THE EMERGENCE OF ACUTE

STRESS DISORDER

The psychological problems that arise from extreme trauma have been
documented in literature since the time of Homer (Alford, 1992). The
early writings have described the anguish caused by distressing memories
and elevated anxiety in a wide range of trauma survivors. Despite this
awareness of the psychological aftermath of trauma, our understanding of
posttrauma reactions has varied considerably over the years. Interestingly,
the conceptualization of trauma response has often been influenced by the
social and ideological movements of the day. For example, in the 19th
century, there was considerable debate over the functional or organic bases
of traumatic neurosis or railway spine. In keeping with prevalent schools of
thought at the time, some theorists argued that such reactions resulted from
molecular changes in the central nervous system (Oppenheim, 1889),
whereas others held that they were a function of anxiety (Page, 1895).
Some years later, the diagnosis of shell shock became fashionable (Mott,
1919) because ascribing stress reactions to organic factors permitted an
acceptable attribution for poor military performance (van der Kolk, 1996a).
Similarly, we need to understand the current conceptualization of acute
stress disorder (ASD) in the context of popular ideological developments
in modem psychiatry.
One of the most influential developments in the current conceptu-
alization of ASD was the work conducted at the Salpitriire in Paris. Al-

3
though this school of thought commenced 100 years ago, its powerful in-
fluence on modern psychiatry has only occurred in the last 20 years. This
early theorizing represents the precursor of current proposals of trauma-
induced dissociation (Nemiah, 1989; van der Kolk & van der Hart, 1989).
Charcot ( 1887) proposed that traumatic shock could evoke responses that
were phenomenologically similar to hypnotic states. Charcot held that
overwhelmingly aversive experiences led to a dissociation that involved
processes observed in both hysteria and hypnosis. Janet (1907) continued
this perspective by arguing that trauma that was incongruent with existing
cognitive schema led to dissociated awareness. Janet believed that by split-
ting off traumatic memories from awareness, individuals could minimize
their discomfort. The price for this dissociation, however, was a loss in
psychological functioning because mental resources were not available for
other processes. Accordingly, Janet argued that adaptation to a traumatic
event involved integrating the fragmented memories into awareness. De-
spite the immediate influence on his contemporaries, Janet’s influence was
short-lived until the renaissance of dissociation in the 1980s. Indeed, it
was these early theorists who provided the basic rationale for the present
diagnosis of ASD.
Increased interest in acute stress reactions developed during the 20th
century as a result of both wartime and civilian traumas. In one of the
earliest studies of acute stress, Lindemann ( 1944) documented the acute
reactions of survivors of the Coconut Grove fire in Boston in 1942. He
observed that the acute symptoms reported by survivors included avoidance
of “the intense distress connected to the grief experience. . . , the expres-
sion of emotion . . . disturbed pictures . . . a sense of unreality , . . increased
emotional distance from other people . . . and waves of discomfort” (pp.
141-143). In general, however, much of the early interest in acute trau-
matic stress reactions came from military sources. Acute stress reactions
were reportedly common in troops from both World War I and World War
I1 (Kardiner, 1941; Kardiner & Spiegel, 1947). The acute psychological
afermath of battle, subsequently known as combat stress reaction (CSR), was
the most studied instance of acute stress. This is not surprising considering
that CSR was observed in more than 20% of US troops in World War I1
(Solomon, Laor, & McFarlane, 1996). CSR is a poorly defined construct
that is marked by its variability and fluctuating course (Solomon, 1993a).
Its symptoms include anxiety, depression, confusion, restricted affect, irri-
tability, somatic pain, withdrawal, listlessness, paranoia, nausea, startle re-
actions, and sympathetic hyperactivity (Bar-On, Solomon, Noy, & Nardi,
1986; Bartemeier, 1946; Grinker, 1945). Inherent in many of the early
notions of CSR was the assumption that stress symptoms were transient
reactions to an extreme stress. That is, they were not recognized as psy-
chopathological reactions because they were observed in troops who were
not regarded as having a predisposition to psychiatric disorders. These mil-

4 A C U T E STRESS DISORDER
itary opinions played a significant role in shaping the early diagnostic
thinking of both the World Health Organization (WHO) and the Amer-
ican Psychiatric Association after World War 11. In 1948, WHO adopted
the Armed Forces’ categorizations when it integrated mental disorders into
the sixth revision of the International Statistical Classification of Diseases,
Injuries, and Causes of Death (ICD-6). Similarly, in 1952, the American
Psychiatric Association developed the Diagnostic and Statistical Manual of
M e n d Disorders (DSM) on the basis of existing conceptualizations within
the Veterans Administration and the Armed Forces. A major effect of this
influence was that initial diagnostic categorizations regarded acute stress
reactions as temporary responses in otherwise normal individuals (Brett,
1996).
Exhibit 1.1 contains a summary of the development of diagnostic
categories relevant to traumatized people in both ICD and DSM. The de-
scriptions of acute trauma reactions in ICD-6 to ICD-9 (World Health
Organization, 1977) all shared the assumption that acute stress reactions
were transient reactions in nonpathological individuals. During the same
period of time, the American Psychiatric Association used variable terms
to describe acute stress reactions. The first edition of DSM (American
Psychiatric Association, 1952) classified acute posttrauma responses under
gross stress reaction, and longer lasting reactions were subsumed under the
anxiety or depressive neuroses. In DSM-11 (American Psychiatric Associa-
tion, 1968), ongoing reactions were similarly categorized, but transient sit-
uational disturbance was used to describe an acute posttrauma response. The
major changes occurred in DSM-111 (American Psychiatric Association,
1980), in which the diagnosis of posttraumatic stress disorder (PTSD) was

EXHIBIT 1.1
Diagnostic Categories for Traumatic Stress Reactions
ICD DSM
ICD-6 (1948) DSM (1952)
Acute situational maladjustment Gross stress reactions
Adult situational reaction
Adjustment reaction
ICD-8 (1969) DSM-I1 (1968)
Transient situational disturbance Adjustment reaction
ICD-9 (1977) DSM-Ill, DSM-Ill-R (1980, 1987)
Acute stress reaction Posttraumatic stress disorder
ICD- 7 0 (1992) DSM-IV (1994)
Acute stress reaction Acute stress disorder
Posttraumatic stress disorder Posttraumatic stress disorder
Enduring personality change after catas-
trophe experience
Note. ICD = lnternational Statistical Classification of Disease (published by the World Health
Organization); DSM = Diagnostic and Statistical Manual of Mental Disorders (published by the
American PsychiatricAssociation).

EMERGENCE OF ASD 5
formally introduced. Whereas DSM-III did not stipulate a duration for
symptoms, the revised version of that edition (DSM-111-R; American Psy-
chiatric Associaion, 1987) required that the symptoms be present for more
than 1 month posttrauma. This stipulation precluded the inclusion of
acutely traumatized individuals, who were instead diagnosed with adjust-
ment disorder (Blanchard & Hickling, 1997; Pincus, Frances, Davis, First,
& Widiger, 1992).

DIAGNOSIS OF ASD

In DSM-IV (American Psychiatric Association, 1994), there was for-

mal recognition of the “nosologic gap” between PTSD and adjustment
disorder (Pincus et al., 1992, p. 115). Specifically, some parties argued for
a diagnostic means to identify traumatized people within the 1st month
after a traumatic event. The major arguments put forward to justify such
a diagnosis were (a) to recognize the significant levels of distress experi-
enced in the initial month after a trauma (Koopman, Classen, Cardeiia, &
Spiegel, 1995), (b) to permit early identification of trauma survivors who
would suffer longer term psychopathology (Koopman et al., 1995), and (c)
to stimulate controlled investigation of acute posttrauma reactions (Solo-
mon et al., 1996). Others were opposed to this new diagnosis, however,
on the grounds that it would potentially pathologize a normal reaction to
a traumatic event and encourage false-positive diagnoses (Pincus et al.,
1992; Wakefield, 1996). Moreover, reluctance to accept this new diagnosis
was reinforced by the alleged relationship between ASD and PTSD being
“based more on logical arguments than on empirical research” (Koopman
et al., 1995, p. 38). Whereas most diagnoses that were accepted into DSM-
IV satisfied stringent criteria, including extensive literature reviews, statis-
tical analyses, and field studies, ASD was included with hardly any sup-
porting data to validate its diagnostic merits (Bryant & Harvey, 1997a).

DEFINITION OF ASD

Table 1.1 demonstrates that the criteria for ASD were closely modeled
on PTSD. The structure of the ASD diagnosis follows that of PTSD in
that it is described in terms of the stressor definition, reexperiencing, avoid-
ance, arousal, duration, and exclusion criteria. There are several critical
differences, however, between ASD and PTSD (see also chapter 4). The
additional cluster that is unique to ASD criteria is the dissociative cluster
of symptoms.
The initial requisite for a diagnosis of ASD is the experience of a
precipitating stressor. This description is identical to the stressor definition

6 ACUTE STRESS DISORDER

 TABLE 1.1
Diagnostic Criteria for ASD and PTSD
~~ ~

Criterion ASD PTSD

Stressor Both Both
Threatening event Threatenting event
Fear, helplessness, or Fear, helplessness, or horror
horror
Dissociation Minimum three of
Numbing -
Reduced awareness
Depersonalization
Derealization
Amnesia
Reexperienc- Minimum one of Minimum one of
ing Recurrent imagesAh0ught.d Recurrent images/thoughts/
distress distress
Consequent distress not Consequent distress pre-
prescribed scribed
Intrusive nature not pre- Intrusive nature prescribed
scribed
Avoidance Marked avoidance of Minimum three of
Thoughts, feelings, or Avoid thoughtslconversa-
places tions
Avoid people/places
Amnesia
Diminished interest
Estrangement from others
Restricted affect
Sense of shortened future
Arousal Marked arousal, including Minimum two of
Restlessness, insomnia, Insomnia
irritability, hypervigi- Irritability
lance, and concentra- Concentration deficits
tion difficulties Hyperviligence
Elevated startle response
Duration At least 2 days and less than At least 1 month posttrauma
1 month posttrauma
Dissociative symptoms may
be present only during
trauma
Impairment Impairs functioning impairs functioning
Note. ASD = acute stress disorder; PTSD = posttraumatic stress disorder. Dissociationsymptoms
were not included as PTSD criteria.
From “Acute Stress Disorder: A Critical Review of Diagnostic and Theoretical Issues,” by R. A.
Bryant and A. G. Harvey, 1997, Clinical Psychology Review, 17, p. 767. Copyright 1997 by Elsevier
Science. Reprinted with permission.

of PTSD and requires that the individual has experienced or witnessed an

event that has been threatening to either himself or herself or another
person. Furthermore, it prescribes that the “person’s response involved in-
tense fear, helplessness, or horror” (American Psychiatric Association,
1994, p. 431). To illustrate, one of the more severe industrial accident

EMERGENCE OF ASD 7
victims we have treated clearly experienced a threatening event. Bart’s arm
was severely severed while operating a factory machine. During the several
hours that he was trapped in the machine, Bart described extreme fright,
pain, and helplessness. Bart’s experience satisfactorily met the ASD stressor
criteria.
The symptom cluster that distinguishes ASD from PTSD is the em-
phasis on dissociative symptoms. To satisfy criteria for this cluster, a person
must display at least three of the following dissociative symptoms: (a) sub-
jective sense of numbing or detachment, (b) reduced awareness of his or
her surroundings, (c) derealization, (d) depersonalization, and (e) dissoci-
ative amnesia. These symptoms may occur either at the time of the trauma
or in the 1st month posttrauma. Numbing refers to detachment from ex-
pected emotional reactions. Reduced awareness of surroundings involves the
person being less aware than one would expect of events occurring either
during the trauma or in the immediate period after it. Derealization is de-
fined as the perception that one’s environment is unreal, dreamlike, or
occurring in a distorted time frame. Depersonalization is the sense that one’s
body is detached or one is seeing oneself from another’s perspective. Dis-
sociative amnesia refers to an inability to recall a critical aspect of the trau-
matic event. Bart met four of these five dissociative criteria. Specifically,
he described that the experience seemed unreal; at the time he could not
believe it was happening. During our assessment session, he said “it all
seemed like a terrible dream.” He reported also that during the ordeal,
events seemed to move slowly, including people’s speech and movements.
These accounts reflect Bart’s reduced awareness of his surroundings and
derealization. He also reported that for a period, he felt he was watching
the ordeal from the ceiling, that he was looking down on himself. This is
a classic example of depersonalization because Bart was viewing himself in
a detached manner. Finally, Bart reported that since the incident, he had
felt detached and “emotionless” from all his daily activities, reflecting the
presence of emotional numbing. Bart reported that he could recall all as-
pects of the trauma, and so he did not display dissociative amnesia.
The diagnosis of ASD requires also that the trauma “is reexperienced
in at least one of the following ways: recurrent images, thoughts, dreams,
illusions, flashback episodes, or a sense of reliving the experience; or distress
on exposure to reminders of the traumatic event” (American Psychiatric
Association, 1994, p. 432). By describing frequent intrusive memories of
the event, especially of his bones protruding from his severed arm, Bart
met the reexperiencing criterion. These images were accompanied by
strong perceptions of pain in the affected arm, the smell of sawdust that
was present at the time of the accident, and a sense that his arm was being
tom off his shoulder. During these experiences, Bart felt that he was ex-
periencing the event all over again. He also reported frequent nightmares

8 ACUTE STRESS DISORDER

in which he saw his arm being tom off his shoulder, which resulted in his
waking in great fright.
The diagnostic criteria for ASD stipulate that the person must display
“marked avoidance of stimuli that arouse recollections of the trauma”
(American Psychiatric Association, 1994, p. 432). This avoidance may
include avoidance of thoughts, feelings, activities, conversations, places,
and people that may remind the person of her or his traumatic experience.
In terms of avoidance, Bart displayed very marked avoidance of all
thoughts, conversations, and places that reminded him of his experience.
He refused to look at his arm and would not go near mirrors. He avoided
proximity to any electrical or mechanical devices and refused to attend
medical appointments. Bart’s avoidance made talking about his experiences
in therapy difficult because focusing on his accident elicited anxiety that
he found difficult to tolerate.
The ASD diagnosis also requires that marked symptoms of anxiety or
arousal be present after the trauma. Arousal symptoms may include rest-
lessness, insomnia, hypervigilance, concentration difficulties, and irritabil-
ity. Bart described being very aware of feeling unsafe in the world. He felt
he needed to continually scan his environment for threats. In addition to
this hypervigilance, he also reported marked insomnia, concentration def-
icits, and heightened startle response. He generalized his sense of physical
vulnerability to many stimuli, even stimuli not directly related to the
trauma. For example, he developed a habit of carrying a knife in his boot
to protect himself from potential assailants. He also refused to turn his
back on anyone and always ensured that he stood with his back to walls
so that he could monitor other people’s activities.
The diagnosis of ASD stipulates that the disturbance must be clini-
cally significant in terms of interruption to social or occupational func-
tioning and must be present for at least 2 days after the trauma, but not
persist for more than 1 month. It is assumed that a diagnosis of PTSD may
be suitable after this time. The diagnosis of ASD is not made if the dis-
turbance is better accounted for by a medical condition or substance use.
Bart clearly satisfied this impairment criterion for ASD because his symp-
toms interfered with his ability to return to any work duties, impaired his
compliance with medical procedures, and prevented any meaningful inter-
personal interactions.
Note that DSM-IV’s description of ASD is significantly different from
ICD-10’s definition of acute stress reaction (see Table 1.2). Whereas ASD
refers to the period after 48 hours posttrauma, acute stress reaction refers to
the period before 48 hours. This reflects the divergence in the underlying
assumptions about the course of the two disorders. Whereas ASD is con-
ceived of as a precursor to PTSD, acute stress reactions are presented as a
transient reaction. Furthermore, the symptoms required by the respective
descriptions are markedly different. In particular, DSM-IV places consid-

EMERGENCE OF ASD 9
 TABLE 1.2
Comparison of Diagnostic Criteria for ASD (DSM-/v) and Acute Stress
Reaction ( E D - 70)
Criteria ASD Acute stress reaction
Stressor Threat to life Exceptional mental or
Subjective response physical stressor
Relationship to PTSD Precursor Alternative diagnosis
Time from trauma 2 days to 4 weeks 48 hours
Course Precursor to PTSD Transient
Symptpms Dissociation Generalized anxiety
Reexperiencing Withdrawal
Avoidance Narrowing of attention
Anxiety or arousal Apparent disorientation
Anger or verbal aggression
Despair or hopelessness
Overactivity
Excessive grief
Note. ASD = acute stress disorder; DSM-IV = Diagnostic and Statistical Manual of Mental
Disorders (4th ed.); ICD-70 = International Classification of Disease (10th ed., rev.); PTSD =
posttraumaticstress disorder.

erable emphasis on dissociative reactions in the acute trauma response,

primarily because this reflects a strong theoretical position held in certain
quarters of American psychiatry. In contrast, ICD- 10’s description incor-
porates a wider range of symptoms, which include both anxiety and de-
pression, and acknowledges the fluctuating course of acute stress reactions.
This conceptualization of acute stress reflects ICD- 10’s strong connection
to military psychiatry and its attempt to provide a descriptive profile of
events that occur in combat settings. Some have noted that the flexibility
of the ICD-I0 diagnosis may make it more clinically useful than the more
rigid DSM-IV definition (Solomon et al., 1996). The utility of a new
diagnosis relating to acute stress reactions depends, however, on its ability
to identify those individuals who will suffer chronic PTSD. The evidence
for and against this critical issue is visited in chapter 3. In the next chapter,
we review the various theoretical perspectives of ASD.

10 ACUTE STRESS DISORDER