New DSM-IV Diagnosis of Acute Stress Disorder

To the Editor: In criticizing the acute stress disorder diagnosis, Dr. Marshall et al. justifiably echoed previously expressed concerns (1). We question the evidence on which some of their conclusions are based. The retrospective studies of acute trauma reactions that they cite are flawed because mood-related memory bias renders questionable the accuracy of retrospective reports. Moreover, only one of the three prospective studies referred to employed a validated diagnostic measure of acute stress disorder (2). The authors did not cite four key prospective studies that found that between 78% and 83% of individuals with acute stress disorder subsequently developed PTSD (3–5; Brewin et al., 1999). The evidence indicates that the acute stress disorder diagnosis can identify a significant proportion of acutely traumatized individuals who develop PTSD. This is a useful development because early intervention with those diagnosed as having acute stress disorder can prevent the development of PTSD (6).

We agree that the current emphasis placed on acute dissociative responses is flawed. Recent studies (although not cited by Dr. Marshall et al.) have demonstrated that there are multiple pathways to PTSD and that most trauma survivors who display severe acute stress reactions without dissociation can develop PTSD (3, 4). The assertion by Dr. Marshall et al. that the diagnosis of PTSD should apply immediately after a trauma is problematic because it potentially “pathologizes” transient stress reactions. Discarding the acute stress disorder diagnosis now may also be an overreaction that “throws the baby out with the bath water.” Although the available evidence does not support the current criteria for acute stress disorder, prospective studies are beginning to identify constellations of acute symptoms that can predict PTSD with greater accuracy. Rather than prematurely deciding the worth of the acute stress disorder diagnosis at this time, it is important to conduct prospective studies that employ standardized measures that will define the optimal criteria for acute stress disorder and determine whether it deserves to survive in DSM-V.