Johns Hopkins Psychiatry Guide

Acute Stress Disorder

Katie W. Hsih, Dean MacKinnon, M.D.


  • Trauma- and stressor-related disorder with onset 3 days to 1 month after a traumatic event (direct exposure or indirectly experienced), characterized by intrusive memories, avoidance of associated stimuli, and changes in mood and arousal that impair daily functioning


  • Prevalence: occurs in 20-50% of victims or witnesses of trauma involving interpersonal assault (e.g. rape, witnessing a shooting), < 20% following trauma without interpersonal assault (e.g. motor vehicle accidents, traumatic brain injury, severe burns)
  • Risk factors: prior trauma, prior mental disorder, female gender, high neuroticism, avoidant coping, hyperarousal (e.g. elevated startle response)
  • Symptoms can vary across culture (e.g. ataque de nervios among Latin Americans)


Clinical Presentation

  • Re-experiencing of the traumatic event through intrusive and distressing memories, nightmares, flashbacks
  • Avoidance of reminders of trauma, which can induce emotional numbing as well as heightened reactivity
  • Catastrophic thoughts about role in traumatic event, response to exposure, or likelihood of future harm
  • Inability to experience positive emotions, but frequent negative emotions (e.g. fear, sadness, anger, guilt, shame)
  • Other signs: hyperarousal, poor concentration, insomnia, irritability, impulsive behavior

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, Acute Stress Disorder Interview, Acute Stress Disorder Scale (more useful for assessing severity).
  • Elevated ASD or PTSD scale scores suggest increased risk for lasting PTSD symptoms.

Differential Diagnosis



  • Limited studies evaluating efficacy of treatment for ASD
  • Goals: reduce symptoms, improve functioning, rehabilitate sense of security, prevent PTSD
  • Consider early intervention with trauma-focused cognitive-behavioral therapy (CBT).


  • Antidepressants may reduce intrusion symptoms, avoidance, dissociation, hyperarousal, and comorbid psychiatric disorders.
  • Anticonvulsants may reduce intrusion symptoms.
  • Morphine for pain management during a critical illness or immediately following a physical trauma (including burns) may help prevent PTSD.
  • Stress-dose corticosteroids (e.g., hydrocortisone) may prevent PTSD in the context of critical illnesses like septic shock or during/following cardiac surgery.
  • Avoid acute use of benzodiazepines, which may paradoxically increase the risk for long-term PTSD symptoms.


  • Trauma-focused CBT
    • Patient education: normalize the stress response, increase the expectation of recovery
    • Exposure: in-imagination (reliving) and in vivo exposure to enable extinction learning; contraindicated with extreme avoidance/dissociation, suicidal risk, acute grief
    • Cognitive processing: reframe maladaptive appraisals about past trauma and future triggers
  • Address salient interpersonal issues such as changes in relationships, loss of trust, anger and aggression, as well as generalization of fears and threats.
  • Administer 2 weeks after exposure for 6 weekly individual sessions.
  • Time therapy with regard for other trauma-related events (e.g. pain, surgery, legal complications).


  • 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.
  • 25-50% of ASD cases will resolve without formal intervention.


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


  • ASD can progress to if symptoms do not resolve within 1 month of exposure.


  • ASD was introduced in the DSM-IV to identify patients at risk for PTSD; criteria were narrower (notably requiring dissociative symptoms to be present) and did not reliably predict PTSD.
  • There is still uncertainty regarding factors that predict ASD or interventions that prevent PTSD.


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Last updated: October 17, 2014