Copyright 2002 by the American Psychological Association, Inc. 0033-2909/02/$5.00 DOI: 10.1037//0033-2909.128.6.886
Acute Stress Disorder: A Synthesis and Critique
Allison G. Harvey
University of Oxford
Richard A. Bryant
University of New South Wales
The diagnosis of acute stress disorder (ASD) was introduced to describeinitial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis onperitraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.
A number of years have elapsed since the introductionof acute stress disorder (ASD) in the Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM–IV; American Psychiatric Association, 1994). This diagnosis was established to describe stress reactions that occur in the initial month after a traumatic experience. The response to this new diagnosis ranged from enthusiastic support (Spiegel, Koopman, Cardena, & Classen, 1996) to scepti˜ cism(Pincus, Frances, Davis, First, & Widiger, 1992; Solomon, Laor, & McFarlane, 1996; Wakefield, 1996). A major reason for the widespread criticism of the ASD diagnosis was that it was a theoretically driven description that lacked sound empirical support (Bryant & Harvey, 1997). Despite this criticism, its introduction has stimulated considerable research on acute stress reactions and theirrelationship to posttraumatic stress disorder (PTSD). It is appropriate to now evaluate the extent to which empirical work has validated this fledging diagnosis. Analysis of the ASD diagnosis also allows close investigation of the theoretical notion that dissociation is a pivotal mechanism in trauma response. In this article we review the background of the ASD diagnosis and provide a critique of theevidence related to the major rationales underlying ASD. Our review suggests that the theoretical and empirical support for the ASD is flawed and challenges the basis for its continued use.
two diagnoses is the duration of the symptoms and the former’s emphasis on dissociative reactions to the trauma. ASD refers to symptoms manifested during the period from 2 days to 4 weeks posttrauma, whereas PTSDcan only be diagnosed from 4 weeks. In terms of dissociation, the diagnosis of ASD requires that the individual has at least three of the following: (a) a subjective sense of numbing or detachment, (b) reduced awareness of one’s surroundings, (c) derealization, (d) depersonalization, or (e) dissociative amnesia.
Rationale Underpinning ASD
The ASD diagnosis was introduced into DSM–IV to fill anosologic gap because the PTSD diagnosis did not address posttrauma symptoms experienced in the first month posttrauma. Since DSM–III–R (3rd ed., rev.; American Psychiatric Association, 1987), diagnosing PTSD within a month of the trauma was precluded because of concerns that this would pathologize transient and normative stress reactions. The ASD diagnosis was driven by the notion thatdissociative reactions are a crucial mechanism in posttraumatic adjustment. This view holds that an acutely traumatized individual will have impaired recovery if their dissociative responses impede access to affect and memories about their traumatic experience (van der Kolk & van der Hart, 1989). The emphasis placed on dissociation in trauma response is reflected in the serious consideration given to the...