostic laboratory test.
  • Screen for exposure to traumatic event considering the nature of the event and the patient’s response.
  • Identify comorbidities; rule out other explanations for symptoms.
  • Structured measurements:
    • Stanford Acute Stress Reaction Questionnaire[22]: 30-item self-report inventory
    • Acute Stress Disorder Interview[23]: 19-item structured clinical interview with high sensitivity, specificity, test-retest reliability and internal consistency
    • Acute Stress Disorder Scale[24] self-report inventory most useful for assessing symptom severity and identify those at increased risk for developing PTSD symptoms.

Differential Diagnosis

  • PTSD : if symptoms have been present for more than a month
  • Adjustment disorder : if response to trauma is outside symptom criteria described above (e.g,. depression, guilt, rumination over trauma as opposed to involuntary intrusive memories) or symptoms are in response to non-traumatic stressor (i.e,. one which does not involve exposure to threatened death, serious injury, or sexual violence; e.g., break-up, loss of job)
  • Traumatic brain injury (can occur concurrently)
  • Effects of analgesic medication or substance use
  • Other psychiatric illnesses (panic disorder, dissociative disorder, OCD, psychotic disorders)

TREATMENT

General

  • Treatment is aimed at reducing symptoms and preventing development of PTSD.
  • General Measures[25][26]: Ensure patient safety, provide emotional and practical support as needed, maintain regular follow-up visits (particularly in the first 6 months after trauma), and screen for suicidality, particularly in those with comorbid psychiatric illnesses.
  • First-line intervention is trauma-focused cognitive-behavioral therapy (CBT).

Pharmacotherapy

  • Adjunctive use of SSRIs/SNRIs in patients with comorbid anxiety or depressive disorders, and/or significant psychosocial impairment or inability to tolerate psychotherapy. Most evidence for symptom reduction comes from PTSD population[27][28][29].
  • Avoid acute use of benzodiazepines, which have been found to be ineffective with significant adverse effects and worse outcomes in patients with PTSD.[30]There is insufficient evidence about benzodiazepine use in ASD.
  • Propranolol may reduce sympathetic symptoms.[31]
  • Second-generation antipsychotics can be considered in refractory cases either as augmentation or monotherapy.[32]
  • Morphine for pain management during a critical illness or immediately following a physical trauma may help prevent PTSD.[33] This may be due to better pain management.[34]
  • Hydrocortisone may be helpful in preventing PTSD in the context of critical illnesses like septic shock or during/following cardiac surgery.[35][36]

Psychotherapy

  • Trauma-focused CBT is effective in reducing symptoms of ASD and risk of developing PTSD [37][38].
  • Components of Trauma-Focused CBT:
    • Patient Education: normalize the stress response, identify reminders of trauma as non-dangerous, and increase the expectation of recovery
    • Exposure: Imaginal and in vivo exposure to enable extinction learning (i.e., decrease response to stimulus that does not come with reinforcement)
      • Contraindicated/Delayed in those with: extreme avoidance or dissociative responses, anger outburts, acute grief, ongoing PTSD symptoms from prior trauma, increase suicide risk (e.g., ongoing suicidality), borderline or psychotic features.
    • Cognitive Restructuring: reframe maladaptive appraisals about past trauma and future triggers
  • Treatment initiation is 2 weeks after traumatic event. Can consider beginning sooner if more acute symptoms are present, or delaying if there are ongoing stressors. (e.g., pain, surgery, legal complications, homelessness).
  • Psychological debriefing (the recollection and rearticulation of traumatic events typically in group format) is NOT recommended and has not been shown to be efficacious.[39][40]

Other

  • If patient is in acute distress immediately after exposure, stabilize with supportive care until psychologically and physiologically safe.
    • Probing questions or inadvertent reminders of the traumatic event may exacerbate distress.
    • After stabilization, establish education, early intervention, and case management.
    • Encourage reliance on patient’s internal strengths and existing support structures.
  • Address concurrent issues such as depression, suicidality, self-harm, substance abuse.
  • 20-50% of ASD cases will resolve and not become PTSD[41].
    • This is an important point to emphasize with patients, who otherwise may be further distressed by the notion that they are fated to suffer an extended course.

WHEN TO REFER

  • Seek psychiatric care, particularly in cases of continued distress or potential for self-harm.

FOLLOW UP

  • ASD is associated with significant risk for PTSD[41], which is present if symptoms do not resolve within 1 month.

COMMENTS

  • There is still uncertainty regarding factors that predict ASD or interventions that prevent PTSD.

References

  1. American Psychiatric Association, issuing body. Diagnostic and Statistical Manual of Mental Disorders : DSM-5-TR / American Psychiatric Association. 5th edition, text Revision., American Psychiatric Association Publishing, 2022.
  2. Brewin CR, Andrews B, Rose S, et al. Acute stress disorder and posttraumatic stress disorder in victims of violent crime. Am J Psychiatry. 1999;156(3):360-6.  [PMID:10080549]
  3. Classen C, Koopman C, Hales R, et al. Acute stress disorder as a predictor of posttraumatic stress symptoms. Am J Psychiatry. 1998;155(5):620-4.  [PMID:9585712]
  4. Elklit A, Christiansen DM. ASD and PTSD in rape victims. J Interpers Violence. 2010;25(8):1470-88.  [PMID:20068117]
  5. Rahtz E, Bhui K, Smuk M, et al. Violent injury predicts poor psychological outcomes after traumatic injury in a hard-to-reach population: an observational cohort study. BMJ Open. 2017;7(5):e014712.  [PMID:28559457]
  6. Harvey AG, Bryant RA. The relationship between acute stress disorder and posttraumatic stress disorder: a prospective evaluation of motor vehicle accident survivors. J Consult Clin Psychol. 1998;66(3):507-12.  [PMID:9642889]
  7. Harvey AG, Bryant RA. Acute stress disorder after mild traumatic brain injury. J Nerv Ment Dis. 1998;186(6):333-7.  [PMID:9653416]
  8. Harvey AG, Bryant RA. Acute stress disorder across trauma populations. J Nerv Ment Dis. 1999;187(7):443-6.  [PMID:10426466]
  9. Harvey AG, Bryant RA. Predictors of acute stress following mild traumatic brain injury. Brain Inj. 1998;12(2):147-54.  [PMID:9492962]
  10. Harvey AG, Bryant RA. Predictors of acute stress following motor vehicle accidents. J Trauma Stress. 1999;12(3):519-25.  [PMID:10467559]
  11. Barton KA, Blanchard EB, Hickling EJ. Antecedents and consequences of acute stress disorder among motor vehicle accident victims. Behav Res Ther. 1996;34(10):805-13.  [PMID:8952123]
  12. Isserlin L, Zerach G, Solomon Z. Acute stress responses: A review and synthesis of ASD, ASR, and CSR. Am J Orthopsychiatry. 2008;78(4):423-9.  [PMID:19123763]
  13. Hinton DE, Lewis-Fernández R: The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5. Depress Anxiety 28(9):783–801, 2011
  14. Dunmore E, Clark DM, Ehlers A. A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behav Res Ther. 2001;39(9):1063-84.  [PMID:11520012]
  15. Smith K, Bryant RA. The generality of cognitive bias in acute stress disorder. Behav Res Ther. 2000;38(7):709-15.  [PMID:10875192]
  16. Ehlers A, Mayou RA, Bryant B. Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study. Behav Res Ther. 2003;41(1):1-10.  [PMID:12488116]
  17. Warda G, Bryant RA: Cognitive bias in acute stress disorder. Behav Res Ther 36(12):1177–1183, 1998



  18. Bryant RA, Panasetis P. Panic symptoms during trauma and acute stress disorder. Behav Res Ther. 2001;39(8):961-6.  [PMID:11480836]
  19. Nixon RD, Bryant RA. Peritraumatic and persistent panic attacks in acute stress disorder. Behav Res Ther. 2003;41(10):1237-42.  [PMID:12971943]
  20. Bryant R. Post-traumatic stress disorder vs traumatic brain injury. Dialogues Clin Neurosci. 2011;13(3):251-62.  [PMID:22034252]
  21. Meares S, Shores EA, Taylor AJ, et al. Mild traumatic brain injury does not predict acute postconcussion syndrome. J Neurol Neurosurg Psychiatry. 2008;79(3):300-6.  [PMID:17702772]
  22. Cardeña E, Koopman C, Classen C, et al. Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): a valid and reliable measure of acute stress. J Trauma Stress. 2000;13(4):719-34.  [PMID:11109242]
  23. Bryant RA, Harvey AG, Dang ST, Sackville T. (1998). Assessing acute stress disorder: psychometric properties of a structured clinical interview. Psychological Assessment 10(3), 215-220.
  24. Bryant RA, Moulds ML, Guthrie RM. Acute Stress Disorder Scale: a self-report measure of acute stress disorder. Psychol Assess. 2000;12(1):61-8.  [PMID:10752364]
  25. Nash WP, Watson PJ. Review of VA/DOD Clinical Practice Guideline on management of acute stress and interventions to prevent posttraumatic stress disorder. J Rehabil Res Dev. 2012;49(5):637-48.  [PMID:23015576]
  26. Gradus JL, Qin P, Lincoln AK, et al. Acute stress reaction and completed suicide. Int J Epidemiol. 2010;39(6):1478-84.  [PMID:20624822]
  27. Bryant RA. The Current Evidence for Acute Stress Disorder. Curr Psychiatry Rep. 2018;20(12):111.  [PMID:30315408]
  28. Ipser JC, Stein DJ. Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD). Int J Neuropsychopharmacol. 2012;15(6):825-40.  [PMID:21798109]
  29. Bisson JI, Baker A, Dekker W, et al. Evidence-based prescribing for post-traumatic stress disorder. Br J Psychiatry. 2020;216(3):125-126.  [PMID:32345407]
  30. Guina J, Rossetter SR, DeRHODES BJ, et al. Benzodiazepines for PTSD: A Systematic Review and Meta-Analysis. J Psychiatr Pract. 2015;21(4):281-303.  [PMID:26164054]
  31. Argolo FC, Cavalcanti-Ribeiro P, Netto LR, et al. Prevention of posttraumatic stress disorder with propranolol: A meta-analytic review. J Psychosom Res. 2015;79(2):89-93.  [PMID:25972056]
  32. Villarreal G, Hamner MB, Cañive JM, et al. Efficacy of Quetiapine Monotherapy in Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled Trial. Am J Psychiatry. 2016;173(12):1205-1212.  [PMID:27418378]
  33. Holbrook TL, Galarneau MR, Dye JL, et al. Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med. 2010;362(2):110-7.  [PMID:20071700]
  34. Norman SB, Stein MB, Dimsdale JE, et al. Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychol Med. 2008;38(4):533-42.  [PMID:17825121]
  35. Astill Wright L, Sijbrandij M, Sinnerton R, et al. Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis. Transl Psychiatry. 2019;9(1):334.  [PMID:31819037]
  36. Amos T, Stein DJ, Ipser JC. Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2014.  [PMID:25001071]
  37. Bisson JI, Wright LA, Jones KA, et al. Preventing the onset of post traumatic stress disorder. Clin Psychol Rev. 2021;86:102004.  [PMID:33857763]
  38. Kliem S, Kröger C. Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling. Behav Res Ther. 2013;51(11):753-61.  [PMID:24077120]
  39. Rose S, Bisson J, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002.  [PMID:12076399]
  40. Roberts NP, Kitchiner NJ, Kenardy J, et al. Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database Syst Rev. 2009.  [PMID:19588408]
  41. Bryant RA. Acute stress disorder as a predictor of posttraumatic stress disorder: a systematic review. J Clin Psychiatry. 2011;72(2):233-9.  [PMID:21208593]
  42. Fanai M, Khan MAB. Acute Stress Disorder. StatPearls. StatPearls Publishing; 2021.  [PMID:32809650]
  43. Benedek MB, Friedman MJ, Zatzick DF, Ursano RJ. (2009). Guideline watch (March 2009): practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. American Psychiatric Association.
  44. Bryant, R. A. (2017). Acute stress disorder and posttraumatic stress disorder. (pp. 161­-184). Washington, DC, US: American Psychological Association. doi:10.1037/0000019­010
  45. Bryant RA, Harvey AG. Acute stress disorder: a critical review of diagnostic issues. Clin Psychol Rev. 1997;17(7):757-73.  [PMID:9397336]
  46. Bryant RA, Mastrodomenico J, Felmingham KL, et al. Treatment of acute stress disorder: a randomized controlled trial. Arch Gen Psychiatry. 2008;65(6):659-67.  [PMID:18519824]
  47. Bryant RA, Creamer M, O'Donnell M, et al. Acute and Chronic Posttraumatic Stress Symptoms in the Emergence of Posttraumatic Stress Disorder: A Network Analysis. JAMA Psychiatry. 2017;74(2):135-142.  [PMID:28002832]
  48. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319-45.  [PMID:10761279]
  49. Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry. 1996;57(9):390-4.  [PMID:9746445]
  50. Gradus JL. Prevalence and prognosis of stress disorders: a review of the epidemiologic literature. Clin Epidemiol. 2017;9:251-260.  [PMID:28496365]
  51. Guthrie RM, Bryant RA. Auditory startle response in firefighters before and after trauma exposure. Am J Psychiatry. 2005;162(2):283-90.  [PMID:15677592]
  52. Howlett JR, Stein MB. Prevention of Trauma and Stressor-Related Disorders: A Review. Neuropsychopharmacology. 2016;41(1):357-69.  [PMID:26315508]
  53. Kornør H, Winje D, Ekeberg Ø, et al. Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: a systematic review and meta-analysis. BMC Psychiatry. 2008;8:81.  [PMID:18801204]
  54. Nestadt, P.S., Speed, T.J., Keefe, F. J. and Dimsdale, J. E. (2017). “Stress and psychiatry”. In Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Edited by: Sadock, B. J., Sadock, V. A., and Ruiz P.: Philadelphia, PA: Lippincott
  55. Ozer EJ, Best SR, Lipsey TL, et al. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73.  [PMID:12555794]
  56. Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety. 2009;26(12):1086-109.  [PMID:19957280]
  57. Ursano RJ, Bell C, Eth S, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 Suppl):3-31.  [PMID:15617511]
Last updated: August 9, 2025