See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/23758805

Acute stress responses: a review and synthesis of ASD, ASR, and CSR
Article in American Journal of Orthopsychiatry · November 2008
DOI: 10.1037/a0014304 · Source: PubMed

CITATIONS READS

29 252

3 authors:

Leanna Isserlin Gadi Zerach

University of Ottawa Ariel University
8 PUBLICATIONS 159 CITATIONS 55 PUBLICATIONS 600 CITATIONS

SEE PROFILE SEE PROFILE

Zahava Solomon
Tel Aviv University
448 PUBLICATIONS 12,010 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Elaboration on Posttraumatic Stress Disorder Diagnostic Criteria: A Factor Analytic Study of PTSD Exposure to War or Terror View project Gender

Diversity clinic QI View project

All content following this page was uploaded by Gadi Zerach on 27 May 2014.

The user has requested enhancement of the downloaded file.

American Journal of Orthopsychiatry Copyright 2008 by the American Psychological Association
2008, Vol. 78, No. 4, 423–429 0002-9432/08/$12.00 DOI: 10.1037/a0014304
 Acute Stress Responses: A Review and Synthesis of ASD, ASR, and CSR
Leanna Isserlin, MD Gadi Zerach, PhD, and Zahava Solomon, PhD
University of Western Ontario Tel Aviv University
Toward the development of a unifying diagnosis for acute stress responses this article attempts to find a
place for combat stress reaction (CSR) within the spectrum of other defined acute stress responses. This
article critically compares the diagnostic criteria of acute stress disorder (ASD), acute stress reaction
(ASR), and CSR. Prospective studies concerning the predictive value of ASD, ASR, and CSR are
reviewed. Questions, recommendations, and implications for clinical practice are raised concerning the
completeness of the current acute stress response diagnoses, the heterogeneity of different stressors, the
scope of expected outcomes, and the importance of decline in function as an indicator of future
psychological, psychiatric, and somatic distress.

Keywords: acute stress disorder, acute stress reaction, combat stress reaction
Initial responses to trauma include emotional, cognitive, somatic,
and behavioral symptoms (for extensive reviews, see Bryant, 2003;
Shalev, 2002). Both theoretical perspectives and empirical findings
have served to validate a unique set of diagnoses describing these
responses (e.g., Bryant & Harvey, 2000). In the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text revision
[DSM–IV–TR]; American Psychiatric Association, 2000), these
responses are classified under Acute Stress Disorder (ASD) and in
the International Classification of Diseases (10th rev. [ICD–10];
World Health Organization, 1992) they are classified under Acute
Stress Reaction (ASR). In the field of military psychiatry the
definition of the acute stress response has been described using
many terms such as war neuroses, battle fatigue, or shell shock, and
more recently, combat stress reaction (CSR). Although seemingly
different with regards to formulation these three diagnoses (i.e.,
ASD, ASR, and CSR) are all essentially attempts at describing the
same clinical entity. Given the multiple sites of ongoing conflict
and concerns of global terrorism it is of timely importance that we
gather and integrate our knowledge with regards to trauma
responses.
Regardless of the definition used or the trauma experienced, the
effects and evolution of the responses is remarkably similar as
illustrated by subjective descriptions shared by survivors of
different traumatic events:
What we went through in Yom Kippur war wasn’t pleasant . . . I saw
a lot of wounded and a lot of guys who died of their wounds because
we couldn’t reach them. They cried out for help. The shelling was
heavy, and you can’t get to them. And all the while they’re
slaughtering, and the wounded are dying like flies.
I remembered the feeling of utter impotence. In just another
423
minute, they’ll finish me off. I’ll die. And there’s no way out. I was
I remember that I went down the market to buy vegetables and other
products. Then suddenly I heard this explosion. I don’t remember a lot
from those moments, I just started to run in the other direction. It all
looked like a movie to me. Like it is not real. It can’t be happening to
me. Today I can’t go to the market. When I need to pass this area I will
take the longer way. Just not to see it and remember. I also can’t handle
the smell its bringing me the taste of mud and blood.
—Bystander at scene of suicide bomber in Israel (R. B., personal
communication, October 26, 2005)
There’s always something to remind me, crawling into my mind,
unbidden, for no obvious reason, in the shower, in line at the grocery
store, I guess just because it is always there . . . I panicked at the rumble
of freight elevators and low flying planes; I dreamed about running
from my life. There was no way to escape . . . Every night I went home
with the air smelled of smoke, the missing stared from fliers on every
corner, and my wife never wanted to let me out of her sight again . . .
I was trying to find some way to talk about what I saw, heard and
tasted, someway to articulate the emptiness that crawled beneath my
skin.
—Survivor of World Trade disaster (Lisberg, 2005, pp. 126–127)
Toward the development of a unified and comprehensive
definition for the acute stress response this article reviews the
knowledge currently available and attempts to integrate insights
gained from CSR veteran studies into the realm of nonmilitary
psychiatry. As an initial step our article aims to: (a) provide a
critical comparison among ASD, ASR, and CSR definitions; (b)
present findings from prospective studies of ASD, ASR, and CSR
that will enable examination of the predictive value of the current
acute stress response definitions; and (c) raise nosological
considerations and challenges for further research concerning
future diagnostic criteria of acute stress responses.

Leanna Isserlin, MD, Department of Psychiatry, University of Western

Ontario, London, Ontario, Canada; Gadi Zerach, PhD, and Zahava
Solomon, PhD, The Bob Shappell School of Social Work, Tel Aviv
University, Tel Aviv, Israel.
For reprints and correspondence: Leanna Isserlin, MD, Department of
Psychiatry, University of Western Ontario, London, Ontario, Canada. E-
mail: lrutherf@uwo.ca
waiting for a miracle. I asked myself, “Why the hell did you
volunteer for the parachutists, of all things? Who needs it? What am
I doing here?” I saw dying men, soldiers of mine, who’d been
training for several months, call me to help them, I couldn’t have
gone. I wanted to talk, but found myself crying. I was sweating.
Crying and trembling, I was shaking, shaking like a leaf. A madness
of fear . . . I was rooted in one spot. I was lying there and couldn’t
get up.
—Soldier of 1982 Lebanon War (Solomon, 1993, pp. 41–42)
Comparison: ASD, ASR and CSR
The way in which a psychiatric condition is conceptualized and
defined has a significant impact on both the clinical identification
threshold and the further investigation of the nature and prevalence
of the condition. Thus it is important to consider the potential
strengths and weaknesses of each approach as well as the links
among them. ASD, ASR, and CSR can be compared and contrasted
with regard to multiple features including the tradition on which
they are based; the setting in which they have been used and
studied; the stressor criterion described, the time frame, and clinical
picture; and the importance placed on functional decline (see Table
1).
The first important contrasting feature is the fact that ASD was
developed for its prognostic value (Spiegel, Classen, Cardena &
Classen, 1996) in which ASR and CSR are more descriptive in
 424 ISSERLIN, ZERACH, AND SOLOMAN
nature. It has been argued by some that because the prevalence of
acute symptoms in the aftermath of trauma is initially quite high
and diminishes spontaneously in many individuals, that the value
of an acute stress response diagnosis lies solely in its ability to
identify those at risk for long term sequelae (Bryant & Harvey,
2000). However, in the midst of a traumatic event, immediate
symptoms and poor functioning have significant implications and
thus identification of acute conditions may also hold intrinsic value
beyond identifying those at risk for future consequences.
The second important difference among ASR, ASD, and CSR is
the type of events and setting on which they were based (i.e., single
and circumscribed vs. wide-spread and cumulative). The feasibility
and precision of ASR, ASD, and CSR in circumstances other than
those for which they were developed is an unanswered but
important question. Furthermore, the accuracy of diagnosis may be
compromised when clinicians themselves are experiencing various
ongoing stressors.
The third area of difference among ASD, ASR, and CSR is the
inclusion of a subjective criterion in the definition of the stressor
required for ASD. The relative contribution of this subjective
component remains debatable. On the one hand numerous reports
have demonstrated the importance of the subjective response to the
prediction of posttraumatic stress disorder (PTSD; e.g., Bryant &
Table 1
Comparison of ASD, ASR, and CSR
Harvey, 1996; Speed, Engdahl, Schwartz, & Eberley, 1989). On the
other hand this requirement is problematic in the context of
dissociation that could act to mask any emotional response (Bryant
& Harvey, 2000).
A fourth area of difference to consider is the time frame and
clinical picture of these definitions, with CSR being the most
immediate and inclusive and ASD being more delayed and specific.
These differences in symptom description do not necessary suggest
ASD
Tradition
Means of identifying individuals at risk
of developing PTSD
Setting/events Multiple—mostly single,
circumscribed stressors
Stressors criteria Objective and subjective
Time frame No onset specifiers; lasts 2 days to 1
month
Clinical picture Specific and static
Functional criteria Nonspecific—clinically significant
distress or impairment
Note. ASD acute stress disorder; ASR acute stress reaction; CSR combat stress reaction; PTSD posttraumatic stress disorder.
that ASD, ASR, and CSR are different clinical entities, but rather
they may reflect the natural history of trauma responses. In the
immediate aftermath of trauma symptom constellations are often
amorphous (Yitzhaki, Solomon, & Kotler, 1991). Within a few days
these symptoms of acute distress crystallize into a clinical picture
that resembles PTSD and depression (Shalev et al., 1998). Thus by
focusing on different time periods following the trauma the
different definitions may be describing various phases of the same
condition.
Finally, the role of functional decline in defining and identifying
acute stress responses differs among ASD, ASR, and CSR. ASR
does not include a functional requirement, whereas both CSR and
ASD do to deferring degrees. The inclusion of a functional
requirement is important as it acknowledges that many of the
symptoms seen in these disorders may be adaptive in stressful
situations, but they become pathological when they are so great that
they impair functioning (Solomon, 1993).
Predictive Value of Acute Stress Responses
Multiple studies have been conducted examining the predictive
value of the ASD, ASR, and CSR paradigms. Generally speaking,
studies of ASD have been conducted on victims of acute,
circumscribed traumas involving individual victims and the follow-
up has been relatively short (see Table 2). Only a few studies of
ASR have been conducted and their follow-up period was less than
1 month. Most studies have examined PTSD as the only outcome
variable. In contrast, studies using the CSR diagnosis have included
a longer follow-up period and examined multiple areas of
psychosocial outcomes. We have reviewed the currently available
prospective research on this topic and in this section we review the
predictive value of ASD, ASR, and CSR based on this literature.
ASR CSR
Means of identifying those
Means of describing immediate response
to trauma unable to function as
combatants
Multiple—mostly single, Use in combat—stressors
circumscribed stressors accumulative and wide-spread
Objective Objective
Immediate onset, duration Immediate onset, no duration
48 hr limit
Polymorphic and labile Polymorphic and labile
None Specific—ceasing to function as
a combatant
 SPECIAL SECTION: ACUTE STRESS RESPONSES 425

Table 2
Summary of Prospective Studies of the Relationship Between (ASD and PTSD) Among Adults (1998 to 2006)
Author and year Event N Follow-up Results

Kutz & Dekel (2006) Terrorist 44 4 months 44% who had been initially diagnosed with ASD subsequently developed
attack PTSD
Holeva et al. (2001) MVA 265 4–6 months 72% who had been initially diagnosed with ASD subsequently developed
PTSD; 59% who had been diagnosed with PTSD had diagnosis of
ASD participant classified ASD were 20 times more likely to develop
PTSD
Harvey & Bryant (1998) MVA 71 6 months 78% who had been initially diagnosed with ASD subsequently developed
PTSD; 39% who had been diagnosed with PTSD had diagnosis of ASD

Brewin et al. (1999) Assault 138 6 months 83% who had been initially diagnosed with ASD subsequently developed
PTSD
Hamanaka et al. (2006) MVA 100 6 months 42% who had been initially diagnosed with ASD subsequently developed
PTSD; 72.2% who had been initially diagnosed with ASD or partial
ASD subsequently developed partial or full PTSD
Elklit & Brink (2004) Assault 214 6 months 89% of the initial ASD cases had PTSD at 6 months, and 11% received a
subclinical PTSD diagnosis; 51% of the subclinical ASD cases had
PTSD at 6 months, and 46% received a subclinical PTSD diagnosis
Fuglsang et al. (2004) Traffic 90 6–8 months 28% of the patients who scored above the ASDS cutoff had a PTSD
accident diagnosis according to PDS; using the second cutoff score of 56 for
ASDS total score, 44.4% reached the threshold for PTSD
Ginzburg et al. (2003) Myocardial 116 7 months 6% of the respondents had both ASD and PTSD, 10% did not have ASD
infraction but did have PTSD, and 12% had ASD but not PTSD
Creamer et al. (2004) Severe 307 1 year Only 1% of the sample met criteria for an ASD diagnosis, whereas the
injury incidence of PTSD was 10% at 12 months
Kangas et al. (2005) Cancer 82 1 year 17% who had been initially diagnosed with ASD subsequently developed
PTSD; 12% who had been initially diagnosed with subsyndromal ASD
subsequently developed PTSD
Harvey & Bryant (1999) MVA 56 2 years 63% who had been initially diagnosed with ASD subsequently developed
PTSD; 29% who had been diagnosed with PTSD had diagnosis of ASD

Note. ASD acute stress disorder; PTSD posttraumatic stress disorder; MVA motor vehicle accident.
ASD Studies cancer patients, 46% of assault victims, and 72% of MVA
casualties who met all the criteria for ASD other than the
The value of ASD for predicting PTSD has been examined using
dissociative features later developed PTSD (Elklit & Brink, 2004;
various trauma paradigms. In studies of motor vehicle accidents
Hamanaka et al., 2006; Kangas et al., 2005). Using ASDS scores,
(MVAs) the diagnosis of ASD in the month following the trauma
Fuglsang, Moergeli, and Schnyder (2004) demonstrated that by
correctly predicted the development of PTSD in 42% to 78% of the
using a less stringent score ( 55 total score) they could increase the
participants (Hamanakaet al., 2006; Harvey & Bryant, 1998, 1999;
identification of those who would later develop PTSD from 28% to
Holeva, Tarrier, & Wells, 2001). Taken together these findings
44%. Thus it appears that by excluding dissociation as a necessary
indicate that the ASD diagnosis has value in identifying those who
criterion for ASD the predictive value may increase.
will develop PTSD; however, the same studies indicated that of
Data on outcomes other than PTSD related to acute,
those that developed PTSD only 29% to 73% had been classified as
circumscribed trauma are minimal. However a few studies have
having ASD.
indicated that depression, anxiety, and substance abuse disorders
In populations of assault victims the specificity was slightly
occur both as comorbid disorders and in isolation in the aftermath
better with between 83% and 89% of those diagnosed with PTSD
of trauma (Kangas et al., 2005; Kessler, Sonnega, Bromet &
having been previously diagnosed with ASD (Brewin, Andrews,
Hughes, 1995). Some studies have reported a higher probability of
Rose, & Kirk, 1999; Elklit & Brink, 2004). In medical related
developing depression following ASD (Fullerton, Ursane, & Wang,
traumatic events the sensitivity and specificity are less encouraging.
2004; Wang, Tsay, & Bond, 2005) as well as panic attacks (Nixon
Only 17% to 33% of samples that were originally diagnosed with
& Bryant, 2003). In sum, these results suggest that the diagnosis of
ASD had PTSD between 7 months and 1 year later (Creamer,
ASD may have the potential to identify individuals at higher risk of
O’Donnell, & Pattison, 2004; Ginzburg et al., 2003; Kangas, Henry,
developing a range of sequelae. Further long-term studies are
& Bryant, 2005). Finally, with regards to terrorism, one prospective
needed to clarify the breadth and longitudinal course of these
study found that 4 months after a terror attack, 44% of those initially
impairments following ASD.
diagnosed with ASD went on to be diagnosed of PTSD (Kutz &
Dekel, 2006).
ASR Studies
Recognizing that the full ASD diagnosis may be too restrictive To the best of our knowledge there have been only a few short-
some studies have also examined the potential of subclinical ASD term studies using the current ASR paradigm. These studies
to predict the development of PTSD. There have been two different assessed ASR in earthquake victims. The first examined the
definitions of subclinical ASD used; either a diminished threshold incidence of ASR as well as the incidence of Protracted ASR,
on the Acute Stress Disorder Scale (ASDS; Bryant, Moulds, & defined as ASR lasting greater than 48 hr. They found that 70% of
Guthrie, 2000) or meeting all the criteria for ASD other than having victims met criteria for ASR in the first 48 hr, and that 60%
three dissociative symptoms. Results have shown that 12% of continued to report symptoms after the initial 48 hr (Bergiannaki,
426 ISSERLIN, ZERACH, AND SOLOMAN
Psarros, Varsou, Paparrigopoulos, & Soldatos, 2003). The second
study (Soldatos, Paparrigopoulos, Pappa, & Christodoulou, 2006)
examined the association between ASR diagnosis and the
development of early PTSD. Eighty-five percent of their research
participants fulfilled the diagnostic criteria for ASR, and 43%
developed PTSD. Of those who developed PTSD, 97% had
experienced an episode of ASR.
Thus, the thought that ASR is primarily a transient condition that
resolves within 2 days appears to be presumptuous. In fact, the
diagnosis appears to identify almost all individuals who go on to
develop PTSD. In this way ASR has the potential to identify an
inclusive “at-risk” group of individuals who have experienced a
traumatic event, unfortunately the specificity of this diagnosis is
low. More research is needed to examine ASR across different
types of traumatic events and long-term outcomes.
CSR Studies
The psychiatric consequences of exposure to combat related
stressors have been observed following multiple wars and in many
different cultures (Bar-On, Solomon, Noy, & Nardi, 1986), and
investigators have examined the role of acute responses in
predicting these long-term sequelae.
Archibald and Tuddenham (1965) examined American soldiers
Trajectories of PTSD in Israeli Soldiers Based on Solomon and Mikulincer (2006)
% of veterans
with CSR
(n 131)
Diagnosis and year
PTSD at Year 1 64.12
PTSD at Year 2 58.78
PTSD at Year 3 39.69
PTSD at Year 20 26.72
Note. PTSD posttraumatic stress disorder; CSR combat stress reaction; CI confidence interval.
from World War II and the Korean War 20 years after they had been
diagnosed with combat fatigue. They found that compared to a
noncombat veteran mental health patient group and combat veteran
control group, the soldiers who had suffered from combat fatigue
reported more ongoing stress related symptoms. Three-quarters of
the combat fatigue group felt that their symptoms were interfering
with providing for their families and enjoying their hobbies. Half
stated that they were unsatisfied with their sex lives and were
unduly irritable with their children, and one-third were
unemployed.
In contrast, Kettner (1972) did not find any significant
differences between a small and highly selected group of 35
Swedish soldiers who served in the Congo and had suffered
Table 3
from combat exhaustion compared to matched controls who had not
suffered from combat exhaustion. This finding was thought to be
explained not only by the small sample size and the highly selected
population, but particularly by the low combat stress exposure
compared to veterans of World War II (Solomon,
1993).
The most extensive prospective studies of CSR have been
conducted in Israel examining casualties of combat related trauma
following both the 1973 Yom Kippur and 1982 Lebanon Wars.
Eighteen years after the Yom Kippur War, CSR veterans were
found have lower PTSD recovery rates than comparable control
veterans; 37% of the veterans with antecedent CSR reported to have
suffered from PTSD, compared to 23% of the comparable veterans
without a diagnosis of CSR (Solomon & Kleinhauz, 1996).
Furthermore, these veterans with CSR also had higher rates of
physical symptoms, adverse health practices (Neria, & Koenen,
2003) and general psychiatric symptoms (Neriaet al., 2000).
Similar studies following the Lebanon War have traced the 20-
year longitudinal course of combat-induced psychological,
psychiatric, and somatic conditions in a representative sample of
CSR casualties and matched controls that had participated in similar
levels of combat but had not suffered a CSR episode. Assessments
were conducted at 1, 2, 3, and 20 years after the 1982 war.
With respect to the trajectories of PTSD it was found that soldiers
who suffered from CSR during combat were more likely to develop
PTSD at all four study points (see Table 3). Moreover individuals
in the CSR group showed significantly higher levels of symptoms
across all years and a more persistent course of PTSD. The odds of
CSR casualties endorsing PTSD symptoms uninterruptedly were
6.6 times higher than those of veterans without CSR. Thus CSR can
be seen as a predictor of the later development severe persistent
PTSD (Solomon & Mikulincer, 2006).
PTSD, however, was not the only deleterious outcome observed
in the CSR group. Individuals in this group also endorsed
significantly greater general psychiatric symptomatology and
distress, more difficulties with social functioning (Solomon, Shklar,
Singer & Mikulincer, 2006), and more health related problems than
% of veterans
without CSR
(n 83)
Odds ratios CI
12.05 8.64 4.10–18.19
7.23 11.53 4.69–28.33
6.02 9.63 3.65–25.41
7.23 4.68 1.87–11.70
those in the non-CSR group (Benyamini & Solomon, 2005).
Very few studies have been conducted examining the effects of
ongoing conflict in Iraq and Afghanistan and there are no studies
monitoring the immediate responses to traumatic events in the
theater of operations. The studies that have been published have
reviewed the diagnoses given to soldiers evacuated for psychiatric
reasons (Rundell, 2006; Turner et al., 2005). These studies show
that 5.5 to 6.9% of psychiatrically evacuated soldiers receive a
diagnosis of ASD or ASR. Unfortunately these studies are
retrospective in nature and have missed a potentially large
proportion of soldiers who were not evacuated. Furthermore, there
have been no studies published using the CSR paradigm. There is
an important need for prospective research in this area to further
understand the immediate and long-term implications of the war
related traumatic experiences ongoing in many parts of the world.
Implications for Research and Relevance to Clinical
Practice
It is clear from this review of the literature that several important
questions remain concerning the relevance, applicability, and
predictive value of the current definitions of the acute stress
response.
Do the Current Diagnoses Adequately Capture the
Complex Nature of Acute Stress Responses?
ASR and ASD as they are currently formulated are mutually
exclusive and either diagnosis alone is too narrow to adequately
 SPECIAL SECTION: ACUTE STRESS RESPONSES
describe the full range of acute stress responses. ASR includes a
broad range of peritraumatic responses; however, the notion of
rapidly resolving symptoms appears to be presumptuous. ASD
acknowledges the sometimes prolonged nature of acute stress
responses and their value as predictors of PTSD, but by delaying
the diagnosis by at least 48 hr important information about the
immediate response may be disregarded and a potentially important
therapeutic window overlooked.
Toward the publication of the DSM–V it may be important to
consider one acute stress response diagnosis that covers the full
range and various degrees of severity of the acute responses in the
first days after the event (as in ASR) as well as the later developing
clusters of symptoms (as in ASD). This change could enhance
current clinical practice by providing definitions for the full
spectrum in time and symptom profile of acute stress responses,
thus enabling the accurate diagnosis of these victims of trauma.
Are All Types of Stressors Commensurate?
Another important issue that needs to be given further
consideration is the type of stressor required for the ASR and ASD
diagnoses. The literature deals mainly with the qualification of
Criteria A for PTSD (e.g., Breslau & Kessler, 2001) and little
attention has been paid to the question of whether the cumulative,
continuous, and changing stressors of combat, terror, and natural or
man-made disasters could be considered together with those that
occur in a single, discrete, and encapsulated trauma (e.g., a car
accident).
The combination of stressors and the protracted nature of combat,
terror, and disasters have the potential to affect many areas of
victims’ lives even after the cessation of the traumatic event (Norris
et al., 2002; Solomon et al., 2006). Theoretically it is likely that an
acute incident in an otherwise well maintained social structure and
natural environment would not have the same depth and breadth of
effects.
In looking to compare among different types of traumatic events
it might be wise to consider the type of event in question and to
compare only those that induce similar levels and types of physical
and social destruction. Further research is needed to determine the
empirical validity of this approach, and given the recent concerns
of increasing frequency of terrorism, disasters, and combat around
the world, it is important to engage in such studies.
Do Acute Stress Responses Have the Potential to Predict
Outcomes Other Than PTSD?
The vast majority of ASD and ASR studies have focused on
PTSD as the only outcome variable of interest, however, emerging
evidence on ASD alongside the insights from CSR research would
suggest that PTSD is not the only important form of distress
subsequent to traumatic events. CSR studies have clearly
demonstrated that the experience of psychological breakdown
during battle can have wide and enduring effects on the psychiatric,
somatic, and interpersonal well-being of veterans (e.g., Solomon et
al., 2006). Awareness of the full range of important outcomes is
essential for the treatment of trauma victims, and future research
might benefit from casting a broader net when looking at outcomes
to determine the scope of the effects that can be expected from other
types of stressors.
What Role Does Functional Decline Play in Identifying
Those at Risk?
It has been demonstrated that early PTSD symptoms are common
and show an overall decline during the first month (e.g., Foa, Stein
427
& McFarlane, 2006). As such, these symptoms alone do not
effectively predict PTSD (Shalev, Freedman, Peri, Brandes, &
Sahar, 1997). The diagnosis of ASD addresses this problem with
the inclusion of Criterion F, (i.e., clinically significant distress and
interference with functioning), as an effort to differentiate between
those with pathological reactions and those likely to recover
spontaneously. Unfortunately this functional criterion as it is
currently formulated is vague and perhaps under emphasized.
Prospective studies of CSR have shed light on the strong
predictive power of the functional criteria alone, and the importance
of functional decline as a risk factor for future PTSD and other
somatic and psychiatric symptoms. Subsequently, it is suggested
that the current significance of the function criteria in the diagnosis
of ASD and ASR might benefit from being reconsidered and their
value as a predictive factor of future psychopathology be
reassessed.
Summary
This article critically compares the diagnostic criteria of ASD,
ASR, and CSR to better understand how CSR might fit within the
spectrum of other defined acute stress responses. The predictive
value of these definitions is examined through a review of the
currently available prospective follow-up studies. Suggestions and
implications for clinical practice are made with respect to: (a) the
development of a unified definition for acute stress responses; (b)
comparing between types of stressors; (c) the expected outcomes of
traumatic experiences; and (d) the importance of the decline in
functioning as an indicator of future psychological, psychiatric, and
somatic symptoms.
References
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text revision). Washington, DC:
Author.
Archibald, H. C., & Tuddenham, R. D. (1965). Persistent stress reaction
after combat. Archives of General Psychiatry, 12, 475–481.
Bar-On, R., Solomon, Z., Noy, S., & Nardi, C. (1986). The clinical picture
of combat stress reactions in the 1982 war in Lebanon: Cross-war
comparisons. In N. A. Milgram (Ed.), Stress and coping in the time of
war (pp. 103–109). New York: Brunner/Mazel.
Benyamini, Y., & Solomon, Z. (2005). Combat stress reactions,
posttraumatic stress disorder, cumulative life stress and physical health
among Israeli veterans twenty years after exposure to combat. Social
Science and Medicine, 61, 1267–1277.
Bergiannaki, J. D., Psarros, C., Varsou, E., Paparrigopoulos, T., & Soldatos,
C. R. (2003). Protracted acute stress reaction following an earthquake.
Acta Psychiatrica Scandinavica, 107, 18–24.
Breslau, N., & Kessler, R. C. (2001). The stressor criterion in DSM–IV
posttraumatic stress disorder: An empirical investigation. Biological
Psychiatry, 50, 699–704.
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress
disorder and posttraumatic stress disorder in victims of violent crime.
American Journal of Psychiatry, 156, 360–366.
Bryant, R. A. (2003). Early predictors of posttraumatic stress disorder.
Biological Psychiatry, 53, 789–795.
Bryant, R. A., & Harvey, A. G. (1996). Initial post-traumatic stress
responses following motor vehicle accidents. Journal of Traumatic
Stress, 9, 223–234.
Bryant, R. A., & Harvey, A. G. (2000). Acute stress disorder: A handbook
of theory, assessment, and treatment. Washington, DC: American
Psychological Association.
Bryant, R. A., Moulds, M. L., & Guthrie, R. M. (2000). Acute Stress
Disorder Scale: A self-report measure of acute stress disorder.
Psychological Assessment, 12, 61–68.
428 ISSERLIN, ZERACH, AND SOLOMAN
Creamer, M., O’Donnell, M., & Pattison, P. (2004). The relationship
between acute stress disorder and posttraumatic stress disorder in
severely injured trauma survivors. Behaviour Research and Therapy, 42,
315–328.
Elklit, A., & Brink, O. (2004). Acute stress disorder as a predictor of post-
traumatic stress disorder in physical assault victims. Journal of
Interpersonal Violence, 19, 709–726.
Foa, E. B., Stein, M. D., & McFarlane, A. C. (2006). Symptomatology and
psychopathology of mental health problems after disaster. Journal of
Clinical Psychiatry, 67(Suppl. 2), 15–25.
Fuglsang, A. K., Moergeli, H., & Schnyder, U. (2004). Does acute stress
disorder predict post-traumatic stress disorder in traffic accident victims?
Analysis of a self-report inventory. Nordic Journal of Psychiatry, 58,
223–229.
Fullerton, C. S., Ursane, R. J., & Wang, L. (2004). Acute stress disorder,
posttraumatic stress disorder, and depression in disaster or rescue
workers. American Journal of Psychiatry, 161, 1370–1376.
Ginzburg, K., Solomon, Z., Koifman, B., Keren, G., Roth, A., Kriwisky, M.,
et al. (2003). Trajectories of posttraumatic stress disorder following
myocardial infarction: A prospective study. Journal of Clinical
Psychiatry, 64, 1217–1223.
Grenall, P., & Marselle, M. (2005). In Y. Danieli, D. Brom, & D. Sills
(Eds.), The trauma of terrorism, sharing knowledge and shared care (pp.
593–604). New York: Haworth Maltreatment and Trauma.
Hamanaka, S., Asukai, N., Kamijo, Y., Hatta, K., Kishimoto, J., & Miyaoka,
H. (2006). Acute stress disorder and posttraumatic stress disorder among
patients severely injured in motor vehicle accidents in Japan. General
Hospital Psychiatry, 28, 234–241.
Harvey, A. G., & Bryant, R. A. (1998). The relationship between acute
stress disorder and posttraumatic stress disorder: A prospective
evaluation of MVA survivors. Journal of Consultation and Clinical
Psychology, 66, 507–512.
Harvey, A. G., & Bryant, R. A. (1999). Relationship of acute stress disorder
and posttraumatic stress disorder following motor vehicle accidents.
Journal of Consultation and Clinical Psychiatry, 67, 985–988.
Holeva, V., Tarrier, N., & Wells, A. (2001). Prevalence and predictors of
acute stress disorder and PTSD following road traffic accidents: Thought
control strategies and social support. Behavioural Therapy, 32, 65–83.
Kangas, M., Henry, J. L., & Bryant, R. A. (2005). The course of
psychological disorders in the 1st year after cancer diagnosis. Journal of
Consulting and Clinical Psychology, 73, 763–768.
Kessler, R. C., Sonnega, A., Bromet, E., & Hughes, M. (1995).
Posttraumatic stress disorder in the National Comorbidity Survey.
Archives of General Psychiatry, 52, 1048–1060.
Kettner, B. (1972). Combat strain and subsequent mental health: A follow-
up study of Swedish soldiers serving in the United Nations forces 1961–
62. Acta Psychiatrica Scandinavica, 230(Suppl.), 1–120.
Kutz, I., & Dekel, R. (2006). Follow-up of victims of one terrorist attack in
Israel: ASD, PTSD and the perceived threat of Iraqi missile attacks.
Personality and Individual Differences, 40, 1579–1589.
Neria, Y., & Koenen, K. C. (2003). Do combat stress reaction and
posttraumatic stress disorder relate to physical health and adverse health
practices? An 18-year follow-up of Israeli war veterans. Anxiety, Stress,
and Coping, 16, 227–239.
Neria, Y., Solomon, Z., Ginzburg, K., Dekel, R., Enoch, D., & Ohry, A.
(2000). Posttraumatic residues of captivity: A follow-up of Israeli ex
POWs. Journal of Clinical Psychiatry, 61, 39–46.
Nixon, R. D., & Bryant, R. A. (2003). Peritraumatic and persistent panic
attacks in acute stress disorder. Behavior Research and Therapy, 41,
1237–1242.
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., &
Kaniasty, K. (2002). 60,000 disaster victims speak: Part I. An empirical
review of the empirical literature, 1981–2001. Psychiatry, 65, 207–239.
Rundell, J. R. (2006). Demographics of and diagnoses in Operation
Enduring Freedom and Operation Iraqi Freedom personnel who were
psychiatrically evacuated from the theater of operations. General
Hospital Psychiatry, 28, 352–356.
Shalev, A. Y. (2002). Acute stress reactions in adults. Biological Psychiatry,
51, 532–543.
Shalev, A. Y., Freedman, S., Peri, T., Brandes, D., Sahar, T., Orr, S. P., et
al. (1998). Prospective study of posttraumatic stress disorder and
depression following trauma. American Journal of Psychiatry, 155, 630–
637.
Shalev, A. Y., Freedman, S., Peri, T., Brandes, D., & Sahar, T. (1997).
Predicting PTSD in trauma survivors: Prospective evaluation of
selfreport and clinician administered instruments. British Journal of
Psychiatry, 170, 558–564.
Soldatos, C. R., Paparrigopoulos, T. J., Pappa, D. A., & Christodoulou, G.
N. (2006). Early post-traumatic stress disorder in relation to acute stress
reaction: An ICD–10 study among help seekers following an earthquake.
Psychiatry Research, 143, 245–253.
Solomon, Z. (1993). Combat stress reaction: The enduring toll of war.
New York: Plenum.
Solomon, Z., & Kleinhauz, M. (1996). War induced psychic trauma: An 18-
year follow-up of Israeli veterans. American Journal of Orthopsychiatry,
66, 152–160.
Solomon, Z., & Mikulincer, M. (2006). Trajectories of PTSD: A 20-year
longitudinal study. American Journal of Psychiatry, 163, 659–666.
Solomon, Z., Shklar, R., Singer, Y., & Mikulincer, M. (2006). Reactions to
combat stress in Israeli veterans twenty years after the 1982 Lebanon
War. Journal of Nervous and Mental Disease, 194, 935–939.
Speed, N., Engdahl, B., Schwartz, J., & Eberley, R. (1989). Posttraumatic
stress disorder as a consequence of the POW experience. Journal of
Nervous and Mental Disease, 177, 147–153.
Spiegel, D., Classen, C., Cardena, E., & Classen, C. (1996). Dissociative
symptoms in the diagnosis of acute stress disorder. In L. K. Michelson
& W. J. Ray (Eds.), Handbook of dissociation: Theoretical, empirical,
and clinical perspectives (pp. 367–380). New York: Plenum.
Turner, M. A., Kiernan, M. D., McKechanie, A. G., Finch, P. J. C., Mc
Manus, F. B., & Neal, L. A. (2005). Acute military psychiatric casualties
from the war in Iraq. British Journal of Psychiatry, 186, 476–479.
Wang, C., Tsay, S., & Bond, A. E. (2005). Posttraumatic stress disorder,
depression, anxiety and quality of life in patients with traffic-related
injuries. Journal of Advanced Nursing, 52, 22–30.
World Health Organization (WHO). (1992). International classification of
diseases (10th rev.). Geneva, Switzerland: Author.
 SPECIAL SECTION: ACUTE STRESS RESPONSES 429

View publication stats

Yitzhaki, T., Solomon, Z., & Kotler, M. (1991). The clinical picture of acute
combat stress reaction among Israeli soldiers in the 1982 Lebanon War.
Military Medicine, 156, 193–197.

Received July 27, 2008

Revision received July 27, 2008
Accepted September 22, 2008