Emergence of Acute Stress Disorder

8/7/2019 Emergence of Acute Stress Disorder

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THE EMERGENCE OF ACUTESTRESS DISORDER

The psychological problems that arise from extreme trauma have beendocumented in literature since the time of Homer (Alford, 1992). Theearly writings have described the anguish caused by distressing memoriesand elevated anxiety in a wide range of trauma survivors. Despite thisawareness of the psychological aftermath of trauma, our understanding ofposttrauma reactions has varied considerably over the years. Interestingly,the conceptualization of trauma response has often been influenced by thesocial and ideological movements of the day. For example, in the 19thcentury, there was considerable debate over the functional or organic basesof traumatic neurosis or railway spine. In keeping with prevalent schools ofthought at the time, some theorists argued that such reactions resulted frommolecular 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 anacceptable attribution for poor military performance (van der Kolk, 1996a).Similarly, we need to understand the current conceptualization of acutestress disorder (ASD) in the context of popular ideological developmentsin 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-

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though this school of thought commenced 100 years ago, its powerful in-fluence on modern psychiatry has only occurred in the last 20 years. Thisearly 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 thatwere phenomenologically similar to hypnotic states. Charcot held thatoverwhelmingly aversive experiences led to a dissociation that involvedprocesses observed in both hysteria and hypnosis. Janet (1907) continuedthis perspective by arguing that trauma that was incongruent with existingcognitive schema led to dissociated awareness. Janet believed that by split-ting off traumatic memories from awareness, individuals could minimizetheir discomfort. The price for this dissociation, however, was a loss inpsychological functioning because mental resources were not available forother processes. Accordingly, Janet argued that adaptation to a traumaticevent involved integrating the fragmented memories into awareness. De-spite the immediate influence on his contemporaries, Janets influence wasshort-lived until the renaissance of dissociation in the 1980s. Indeed, itwas these early theorists who provided the basic rationale for the presentdiagnosis of ASD.

Increased interest in acute stress reactions developed during the 20thcentury as a result of both wartime and civilian traumas. In one of theearliest studies of acute stress, Lindemann (1944) documented the acutereactions of survivors of the Coconut Grove fire in Boston in 1942. Heobserved that the acute symptoms reported by survivors included avoidanceof the intense distress connected to the grief experience. .. , the expres-sion of emotion . . .disturbed pictures . ..a sense of unreality , . . increasedemotional 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 reactionswere reportedly common in troops from both World War I and World WarI1 (Kardiner, 1941; Kardiner & Spiegel, 1947). The acute psychologicalafermath of battle, subsequently known as combat stress reaction (CSR), wasthe most studied instance of acute stress. This is not surprising consideringthat CSR was observed in more than 20% of US troops in World War I1(Solomon, Laor, & McFarlane, 1996).CSR is a poorly defined constructthat 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 earlynotions of CSR was the assumption that stress symptoms were transientreactions to an extreme stress. That is, they were not recognized as psy-chopathological reactions because they were observed in troops who wereno t regarded as having a predisposition to psychiatric disorders. These mil-4 AC UT E S TRESS DI S ORDER


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itary opinions played a significant role in shaping the early diagnosticthinking of both the World Health Organization (WHO) and the Amer-ican Psychiatric Association after World War 11. In 1948, WHO adoptedthe Armed Forces categorizations when it integrated mental disorders intothe sixth revision of the International Statistical Classification of Diseases,Injuries, and Causes of Death (ICD-6). Similarly, in 1952, the AmericanPsychiatric Association developed the Diagnostic and Statistical Manual ofM e n d Disorders (DSM) on the basis of existing conceptualizations withinthe Veterans Administration and the Armed Forces. A major effect of thisinfluence was that initial diagnostic categorizations regarded acute stressreactions as temporary responses in otherwise normal individuals (Brett,1996).

Exhibit 1.1 contains a summary of the development of diagnosticcategories relevant to traumatized people in both IC D and DSM. The de-scriptions of acute trauma reactions in ICD-6 to ICD-9 (World HealthOrganization, 1977) all shared the assumption that acute stress reactionswere transient reactions in nonpathological individuals. During the sameperiod of time, the American Psychiatric Association used variable termsto describe acute stress reactions. The first edition of DSM (AmericanPsychiatric Association, 1952) classified acute posttrauma responses undergross stress reaction, and longer lasting reactions were subsumed under theanxiety 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. Themajor changes occurred in DSM-111 (American Psychiatric Association,1980), in which the diagnosis of posttraumatic stress disorder (PTSD) was

EXHIBIT 1.1Diagnostic Categories for Traumatic Stress ReactionsICD DSM

ICD-6 (1948)Acute situational maladjustment

ICD-8 (1969)ICD-9 (1977)ICD- 70 (1 992)

Transient situational disturbanceAcute stress reactionAcute stress reactionPosttraumatic stress disorderEnduring personality change aftertrophe experience

DSM (1952)Gross stress reactionsAdult situational reactionAdjustment reactionAdjustment reactionPosttraumatic stress disorderAcute stress disorderPosttraumatic stress disorder

DSM-I1 (1 968)DSM-Ill, DSM-Ill-R (1980, 1987)DSM-IV (1994)

catas-Note. ICD = lnternational Statistical Classification of Disease (published by the World HealthOrganization);DSM = Diagnostic and Statistical Manual of Mental Disorders (published by theAmerican Psychiatric Association).

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

DIAGNOSIS OF ASDIn DSM-IV (American Psychiatric Association, 1994), there was for-

mal recognition of the nosologic gap between PTSD and adjustmentdisorder (Pincus et al., 1992, p. 115).Specifically, some parties argued fora diagnostic means to identify traumatized people within the 1st monthafter a traumatic event. The major arguments put forward to justify sucha 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 whowould 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 toa traumatic event and encourage false-positive diagnoses (Pincus et al.,1992;Wakefield, 1996).Moreover, reluctance to accept this new diagnosiswas reinforced by the alleged relationship between ASD and PTSD beingbased more on logical arguments than on empirical research (Koopmanet 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 ASDTable 1.1 demonstrates that the criteria for ASD were closely modeled

on PTSD. The structure of the ASD diagnosis follows that of PTSD inthat it is described in terms of the stressor definition, reexperiencing, avoid-ance, arousal, duration, and exclusion criteria. There are several criticaldifferences, however, between ASD and PTSD (see also chapter 4).Theadditional cluster that is unique to ASD criteria is the dissociative clusterof symptoms.The initial requisite for a diagnosis of ASD is the experience of aprecipitating stressor. This description is identical to the stressor definition6 AC UTE STRESS DISORDER


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~~ ~CriterionStressor

Dissociation

Reexperienc-ing

Avoidance

Arousal

Duration

Impairment

TABLE 1.1Diagnostic Criteria for ASD and PTSDASD PTSD

Both BothThreatening event Threatenting eventFear, helplessness, or Fear, helplessness, or horrorhorrorMinimum three ofNumbing -Reduced awarenessDepersonalizationDerealizationAmnesiaMinimum o ne ofRecurrent imagesAh0ught.d Recurrent images/thoughts/Consequent distress notIntrusive nature not pre-

Thoughts, feelings, or Avoid thoughtslconversa-

Minimum one ofdistress distressprescribed scribedscribed

places tions

Consequent distress pre-Intrusive nature prescribed

Marked avoidance of Minimum three ofAvoid people/placesAmnesiaDiminished interestEstrangement from othersRestricted affectSense of shortened futureMarked arousal, including Minimum two ofRestlessness, insomnia, Insomniairritability, hypervigi- Irritabilitylance, and concentra- Concentration deficitstion difficulties HyperviligenceElevated startle responseAt least 2 days and less than At least 1 month posttrauma1 month posttraumaDissociative symptoms maybe present only duringtrauma

Impairs functioning impairs functioningNote. ASD = acute stress disorder; PTSD = posttraumatic stress disorder. Dissociation symptomswere 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 PsychologyReview, 17, p. 767. Copyright 1997 by ElsevierScience. Reprinted with permission.

of PTSD and requires that the individual has experienced or witnessed anevent that has been threatening to either himself or herself or anotherperson. Furthermore, it prescribes that the persons response involved in-tense fear, helplessness, or horror (American Psychiatric Association,1994, p. 431). To illustrate, one of the more severe industrial accident

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victims we have treated clearly experienced a threatening event. Barts armwas severely severed while operating a factory machine. During the severalhours that he was trapped in the machine, Bart described extreme fright,pain, and helplessness. Barts experience satisfactorily met the ASD stressorcriteria.

The symptom cluster that distinguishes ASD from PTSD is the em-phasis on dissociative symptoms. To satisfy criteria for this cluster, a personmust display at least three of the following dissociative symptoms: (a) sub-jective sense of numbing or detachment, (b) reduced awareness of his orher surroundings, (c) derealization, (d) depersonalization, and (e) dissoci-ative amnesia. These symptoms may occur either at the time of the traumaor in the 1st month posttrauma. Numbing refers to detachment from ex-pected emotional reactions. Reduced awareness of surroundings involves theperson being less aware than one would expect of events occurring eitherduring the trauma or in the immediate period after it. Derealization is de-fined as the perception that ones environment is unreal, dreamlike, oroccurring in a distorted time frame. Depersonalization is the sense that onesbody is detached or one is seeing oneself from anothers 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 notbelieve it was happening. During our assessment session, he said it allseemed like a terrible dream. He reported also that during the ordeal,events seemed to move slowly, including peoples speech and movements.These accounts reflect Barts reduced awareness of his surroundings andderealization. He also reported that for a period, he felt he was watchingthe ordeal from the ceiling, that he was looking down on himself. This isa classic example of depersonalization because Bart was viewing himself ina detached manner. Finally, Bart reported that since the incident, he hadfelt detached and emotionless from all his daily activities, reflecting thepresence of emotional numbing. Bart reported that he could recall all as-pects of the trauma, and so he did not display dissociative amnesia.Th e diagnosis of ASD requires also that the trauma is reexperiencedin at least one of the following ways: recurrent images, thoughts, dreams,illusions, flashback episodes, or a sense of reliving the experience; or distresson exposure to reminders of the traumatic event (American PsychiatricAssociation, 1994, p. 432). By describing frequent intrusive memories ofthe event, especially of his bones protruding from his severed arm, Bartmet the reexperiencing criterion. These images were accompanied bystrong perceptions of pain in the affected arm, the smell of sawdust thatwas present at the time of the accident, and a sense that his arm was beingtom off his shoulder. During these experiences, Bart felt that he was ex-periencing the event all over again. He also reported frequent nightmares8 ACUTE STRESS DISORDER


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in which he saw his arm being tom off his shoulder, which resulted in hiswaking in great fright.

The diagnostic criteria for ASD stipulate that the person must displaymarked avoidance of stimuli that arouse recollections of the trauma(American Psychiatric Association, 1994, p. 432). This avoidance mayinclude 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 allthoughts, conversations, and places that reminded him of his experience.He refused to look at his arm and would not go near mirrors. He avoidedproximity to any electrical or mechanical devices and refused to attendmedical appointments. Barts avoidance made talking about his experiencesin therapy difficult because focusing on his accident elicited anxiety thathe found difficult to tolerate.The ASD diagnosis also requires that marked symptoms of anxiety orarousal 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 felthe needed to continually scan his environment for threats. In addition tothis hypervigilance, he also reported marked insomnia, concentration def-icits, and heightened startle response. He generalized his sense of physicalvulnerability to many stimuli, even stimuli not directly related to thetrauma. For example, he developed a habit of carrying a knife in his bootto protect himself from potential assailants. He also refused to turn hisback on anyone and always ensured that he stood with his back to wallsso that he could monitor other peoples 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 notpersist for more than 1 month. It is assumed that a diagnosis of PTSD maybe 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 hiscompliance with medical procedures, and prevented any meaningful inter-personal interactions.

Note that DSM-IVs description of ASD is significantly different fromICD-10s definition of acute stress reaction (see Table 1.2). Whereas ASDrefers to the period after 48 hours posttrauma, acu te stress reaction refers tothe period before 48 hours. This reflects the divergence in the underlyingassumptions about the course of the two disorders. Whereas ASD is con-ceived of as a precursor to PTSD, acute stress reactions are presented as atransient reaction. Furthermore, the symptoms required by the respectivedescriptions are markedly different. In particular, DSM-IV places consid-

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TABLE 1.2Comparison of Diagnostic Criteria for ASD (DSM-/v) and Acute StressReaction (ED- 70)Criteria ASD Acute stress reaction

Stressor Threat to life Exceptional mental orRelationship to PTSD Precursor Alternative diagnosisTime from trauma 2 days to 4 weeks 48 hoursCourse Precursor to PTSD TransientSymptpms Dissociation Generalized anxiety

Subjective response physical stressor

Reexperiencing WithdrawalAvoidance Narrowing of attentionAnxiety or arousal Apparent disorientationAnger or verbal aggressionDespair or hopelessnessOveractivityExcessive grief

Note. ASD = acute stress disorder; DSM-IV = Diagnostic and Statistical Manual of MentalDisorders (4th ed.); ICD-70 = International Classificationof Disease (10th ed., rev.); PTSD =posttraumatic stress disorder.

erable emphasis on dissociative reactions in the acute trauma response,primarily because this reflects a strong theoretical position held in certainquarters of American psychiatry. In contrast, ICD- 10s 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- 10s strong connectionto military psychiatry and its attempt to provide a descriptive profile ofevents that occur in combat settings. Some have noted that the flexibilityof the ICD-I0 diagnosis may make it more clinically useful than the morerigid DSM-IV definition (Solomon et al., 1996). The utility of a newdiagnosis relating to acute stress reactions depends, however, on its abilityto identify those individuals who will suffer chronic PTSD. The evidencefor and against this critical issue is visited in chapter 3. In the next chapter,we review the various theoretical perspectives of ASD.

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Emergence of Acute Stress Disorder

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