Acute stress disorder is a brief period of intrusive recollections occurring within 4 weeks of witnessing or experiencing an overwhelming traumatic event. Diagnosis is based on clinical criteria. Treatment focuses on self-care and psychotherapy, primarily trauma-focused cognitive-behavioral therapy. Pharmacotherapy has a limited role.
Acute stress disorder involves acute stress reactions that develop within 1 month of exposure to a traumatic event. These stress reactions include intrusive recollections of the trauma, avoidance of stimuli that remind the patient of the trauma, negative mood, dissociative symptoms (including derealization and amnesia), avoidance of reminders, and increased arousal. If significant symptoms last more than 1 month, a diagnosis of posttraumatic stress disorder (PTSD) should be considered.
Acute stress disorder describes a population of people with significant distress following a traumatic experience beyond that consistent with an adjustment disorder. It may precede PTSD (1).
General reference
1. Bryant RA. The Current Evidence for Acute Stress Disorder. Curr Psychiatry Rep. 2018;20(12):111. Published 2018 Oct 13. doi:10.1007/s11920-018-0976-x
Diagnosis of Acute Stress Disorder
Psychiatric assessment
To meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria for diagnosis of acute stress disorder, patients must have been exposed directly or indirectly to a traumatic event (1). Additionally, ≥ 9 of the following symptoms from any of the 5 categories (intrusion, negative mood, dissociation, avoidance, and arousal) must be present for a period of 3 days up to 1 month:
Intrusion symptoms
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 psychological or physiologic distress when reminded of the event (eg, by entering a similar location, by sounds similar to those heard during the event)
Negative mood
Persistent inability to experience positive emotions (eg, happiness, satisfaction, loving feelings)
Dissociative symptoms
An altered sense of reality (eg, feeling in a daze, time slowing, altered perceptions)
Inability to remember an important part of the traumatic event
Avoidance symptoms
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
Arousal symptoms
Sleep disturbance
Irritability or angry outbursts
Hypervigilance
Difficulty concentrating
Exaggerated startle response
In addition, these symptoms must cause significant distress and/or significantly impair social or occupational functioning. They should not be attributable to the physiologic effects of a substance-related, another medical disorder, or brief psychotic disorder.
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed,Text Revision. American Psychiatric Association Publishing; 2022.
Treatment of Acute Stress Disorder
Safety and self-care
Psychotherapy
Limited role of pharmacotherapy
Safety and self-care are important for successful recovery from acute stress disorder. It is difficult to overcome acute stress disorder if the traumatic experience is recurring and the surrounding conditions remain unsafe. Attention to physical needs and sufficient sleep are helpful.
In addition, psychotherapy focused on the emotional aftermath of the trauma may be effective. The adverse effects of sudden traumatic experience can include shame and inappropriate guilt, which can be modulated by emotional protection and support.
Self-care
Self-care is crucial during and after a crisis or trauma. Self-care can be divided into 3 components:
Personal safety
Physical health and practical support
Mindfulness
Maintenance of normal schedule and community involvement
Personal safety is fundamental. After a traumatic episode, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek safety for themselves and their loved ones to the extent possible.
Physical health can be put at risk during and after traumatic experiences. As much as possible, the at-risk person should try to maintain a healthy schedule of eating, sleeping, and exercise. Medications and substances that sedate (eg, benzodiazepines) and intoxicate (eg, alcohol) should be used sparingly, if at all. Practical support includes assistance with housing, legal support, insurance, and other issues that need to be addressed but can be overwhelming.
A mindfulness-based approach to self-care aims to reduce the stress, boredom, anger, sadness, and isolation that traumatized people normally experience.
If circumstances allow, at-risk individuals should make and follow a normal daily schedule. Community involvement can be crucial, even if maintaining human connection is difficult during a crisis. It is useful to practice familiar hobbies as well as activities that sound fun and distracting: draw a picture, watch a movie, cook. Stretching and exercise are beneficial, as are self-soothing techniques such as counting one's own breaths, meditating, or self-hypnosis can also be helpful. Social connection with family and friends is also encouraged.
Under stress, people can become short-tempered, even with those they care about. Friends and family can be expecially helpful in reaching out and providing expressions of concern and comfort. Sending a nice note, making someone cookies, and offering up a smile may not only be a nice surprise for the recipient, but such actions can reduce the hopelessness and shame that tend to be part of the experience of trauma.
Psychotherapy
Trauma-focused cognitive-behavioral therapy (CBT) is a time-limited CBT treatment that has the most robust evidence base for treatment of acute stress disorder and prevention of PTSD (1). As with PTSD, this psychotherapy consists of 3 parts:
Patient education is an important initial step. Normalization and explanation of the stress response is often helpful, as is a reminder that symptoms should improve.
Cognitive restructuring helps correct maladaptive thoughts the patient might have about the trauma or personal response to the trauma.
Exposure to traumatic memories or safe reminders of traumatic experiences is an important—if difficult—part of the psychotherapy. Through re-experiencing, the patient is better able to emotionally process material that had previously been experienced as overwhelming.
Trauma-focused CBT is generally delayed for at least 2 weeks following the trauma. This time period allows most situations to calm down and gives patients some distance from acute issues related to such complications as danger, pain, surgery, and geographical relocation. Since trauma-focused CBT can itself be stressful, therapy may be deferred for months while the clinician identifies factors that might complicate treatment. These complicating factors include clinically significant suicidality, dissociation, grief, anger, psychosis, or PTSD symptoms from an earlier trauma. There are, however, some trauma-focused CBT protocols developed for use within the first month after the trauma, or even initiated in the emergency department (2).
Debriefing is a form of psychotherapy in which the patient is asked to provide a detailed description of the trauma within the first 72 hours. Debriefing has not proven to be effective and may worsen symptoms; trauma experts tend to discourage its use (3).
Pharmacotherapy
There is no current evidence that supports the routine use of medications to treat acute stress disorder or to prevent the development of PTSD (4).
Short-term use of benzodiazepines may be helpful for patients with insomnia, anxiety, and agitation, but prolonged use appears to interfere with recovery. While there may be subsets of patients with acute stress disorder who experience relief with medications such as selective serotonin reuptake inhibitors (SSRIs), propranolol, or morphine, studies have not demonstrated robust efficacy (Short-term use of benzodiazepines may be helpful for patients with insomnia, anxiety, and agitation, but prolonged use appears to interfere with recovery. While there may be subsets of patients with acute stress disorder who experience relief with medications such as selective serotonin reuptake inhibitors (SSRIs), propranolol, or morphine, studies have not demonstrated robust efficacy (5). One retrospective study from the U.S. military suggested that use of morphine in the acute aftermath of serious physical trauma reduced the risk of the subsequent development of PTSD (). One retrospective study from the U.S. military suggested that use of morphine in the acute aftermath of serious physical trauma reduced the risk of the subsequent development of PTSD (6); this approach has not been replicated.
Treatment references
1. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 35(6):502-514, 2018. doi: 10.1002/da.22728
2. Bryant RA. The Current Evidence for Acute Stress Disorder. Curr Psychiatry Rep. 2018;20(12):111. Published 2018 Oct 13. doi:10.1007/s11920-018-0976-x
3. Shalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017;376(25):2459-2469. doi:10.1056/NEJMra1612499
4. Wright LA, 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. 9(1):334, 2019. doi: 10.1038/s41398-019-0673-5
5. Bertolini F, Robertson L, Bisson JI, et al. Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms. Cochrane Database Syst Rev. 2024;5(5):CD013613. Published 2024 May 20. doi:10.1002/14651858.CD013613.pub2
6. Holbrook TL, Galarneau MR, Dye JL, et al. Morphine use after combat injury in Iraq and post-traumatic stress disorder . Morphine use after combat injury in Iraq and post-traumatic stress disorderN Engl J Med. 362(2):110-117, 2010. doi: 10.1056/NEJMoa0903326.
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