Acute Stress Disorder

What acute stress disorder is

After a traumatic event, nearly everyone has some reaction: shock, fear, disbelief, trouble sleeping. These usually fade within days. Acute stress disorder is diagnosed when symptoms are intense, last at least 3 days, and interfere with daily life during the first month.

Under the DSM-5-TR, the trauma involves exposure to actual or threatened death, serious injury or sexual violence, by experiencing it, witnessing it, learning it happened to a close family member or friend, or repeated exposure to disturbing details (for example, first responders).

Symptoms of acute stress disorder

Diagnosis requires at least 9 of 14 symptoms across five groups:

Intrusion

• unwanted, distressing memories of the event
• nightmares about it
• flashbacks: feeling or acting as if it is happening again
• intense distress or physical reactions to reminders

Negative mood

• persistent inability to feel happiness, love or satisfaction

Dissociation

• feeling unreal, detached, in a daze, or as if time has slowed
• inability to remember important parts of the event

Avoidance

• avoiding thoughts, feelings or memories about it
• avoiding people, places, conversations or activities that are reminders

Arousal

• trouble sleeping
• irritability or angry outbursts
• hypervigilance: constantly scanning for danger
• poor concentration
• an exaggerated startle response

Physical symptoms are common too: racing heart, sweating, nausea, headaches, muscle tension and fatigue.

Acute stress disorder vs acute stress reaction vs PTSD

An acute stress reaction is a normal, short-lived response. If symptoms last beyond a month, the diagnosis becomes post-traumatic stress disorder.

Causes and risk factors

Any traumatic event can trigger ASD, including:

• physical or sexual assault, robbery, abuse
• serious car crashes and other accidents
• natural disasters, fires, mass violence
• sudden, violent or unexpected death of a loved one
• a frightening medical event, such as a heart attack, ICU stay or difficult childbirth
• combat and first-responder work

Rates are highest after interpersonal violence. Risk is higher with:

• previous trauma or earlier mental health problems
• the severity of the event and injury
• dissociation during the event
• lack of social support afterward
• ongoing stress, such as legal or financial problems after the event
• female sex

Diagnosis

A doctor, psychologist or psychiatrist diagnoses ASD through an interview about the event, symptoms and their effect on daily life. Questionnaires such as the Acute Stress Disorder Scale may be used. The clinician checks for head injury, substance use, medical conditions and other mental health problems, and asks about safety and suicidal thoughts.

Treatment

Psychological treatment

• Trauma-focused cognitive behavioral therapy (TF-CBT): the best-supported treatment. It typically involves 5 to 12 sessions that help you process the memory, challenge unhelpful beliefs (such as "it was my fault" or "the world is completely unsafe") and gradually face avoided reminders.
• Eye movement desensitization and reprocessing (EMDR): used for PTSD and sometimes for early trauma symptoms.

Psychological debriefing, a single session in which people are asked to describe the event in detail soon after it, is not recommended. It does not prevent PTSD and may make things worse for some.

Medicines

There is no medicine that reliably prevents PTSD. Short-term medicines may be used for specific symptoms, such as sleep problems. Benzodiazepines are generally avoided in the early weeks after trauma, as they may interfere with recovery. SSRIs are used if symptoms persist or develop into PTSD or depression.

Practical support and self-care

• Spend time with people you trust and accept practical help.
• Keep to a daily routine of meals, sleep and activity.
• Limit alcohol, cannabis and caffeine.
• Reduce exposure to repeated news or social media coverage of the event.
• Try slow breathing and grounding techniques: name 5 things you see, 4 you hear, 3 you can touch.
• Return gradually to normal activities rather than avoiding everything.
• Be patient: ups and downs are normal in the first weeks.

Outlook

Many people with ASD recover fully, especially with support and early therapy. Without treatment, roughly half go on to develop PTSD. ASD is a strong warning sign rather than a certainty. Other possible outcomes include depression, anxiety disorders and substance use problems, which also respond to treatment.

Frequently asked questions

What are the symptoms of acute stress disorder?

Symptoms include intrusive memories, nightmares and flashbacks; feeling numb, unreal or detached; avoiding reminders of the event; and being on edge, with poor sleep, irritability, poor concentration and a strong startle response. They start within a month of the trauma and last 3 days to 1 month.

What is the difference between acute stress disorder and PTSD?

The main difference is timing. Acute stress disorder lasts from 3 days to 1 month after a trauma. If similar symptoms continue beyond a month, the diagnosis becomes PTSD. Acute stress disorder places more emphasis on dissociative symptoms such as feeling unreal.

What is an acute stress reaction?

An acute stress reaction is the immediate, normal response to a shocking event, with symptoms such as shock, anxiety, confusion and tearfulness that usually settle within hours to a few days. Acute stress disorder is diagnosed when symptoms are more severe and persist beyond 3 days.

How is acute stress disorder treated?

The most effective treatment is trauma-focused cognitive behavioral therapy, usually over a few weeks. Social support, routine, good sleep and avoiding alcohol help recovery. Medicines may be used for sleep or severe anxiety, but single-session debriefing is not recommended.

Can acute stress disorder go away on its own?

It can. Many people improve naturally over the first month, especially with support from family and friends. However, about half develop PTSD without treatment, so seeing a mental health professional early is worthwhile, particularly if symptoms are severe.