New DSM-IV Diagnosis of Acute Stress Disorder

To the Editor: In their recent article, Randall D. Marshall, M.D., et al. (1) raised important considerations regarding the diagnosis of acute stress disorder. This was a much-needed analysis; however, I have reached different conclusions with respect to the importance of including dissociative symptoms in the acute stress disorder diagnosis. Dr. Marshall et al. interpreted their inconsistent findings regarding the ability of peritraumatic dissociative symptoms to predict later posttraumatic stress disorder (PTSD) to indicate that dissociative symptoms should not be required in the diagnosis of acute stress reactions to a traumatic life event. I have two major concerns with this argument, although there may be a common ground, suggested by the analysis by Dr. Marshall et al., on which to resolve this debate.

First, dissociative symptoms do seem to be of clinical relevance in the immediate as well as long-term aftermath of traumatic life events. For example, individuals exposed to a firestorm who reported more dissociative symptoms, compared to those who reported fewer dissociative symptoms, were significantly less likely to engage in active coping strategies in response to the fire (2), were more likely to engage in dangerous coping strategies such as crossing police barricades to get closer to the fire (under conditions of high traumatic exposure) (2), and were more likely to experience major illness or injury and other stressful life events in the next 7–10 months (3).

Second, if there is a form of PTSD in which dissociative symptoms play a major role, and this is not recognized in the PTSD diagnostic criteria, then this weakens the relationship that researchers find between acute dissociative symptoms and subsequent PTSD. Given the dilemmas inherent in determining the acute stress disorder diagnosis on the basis of its empirical links to a controversial PTSD diagnosis, it is important to develop stronger conceptual models of acute stress disorder and PTSD on the basis of empirical data to determine the diagnostic criteria. My colleagues and I have described a diathesis-stress model (4) grounded in considerable empirical research in which dissociative symptoms play a major role in immediate and long-term stress responses to traumatic life events.

The evidence thus far is consistent with the possibility suggested by Dr. Marshall et al. that alternative pathways of symptoms may most accurately characterize traumatic stress responses in the immediate aftermath of trauma, perhaps differing in whether dissociative symptoms are a core feature. We should also consider the possibility that the diagnosis of PTSD may need to be similarly redefined as well.