Introduction

Acute Stress Disorder (ASD) is a group of several acute stress reactions that occur between three days and four weeks after a traumatic event has taken place.¹ The amount of time someone suffers with these symptoms is what differentiates Post-Traumatic Stress Disorder (PTSD) and ASD. PTSD occurs after someone has witnessed or been involved in a traumatic event and has experienced several symptoms for longer than a month.^1,2 Identifying the risk factors of ASD would not only help identify vulnerable individuals but also allow healthcare providers to provide early and personalised intervention.³

What is acute stress disorder? 

While the majority of people in life will go through at least one traumatic event, the exact reason that ASD occurs isn’t known. For most people, when a traumatic event occurs, there is usually a context or something that was distinct but had nothing to do with the event itself, for example, maybe the smell of something or, for context, the time of day. Our brains would then associate those things with the traumatic event, and we would then begin to feel the fear and the panic we had felt in those events. However, with time, most of these feelings begin to decrease naturally, and you don’t associate them with the event, and the feelings stop, but for people with ASD, this isn’t the case.¹

Common triggers for ASD

The triggers for ASD are usually: accidents on the road, witnessing conflicts and terrorist acts, natural disasters, and assaults (physical or sexual).⁴ 

• Experiencing or witnessing a traumatic event
• Having dreams or memories of the event which causes a negative emotion
• Flashbacks 
• The person feeling upset or distressed in remembrance of the event, due to context or the situation, is reminded of the event
• Feelings of sadness
• Dissociation
• Avoiding anything to do with the event, such as feelings, places, memories, and people
• issues with sleep¹

The timing of ASD is between 3 days and four weeks, so this timing and the presence of these symptoms would ultimately lead to a diagnosis of ASD.¹

Categories of risk factors

There are different risk factors when talking about ASD, and these are divided into three categories: pre-trauma factors, peri-trauma factors and post-trauma factors. Pre-trauma factors are factors that may increase someone’s chance of getting ASD before the event has taken place. Peri-trauma factors are factors that would increase someone’s chance of getting ASD during the event, and post-trauma factors are what increase the chances of someone having ASD after the event.⁵

Pre-trauma risk factors

Many different pre-trauma factors can increase the risk of someone having ASD before the traumatic event has occurred. These include: 

• Sex - People who are assigned female at birth are at a higher risk of ASD 
• Level of education¹
• Mental health disorders before the incident, such as depression, PTSD and anxiety⁶
• Past traumatic events^1,7
• Personality traits - Such as how they cope with stress and how stressed they are⁷
• Age - younger people are more likely to get ASD³

Peri-trauma risk factors (during the event)

The types of events that are more likely to cause peri-traumatic risk factors are events such as assault, rape, injury and also the severity of the trauma.¹ These events usually involve a threat to life and a lack of control. The peri-trauma risk factors that increase the severity of ASD are peri-trauma panic, peri-traumatic dissociation, anxiety and cognitive responses.⁸

Peri-trauma panic is one of the common risk factors of ASD severity; it involves fear of dying, nausea, loss of control, shaking, sweating, heart palpitations, and shortness of breath. Peri-traumatic dissociation involves feelings such as derealisation, depersonalisation, detachment from others and their surroundings and numbness during the event itself.

The reason it is one of the peri-traumatic risk factors is that it affects the person's ability to process their memories of the traumatic event. Cognitive responses, such as negative cognition about themselves, have been the strongest risk factor for not only ASD but also PTSD.⁸ 

The other risk factors include being injured in the event and the person's proximity to the event, for example, if it was an explosion.⁷

Post-trauma risk factors

Things such as financial situations and support situations also increase or decrease the chance of ASD, as those can present as additional stressors.⁷ Social support significantly decreases or increases the risk of ASD compared to those with adequate or good support systems.

This may be due to the lack of support, leading to stress related to the trauma and also making it more difficult to cope well. Prolonged hospital stays and medical complications were also seen as post-trauma risk factors.⁴ Another important post-trauma risk factor is the person's interpretation of the event.⁹

High-risk groups 

Certain groups of individuals are at a higher risk of getting ASD. One of these groups of individuals is victims of violent crimes, who are at a higher risk of ASD. A subsection of this specific group is women, as they are more likely to have ASD than men. Women also tend to have more peri-traumatic stress.¹⁰

Another group of individuals are those with traumatic spinal injury patients’ variables, such as income, gender, the severity of their injuries, and age, which affected their likelihood of ASD. This shows that those who have clinical injuries are important high-risk groups as well, and that not only violent trauma can cause ASD.¹¹

Violent events and severe injuries result in the continuous cycle of stress responses seen in ASD. The ASD from events such as car accidents has been seen to overlap with an individual's susceptibility to PTSD. This shows that survivors of accidents are another high-risk group.¹²

How these risk factors interact

Having multiple types of traumatic experiences in your life is a direct and independent predictor of ASD symptoms. This supports the ‘tipping point’ effect in which all the traumatic experiences are like a tower of blocks, and adding a traumatic experience is like adding another tower until one experience causes the tower block to fall, leading to ASD.¹³

With anxiety, depression and neuroticism tendencies being pre-traumatic symptoms, it adds to the fact that they are risk factors that increase the chance of ASD occurring. With social support and context also playing a role, the psychological and personality traits could lead to much stronger responses to the traumatic event and therefore increase the likelihood of ASD.³

The Diathesis–Stress model is a model used to describe the idea that vulnerabilities that are preexisting in an individual interact with life stresses, which then produce a psychological disorder such as ASD. This model could explain why two individuals who have been through the same traumatic experience then have different outcomes or recover mentally from it differently.¹⁴

Having multiple of these different risk factors can increase the chance of ASD occurring. 

When to seek professional help

The areas in which healthcare providers look out for any changes and for a patient's well-being are: 

• The safety of the patient
• Emotional support is available for the patient 
• Practical support 
• Providing follow-ups 
• Assessing the risk of suicide¹

Psychotherapy treatments

The usual psychotherapy treatment for ASD is cognitive behavioural therapy (CBT).¹ CBT aims to reduce the feelings you have in certain situations by trying to approach the problem in different ways.¹⁵

Pharmaceuticals treatments 

There is no current drug on the market that is designated or works well with ASD. The use of serotonin inhibitors (SRIs) and propanol has been tried but has not been seen to be effective in ASD. However, selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs) are highly effective in those with PTSD. When patients don’t particularly respond well to those previously mentioned treatments, including CBT, that is when second-generation antipsychotics are used.¹

Summary 

Acute stress disorder (ASD) is a condition that develops immediately after a trauma has occurred, and not all of those who experience traumatic events develop ASD.¹ Pre-trauma, peri-trauma and post-traumatic risk factors and the interaction of prior mental health conditions, personality traits, prior trauma, how traumatic the event was, limited social support and financial support all contribute to the risk of developing ASD symptoms.

The diathesis-stress framework highlights how an individual's predispositions and the trauma from the event interact and explain why one person may develop ASD while another won’t. Early recognition of populations at risk may help them with the early targeted delivery to support patients in the best way for them.