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 conceptualization 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 influence on modern psychiatry has only occurred in the last 20 years. This early theorizing represents the precursor of current proposals of traumainduced 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 splitting 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. Despite 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 expression 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 traumatic 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, irritability, somatic pain, withdrawal, listlessness, paranoia, nausea, startle reactions, 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 psychopathological reactions because they were observed in troops who were not regarded as having a predisposition to psychiatric disorders. These mil-
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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 American 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 descriptions 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 Association, 1968), ongoing reactions were similarly categorized, but transient situational 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 ICD-6 (1948) Acute situational maladjustment ICD-8 (1969) Transient situational disturbance ICD-9 (1977) Acute stress reaction ICD- 7 0 (1992) Acute stress reaction Posttraumatic stress disorder Enduring personality change after catastrophe experience
DSM DSM (1952) Gross stress reactions Adult situational reaction Adjustment reaction DSM-I1 (1968) Adjustment reaction DSM-Ill, DSM-Ill-R (1980, 1987) Posttraumatic stress disorder DSM-IV (1994) Acute stress disorder Posttraumatic stress disorder
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
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formally introduced. Whereas DSM-III did not stipulate a duration for symptoms, the revised version of that edition (DSM-111-R; American Psychiatric 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 adjustment disorder (Blanchard & Hickling, 1997; Pincus, Frances, Davis, First, & Widiger, 1992).
DIAGNOSIS OF ASD In DSM-IV (American Psychiatric Association, 1994), there was formal 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 experienced 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 (Solomon 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 DSMIV satisfied stringent criteria, including extensive literature reviews, statistical analyses, and field studies, ASD was included with hardly any supporting 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, avoidance, 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
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ACUTE STRESS DISORDER
TABLE 1.1 Diagnostic Criteria for ASD and PTSD ~~
~
Criterion Stressor
Dissociation
Reexperiencing
Avoidance
Arousal
Duration
Impairment
ASD
PTSD
Both Both Threatening event Threatenting event Fear, helplessness, or horror Fear, helplessness, or horror Minimum three of Numbing Reduced awareness Depersonalization Derealization Amnesia Minimum one of Minimum one of Recurrent imagesAh0ught.d Recurrent images/thoughts/ distress distress Consequent distress preConsequent distress not prescribed scribed Intrusive nature prescribed Intrusive nature not prescribed Minimum three of Marked avoidance of Thoughts, feelings, or Avoid thoughtslconversaplaces tions Avoid people/places Amnesia Diminished interest Estrangement from others Restricted affect Sense of shortened future Minimum two of Marked arousal, including Restlessness, insomnia, Insomnia irritability, hypervigiIrritability lance, and concentraConcentration deficits tion difficulties Hyperviligence Elevated startle response At least 2 days and less than At least 1 month posttrauma 1 month posttrauma Dissociative symptoms may be present only during trauma 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 intense fear, helplessness, or horror” (American Psychiatric Association, 1994, p. 431). To illustrate, one of the more severe industrial accident EMERGENCE OF ASD
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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 emphasis on dissociative symptoms. To satisfy criteria for this cluster, a person must display at least three of the following dissociative symptoms: (a) subjective sense of numbing or detachment, (b) reduced awareness of his or her surroundings, (c) derealization, (d) depersonalization, and (e) dissociative amnesia. These symptoms may occur either at the time of the trauma or in the 1st month posttrauma. Numbing refers to detachment from expected 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 defined 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. Dissociative amnesia refers to an inability to recall a critical aspect of the traumatic 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 aspects 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 experiencing the event all over again. He also reported frequent nightmares
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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 restlessness, insomnia, hypervigilance, concentration difficulties, and irritability. 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 deficits, 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 clinically significant in terms of interruption to social or occupational functioning 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 disturbance is better accounted for by a medical condition or substance use. Bart clearly satisfied this impairment criterion for ASD because his symptoms interfered with his ability to return to any work duties, impaired his compliance with medical procedures, and prevented any meaningful interpersonal 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 conceived 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 considEMERGENCE OF ASD
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TABLE 1.2 Comparison of Diagnostic Criteria for ASD (DSM-/v) and Acute Stress Reaction ( E D - 70) Criteria Stressor Relationship to PTSD Time from trauma Course Symptpms
ASD
Acute stress reaction
Threat to life Subjective response Precursor 2 days to 4 weeks Precursor to PTSD Dissociation Reexperiencing Avoidance Anxiety or arousal
Exceptional mental or physical stressor Alternative diagnosis 48 hours Transient Generalized anxiety Withdrawal Narrowing of attention 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 incorporates a wider range of symptoms, which include both anxiety and depression, 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.
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ACUTE STRESS DISORDER
