Acute Stress Disorder as a Predictor of Posttraumatic Stress Disorder a Systematic Review

Astute stress disorder is a new psychiatric diagnosis in DSM-IV that includes a set of symptoms experienced by some individuals presently subsequently a traumatic issue. To be diagnosed as suffering from acute stress disorder the individual must exhibit at least three dissociative symptoms along with at least ane intrusion, abstention, and hyperarousal symptom. In addition, the symptoms must cause clinically significant difficulties in functioning and persist ii–28 days. Likewise, the reaction must not be due to the ingestion of substances or to a general medical condition or be owing to a brief psychotic disorder or a preexisting axis I or axis Ii disorder.

This diagnosis is based on a big trunk of inquiry dating back to Lindemann's archetype paper (1) in which he described survivors' immediate reactions to the Coconut Grove fire. Since Lindemann's observations there take been numerous studies that have reports of dissociative, abstention, and hyperarousal symptoms shortly afterward traumatic experiences (2–10). The specific diagnostic criteria for acute stress disorder were based on empirical evidence from studies that systematically documented acute stress reactions in response to traumatic events (ii–4, 7).

The scientific basis for the diagnostic category of acute stress disorder was too justified past research showing that dissociative reactions immediately afterwards a traumatic experience predicted afterward posttraumatic stress disorder (PTSD) symptoms (2–4, vii, 11–14). These studies were conducted before the final definition of acute stress disorder and its inclusion in DSM-Four and, therefore, did not include a systematic assessment of all acute stress disorder symptoms and their relationship with afterward PTSD symptoms. To our knowledge, no published research has systematically examined the human relationship betwixt acute stress disorder and PTSD symptoms, despite the assumption stated in DSM-Four that acute stress disorder can lead to PTSD. Therefore, we conducted a study to examine the human relationship between acute stress disorder symptoms and PTSD symptoms.

Along with documenting the human relationship betwixt acute stress disorder symptoms and PTSD symptoms, in the nowadays study we examined this relationship inside the context of two other factors, gender and degree of exposure to the traumatic event. Gender has been shown to be associated with astute stress reactions (xv) and PTSD symptoms (16–nineteen), with women reporting the most symptoms. Degree of exposure to the traumatic event has been found to be associated with the level of symptoms post-obit a traumatic event (seven, 8, xiv, 19–26), although in one anecdotal study no such relationship was found (27).

The hypotheses in this written report were as follows: 1) meeting all of the symptom criteria for acute stress disorder would predict subsequent PTSD symptoms, ii) women would be more likely than men to exhibit PTSD symptoms, and iii) caste of exposure to the threat would exist positively associated with PTSD symptoms. Along with gender, other demographic variables (instruction and marital status) were included in the analyses in order to control for their contribution to the development of PTSD symptoms.

The traumatic incident examined was the shooting of persons by a gunman in an part edifice where the respondents in this report worked. Unfortunately, such events are not rare. In 1993, a chiliad employees in the Usa were murdered at their places of work (28). Research suggests that persons who are bystanders, such as other employees, are deeply affected by these events. Several studies have examined stress reactions to existence a bystander to shootings (24, 29–31). These studies indicated that acute stress reactions to such an event are normal. Notwithstanding, some individuals may exhibit more than extreme reactions to the result, warranting a diagnosis of acute stress disorder in the firsthand aftermath, and may afterwards experience posttraumatic stress symptoms.

We conducted a study of employees working in an role building where a shooting spree occurred during the workday. Nosotros examined their astute stress reactions in the immediate aftermath of this event. Their posttraumatic stress symptoms were assessed vii to 10 months later.

METHOD

The Traumatic Effect

On the afternoon of Thursday, July 1, 1993, 14 persons were shot on ii floors and in the stairwell of a high-ascent office building at 101 California Street in San Francisco. Eight persons, including the gunman, were shot fatally. Many employees were trapped within the building for hours while police officers tried to terminate the gunman, and there were rumors that at that place were at least two gunmen on the loose. Within 8 days after the shootings, 36 employees from two firms on nearby floors of the building attended a crisis intervention session and completed questionnaires about their acute distress symptoms and other reactions.

Study Grouping

After obtaining permission from our institutional homo subjects review committee to perform this study, nosotros were granted permission from ii firms to meet with their employees to offer a crisis intervention session and to seek their participation in this study. Before the intervention and data drove, the subjects were fully informed regarding the crisis intervention and the data collection. They were invited to participate in the intervention session and were told that their participation in the intervention in no way obligated them to participate in the study. The intervention took approximately 1 hour and consisted of inviting the employees to describe the thoughts and feelings they had had both during and after the traumatic consequence, providing a brief overview of mutual reactions to trauma as a mode of normalizing their experience, providing suggestions for what they could exercise to help themselves integrate the experience then motility on in their lives, and describing how to determine whether they required professional help.

After the crisis intervention session, the written report was introduced, the procedure of the study was fully explained, and the employees were once again reminded that they were nether no obligation to participate. Written informed consent was received, and the questionnaires were distributed; 36 employees completed the questionnaires. All worked in the office building where the shootings occurred; 26 worked in one firm and ten worked in some other. All questionnaires were completed within 8 days after the shootings. A follow-up assessment was mailed to the participants 7 months later, and follow-up mailings and phone calls were conducted to encourage willing participants to complete this follow-up assessment. Of the 36 persons who participated in the original assessment, 32 (89%) completed the follow-up assessment.

Measures

Demographic characteristics. The respondents provided demographic data in a self-report questionnaire. The variables assessed were sexual practice, age, marital status, and years of education.

Ratings of the threatening event. An additive exposure scale assessed the degree of contact that the respondents had with the traumatic outcome. The types of exposure included being in the function building at the time of the shooting and seeing the S.Due west.A.T. (police tactical) team. None of the subjects saw the gunman or his victims. The respondents were asked to indicate whether they had experienced each of these forms of exposure to the event. Exposure was scored every bit 0 if the respondent was not in the building at the fourth dimension, 1 if the respondent was in the building but did not run into the South.Westward.A.T. team, and 2 if the respondent was in the building and saw the S.Due west.A.T. squad.

The respondents were asked to rate how disturbing their experience with this event was, on a scale of 0–ten, where 0 represented "not at all disturbing" and 10 indicated "extremely disturbing."

Stanford Acute Stress Reaction Questionnaire. This self-study measure asks the respondent to indicate the frequency with which he or she experiences a variety of symptoms during or after a stressful consequence. Versions of this measure out have been used in studies that have assessed astute reactions to an convulsion (2), witnessing an execution (4), and a firestorm (vii). This version of the Stanford Acute Stress Reaction Questionnaire assessed four types of symptoms matching the criteria for a diagnosis of acute stress disorder: dissociation (ix items, e.grand., "I experienced myself as though I were a stranger"); hyperarousal (v items, e.grand., "I felt hypervigilant or on border"); reexperiencing the traumatic event (six items, e.1000., "I had repeated and unwanted memories of the shootings"); and avoidance of reminders of the traumatic event (two items, due east.m., "I tried to avoid activities or situations that reminded me of the shootings"). Internal consistency for this group of subjects, based on Cronbach's blastoff, was high overall (0.93) and too for the detail symptom subscales of the questionnaire (0.72–0.88).

Bear upon of Upshot Scale. The Impact of Result Scale (32) is a cocky-written report measure assessing the degree of subjective distress experienced afterward a stressful life event. In this study, the Impact of Outcome Scale was used in the seven-month follow-upward assessment as an additional measure out of PTSD symptoms. Individuals were asked to rate the frequency with which they had had intrusive or avoidant experiences in the 7 days before cess. Intrusive experiences include unwanted thoughts, feelings, or images of the trauma (east.grand., "Pictures about it popped into my listen"). Avoidant experiences include having tried to avoid reminders of the trauma or to dull emotional reactions to it (e.grand., "I stayed away from reminders of it"). Internal consistency (Cronbach's alpha) for this grouping was high overall (0.91) and for both subscales (intrusion=0.89, avoidance=0.88).

Davidson Trauma Calibration. The Davidson Trauma Scale (33) was developed to assess each of the symptoms in DSM-IV needed for a diagnosis of PTSD. This instrument comprises 17 items inquiring virtually frequency and severity of PTSD symptoms within the past week; frequency is assessed on a 0–iv-point scale in which 0 represents "non at all" and 4 indicates "every day," and severity is assessed on a 0–4-point calibration in which 0 represents "not at all distressing" and 4 means "extremely distressing." This instrument is used to appraise PTSD symptoms and has been validated with adult survivors of childhood sexual abuse (33), rape survivors, and Hurricane Andrew survivors (Davidson, unpublished manuscript). Its internal consistency is fantabulous; the Cronbach's alpha was 0.91 in a exam with rape survivors. Its criterion validity was evidenced in the studies of both rape and hurricane survivors, in which the survivors diagnosed as having PTSD (with the Structured Clinical Interview for DSM-III-R) had significantly higher hateful scores than did the survivors non meeting the diagnostic criteria for PTSD. Also, this measure'due south concurrent validity is supported by strong correlations with the scores on the Impact of Event Scale of rape survivors and with the SCL-90 global severity scores, feet subscale scores, and low subscale scores of hurricane survivors (Davidson, unpublished manuscript). Internal consistency for this study group was high (Cronbach's alpha=0.92). To yield a summary score on this measure, we tallied the number of symptoms experienced at to the lowest degree once in the past week (at to the lowest degree twice for recurrent symptoms) that were minimally to extremely distressing.

Data Analysis

Means, standard deviations, and frequencies were computed to summarize the distribution of values for each variable. To test the relationships betwixt PTSD symptoms and the independent variables, we conducted multiple regression analysis to analyze PTSD symptoms (assessed as number of symptoms reported on the Davidson Trauma Scale and subscale scores on the intrusion and avoidance subscales of the Impact of Event Calibration) by 3 blocks of independent variables, entered hierarchically. In the outset block we used the stepwise forward procedure with the variables of sexual practice, age, years of instruction, and marital status to examine for preexisting demographic differences that could account for the variance in posttraumatic stress symptoms. In the 2nd block we over again used the stepwise forward process and entered the degree of exposure to the threatening consequence, and in the third block we entered whether the respondent met the symptom criteria for an acute stress disorder diagnosis. Using this analytic strategy, nosotros were able to examine whether any significant variance in PTSD symptoms was associated with demographic and exposure variables before nosotros analyzed the variance in PTSD symptoms associated with meeting the criteria for acute stress disorder, the variable of most interest. To clarify the relationships betwixt specific symptoms of acute stress disorder and PTSD symptoms, we computed Pearson's product moment correlations between the four types of acute stress disorder symptoms (dissociation, hyperarousal, intrusion, and avoidance) and the three measures of PTSD symptoms.

RESULTS

Univariate Statistics on Independent and Dependent Variables

Of the 36 employees, 24 (67%) were women. The employees ranged in age from 22 to 74 years (mean=33.2, SD=ten.four) and ranged in instruction from high schoolhouse diploma to graduate school, with lxxx% having completed higher (28 of 35). Their marital status distribution (North=35) was every bit follows: unmarried, 54% (N=nineteen); married, 34% (N=12); and divorced, 11% (N=four).

The majority of the respondents (69%, N=25) were in the building at the time of the shooting and saw the S.W.A.T. team, 17% of the respondents (N=vi) were trapped in the building only did not see the S.Due west.A.T. team, and 14% (N=5) neither were trapped in the building nor saw the S.W.A.T. team. None of our subjects really saw the gunman or the victims.

When asked how disturbing the outcome was, the respondents gave the event a mean rating of 6.nine (SD=two.6). This is near 2 points above v, which is labeled "moderately agonizing."

Of the 36 subjects, 12 (33%) met the criteria for the acute stress disorder diagnosis. The respondents experienced a mean of two.0 dissociative symptoms (SD=one.5) out of a possible five symptoms, a mean of 1.3 symptoms of reexperiencing the traumatic effect (SD=i.3) out of 5, a mean of ii.seven symptoms of feet and hyperarousal (SD=1.7) out of five, and a mean of one.0 of 2 possible symptoms of fugitive reminders of the upshot (SD=0.9).

At the 7–10-calendar month follow-upwardly assessment, 32 of the 36 respondents completed the questionnaires, although one of these respondents did not complete the Davidson Trauma Calibration. The respondents' mean frequency of PTSD symptoms reported on the Davidson Trauma Scale was two.5 (SD=3.9) out of a possible iv. Also, the respondents' hateful score at follow-upwardly on the Bear upon of Event Scale intrusion subscale was seven.9 (SD=seven.8); their hateful score on the abstention subscale was 8.1 (SD=ix.3).

Relation of PTSD Symptoms to Astute Stress Disorder, Trauma Exposure, and Demographic Characteristics

The overall regression models were pregnant for predicting overall posttraumatic stress frequency scores on the Davidson Trauma Scale (F=five.86, df=1,27, p<0.05, adjusted R²=0.15), frequency of intrusive symptoms as indicated by the intrusion subscale of the Impact of Upshot Calibration (F=30.38, df=one,28, p<0.0001, adjusted R²=0.fifty), and frequency of abstention symptoms as indicated past the avoidance subscale of the Bear on of Outcome Scale (F=21.25, df=1,28, p<0.0001, adjusted R²=0.41). The results supported the hypothesis that PTSD symptoms were associated with meeting all of the symptom criteria for astute stress disorder; however, PTSD symptoms were not significantly related to exposure to the traumatic event, contrary to our hypothesis. None of the demographic variables was significantly related to whatsoever of the measures of PTSD symptoms, thereby providing no support for the hypothesis that women would be more likely to show PTSD symptoms. Meeting the criteria for the acute stress disorder diagnosis was significantly related to the overall posttraumatic stress frequency score on the Davidson Trauma Scale (B=3.39, SE=1.40, t=ii.42, df=one,27, p<0.05), to frequency of intrusive symptoms as indicated past the intrusion subscale of the Impact of Result Calibration (B=11.79, SE=2.xiii, t=v.51, df=1,28, p<0.0001), and to frequency of avoidance symptoms as indicated by the avoidance subscale of the Impact of Upshot Scale (B=12.70, SE=2.76, t=iv.61, df=ane,28, p<0.0001).

Relation of Acute Stress Disorder to PTSD Symptoms

Table i shows the Pearson'due south product moment correlation coefficients for the association between acute stress disorder symptoms and PTSD symptoms in response to the shootings. All but two of the 15 relationships were statistically significant and in the positive direction. This showed that iii of the four symptoms included in the acute stress disorder diagnosis (dissociation, reexperiencing, and avoidance) and the overall diagnosis were strongly related to the frequency of experiencing posttraumatic stress symptoms. Hyperarousal was establish to be positively correlated with intrusion, although it was non significantly correlated with overall PTSD or avoidance.

DISCUSSION

This written report provides evidence that acute stress disorder predicts PTSD. As hypothesized, individuals who met all of the symptom criteria for acute stress disorder were more likely to report PTSD symptoms seven to 10 months later. Yet, neither extent of exposure to the traumatic event nor gender was establish to predict PTSD symptoms. An exploratory analysis showed that 3 of the four symptoms included in the acute stress disorder diagnosis (dissociation, reexperiencing the traumatic event, and avoidance) and the overall diagnosis of acute stress disorder were strongly related to the frequency of experiencing PTSD symptoms. Of these acute stress disorder symptoms, dissociation in response to the trauma was found to be one of the strongest predictors of PTSD symptoms 7 to 10 months later. This suggests that dissociation may exist a central symptom of acute stress disorder. Hyperarousal was found to predict intrusion at follow-up but not abstention or overall posttraumatic stress. This suggests that hyperarousal might be less important as a predictor of PTSD.

In that location are several limitations to this study. The main limitation is that the subjects were not formally diagnosed past a clinician equally having either acute stress disorder or PTSD. Instead, the diagnoses were based on paper-and-pencil measures that were designed to appraise some only not all diagnostic criteria. The measures did non assess whether the symptoms acquired clinically meaning distress or harm in functioning, which is necessary for a formal diagnosis of acute stress disorder or PTSD. Also, other diagnoses that may take accounted for the astute stress disorder symptoms were not ruled out.

The report group in this study was small, the subjects were not randomly selected, and at that place was no command group. The subjects were recruited from 2 nearby floors and consisted of individuals who had agreed to participate after having received a crisis intervention session. A larger group of subjects randomly selected from all floors would have been better. It would have given the states greater ability to exam our hypotheses, ensured varying degrees of exposure, and circumvented the problem of having subjects who were self-selected on the basis of their desire for crisis intervention. Having a control group that experienced the traumatic outcome and did not receive an intervention would have enabled us to also examine the human relationship between acute stress disorder and PTSD symptoms when at that place is no intervention.

Our clinical impression was that the debriefing was experienced equally beneficial. The participants appeared relieved to be able to share their experiences with others and to learn that they were non lonely in their reactions. Several commented on the helpfulness of the intervention. Thus, to the extent that the intervention was effective, the human relationship between acute stress disorder and PTSD symptoms may be underestimated.

In this written report we did not find a relationship betwixt exposure and PTSD symptoms, and this negative finding might be due to the small number of subjects or to a restricted range of exposure. Additionally, information technology may be considering our measure out of exposure lacked sensitivity. In addition, the small number of subjects precluded examining the office of astute stress disorder relative to other predictors of PTSD, such every bit stressful life events (11).

All the same these limitations, the results suggest that when individuals experience a traumatic event and suffer from astute stress disorder, they may besides be vulnerable to developing PTSD and might benefit from immediate treatment (34–36). Given the role of dissociation in acute reactions to a traumatic event, affected individuals are likely to distance themselves from the upshot through amnesia, depersonalization, derealization, or other means, thereby avoiding the "grief work" necessary to working through the traumatic experience and putting it into perspective (1, 37, 38). Sufferers of acute stress disorder are likely to split off the event from their feel if untreated.

Thus, individuals who have experienced a traumatic issue should be given the opportunity to process it. The goals should include normalizing the reactions to the trauma, providing a prophylactic environment that enables the expression of strong feelings, enhancing understanding, and making pregnant out of the feel (38, 39).

Another implication of this study is that when individuals are non directly the targets of violence just experience only the threat of violence, they too are vulnerable to developing astute stress disorder and PTSD. A full one-tertiary of the individuals in this study met the symptom criteria for acute stress disorder and were more likely to develop PTSD symptoms. These were individuals who never actually saw the gunman, although several individuals stated that they saw a member of the S.W.A.T. team and momentarily idea it was the gunman. Nevertheless, there was only the threat of violence, and it was sufficient for development of symptoms.

The results of this report suggest that individuals who are exposed to violence may develop acute stress disorder as a precursor to PTSD symptoms. Given the increasingly vehement nature of our society, this puts substantial numbers of individuals at gamble of developing psychological problems. Given the predictive value of acute stress disorder symptoms, they provide an opportunity for early on case identification and intervention to prevent the development of PTSD.

TABLE 1

Received March 25, 1996; revisions received Feb. 19 and July xi, 1997; accepted Sept. 18, 1997. From the Section of Psychiatry and Behavioral Sciences, Stanford Academy School of Medicine, and the Department of Psychiatry, University of California, Davis. Accost reprint requests to Dr. Classen, Department of Psychiatry and Behavioral Sciences, Stanford University Schoolhouse of Medicine, Stanford, CA 94305-5718; [electronic mail protected] (east-mail). Supported by grants from the John D. and Catherine T. MacArthur Foundation and the American Psychiatric Association. The authors give thanks Ami Atkinson, John Mori, and the persons who participated in the study.

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