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Acute Stress Disorder (ASD)

By John H. Greist, MD, Clinical Professor of Psychiatry; Distinguished Senior Scientist, University of Wisconsin School of Medicine and Public Health; Madison Institute of Medicine

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Acute stress disorder is a brief period of intrusive recollections occurring within 4 wk of witnessing or experiencing an overwhelming traumatic event.

In acute stress disorder, people have been through a traumatic event, experiencing it directly (eg, as a serious injury or the threat of death) or indirectly (eg, witnessing events happening to others, learning of events that occurred to close family members or friends). People have recurring recollections of the trauma, avoid stimuli that remind them of the trauma, and have increased arousal. Symptoms begin within 4 wk of the traumatic event and last a minimum of 3 days but, unlike posttraumatic stress disorder (see Posttraumatic Stress Disorder (PTSD)), last no more than 1 mo. People with this disorder may experience dissociative symptoms.


  • Clinical criteria

Diagnosis is based on criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); these criteria include intrusion symptoms, negative mood, and dissociative, avoidance, and arousal symptoms.

To meet the criteria for diagnosis, patients must have been exposed directly or indirectly to a traumatic event, and ≥ 9 of the following must be present for a period of 3 days up to 1 mo:

  • Recurrent, involuntary, and intrusive distressing memories of the event

  • Recurrent distressing dreams of the event

  • Dissociative reactions (eg, flashbacks) in which patients feel as if the traumatic event is recurring

  • Intense psychologic or physiologic distress when reminded of the event (eg, by its anniversary, by sounds similar to those heard during the event)

  • Persistent inability to experience positive emotions (eg, happiness, satisfaction, loving feelings)

  • An altered sense of reality (eg, feeling in a daze, time slowing, altered perceptions)

  • Inability to remember an important part of the traumatic event

  • Efforts to avoid distressing memories, thoughts, or feelings associated with the event

  • Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) associated with the event

  • Sleep disturbance

  • Irritability or angry outbursts

  • Hypervigilance

  • Difficulty concentrating

  • Exaggerated startle response

In addition, manifestations must cause significant distress or significantly impair social or occupational functioning and not be attributable to the physiologic effects of a substance or another medical disorder.


  • Nondrug measures

Many people recover once they are removed from the traumatic situation, shown understanding and empathy, and given an opportunity to describe the event and their reaction to it.

To prevent or minimize this disorder, some experts recommend systematic debriefing to assist people who were involved in or witnessed a traumatic event as they process what has happened and reflect on its effect. In one approach to debriefing, the event is referred to as the critical incident, and the debriefing is referred to as critical incident stress debriefing (CISD). Other experts have expressed concern and some studies show that CISD may not be as helpful as supportive, empathic interviewing, may be quite distressful for some patients, and may even impede natural recovery.

Drugs to assist sleep may help, but other drugs are generally not indicated.