Early predictors of posttraumatic stress disorder

doi:10.1016/S0006-3223(02)01895-4

Biological Psychiatry

Volume 53, Issue 9, 1 May 2003, Pages 789-795

https://doi.org/10.1016/S0006-3223(02)01895-4 Get rights and content

Abstract

The benefits of providing early intervention for people recently exposed to trauma have highlighted the need to develop means to identify people who will develop chronic posttraumatic stress disorder (PTSD). This review provides an overview of prospective studies that have indexed the acute reactions to trauma that are predictive of chronic posttraumatic stress disorder. Ten studies of the predictive power of the acute stress disorder diagnosis indicate that this diagnosis does not have adequate predictive power. There is no convergence across studies on any constellation of acute symptoms that predict posttraumatic stress disorder. A review of biological and cognitive mechanisms occurring in the acute posttraumatic phase suggests that these factors may provide more accurate means of predicting chronic posttraumatic stress disorder. Recommendations for future research to facilitate identification of key markers of acutely traumatized people who will develop posttraumatic stress disorder are discussed.

Introduction

There is initial evidence that there are potential benefits in treating people shortly after exposure to a traumatic event Foa et al 1995, Bryant et al 1998, Bryant et al 1999. The likelihood of developing a long-term psychiatric disorder may be reduced if effective treatments can be implemented before the disorder becomes entrenched. Early intervention requires reliable means of identifying people who require intervention. This review provides a critical analysis of the evidence for early markers of posttraumatic stress disorder (PTSD), discusses the utility of the acute stress disorder diagnosis, and provides options for increasing our identification of acutely traumatized people who are at risk of PTSD.

Section snippets

Acute stress reactions

Before reviewing the means of identifying who will develop PTSD, it is critical to clarify the course of posttraumatic adjustment. There is overwhelming evidence describing the range of anxiety symptoms experienced following trauma exposure. There is documented evidence of high rates of numbing Feinstein 1989, Noyes et al 1977, reduced awareness of one’s environment Berah et al 1984, Hillman 1981, derealization Cardeña and Spiegel 1993, Noyes and Kletti 1977, Sloan 1988, Freinkel et al 1994,

The natural course of psychological adaptation

Despite the prevalence of acute stress reactions, there is also considerable evidence that the typical course of adaptation is to recover in the following months after trauma exposure. For example, in one study, 70% of women and 50% of men were diagnosed with PTSD at an average of 19 days after an assault; the rate of PTSD at 4-month follow-up dropped to 21% for women and zero for men (Riggs et al 1995). Similarly, whereas 94% of rape victims displayed PTSD symptoms 2 weeks posttrauma, this

Acute stress disorder

In 1994, DSM-IV introduced the acute stress disorder (ASD) diagnosis as an attempt to identify acutely traumatized people who would develop chronic PTSD. This diagnosis describes stress reactions in the initial month after a trauma. DSM-IV stipulates that ASD can occur after a fearful response to experiencing or witnessing a threatening event (Cluster A). The requisite symptoms to meet criteria for ASD include three dissociative symptoms (Cluster B), one re-experiencing symptom (Cluster C),

The evidence for acute stress disorder

Since the introduction of the ASD diagnosis, there have been 10 prospective studies Harvey and Bryant 1998, Bryant and Harvey 1998, Brewin et al 1999, Holeva et al 2001, Creamer et al, Schnyder et al 2001, Staab et al 1996, Bryant and Harvey 2002, Harvey and Bryant 1999, Harvey and Bryant 2000 conducted that assessed ASD in the initial month after trauma and subsequently assessed participants for PTSD. The majority of these studies focused on survivors of motor vehicle accidents or assaults. It

The future of acute stress disorder

The ASD diagnosis has been criticized because 1) the primary role of the ASD diagnosis is to predict another diagnosis (Harvey and Bryant 2002), 2) distinguishing between two diagnoses that have similar symptoms on the basis of the duration of the symptoms is not justified (Marshall et al 1999), 3) the diagnosis may pathologize transient stress reactions (Bryant and Harvey 1997), and 4) the diagnosis was introduced with very little evidence to support its inclusion. It is important to recognize

Acute symptoms and chronic PTSD

There have been numerous studies that have indexed the relationship between initial symptoms and PTSD. A range of studies has reported that acute dissociation is predictive of subsequent PTSD Koopman et al 1994, Shalev et al 1997, Shalev et al 1993, Shalev et al 1996. In contrast, other studies have reported that dissociation is not strongly predictive Harvey and Bryant 1998, Dancu et al 1996. In terms of re-experiencing symptoms, there is convergent evidence that intrusive memories are not

How do we improve early identification of PTSD?

The impasse in the search for initial symptoms that may predict PTSD has led to greater attention on biological and cognitive mechanisms occurring shortly after trauma exposure that may mediate long-term PTSD. The focus on processes that lead to poor adjustment appears to be a more fruitful avenue for research because identifying risk factors that are embodied in diagnostic categories or are observed symptoms may limit the identification of indicators in the acute phase that have optimal

What is the optimal approach for predicting PTSD?

The available evidence suggests that there is limited value in solely focusing on a diagnostic category or a constellation of symptoms as a marker of acutely traumatized people who are at risk of developing PTSD. The purpose of a diagnosis is to discriminate between clusters of symptoms. Accordingly, it seems limiting to try to embody risk factors within a diagnostic category. Similarly, it may not be optimal to focus on symptoms, because they may not be optimally sensitive to those factors

Future directions

The identification of acute reactions following trauma that predict PTSD with optimal sensitivity and specificity requires considerably more prospective research. This research will need to encompass the broad range of symptoms, biological indices, and cognitive responses if the interrelationships between these factors are to be understood. Whereas most previous studies have been conducted with several hundred participants, future studies need to be conducted with thousands of participants to

Acknowledgements

Aspects of this work were presented at the conference, “Consensus Conference on Acute Posttraumatic Reactions,” held June 2–4, 2002 in Chantilly, VA. The conference was sponsored by the Anxiety Disorders Association of America, and supported by an unrestricted educational grant provided by Eli Lilly and Company.

References (73)

E.B. Blanchard et al.
One-year prospective follow-up of motor vehicle accident victims
Behav Res Ther
(1996)
R.A. Bryant et al.
Acute stress disorderA critical review of diagnostic issues
Clin Psychol Rev
(1997)
R.A. Bryant et al.
Panic symptoms during trauma and acute stress disorder
Behav Res Ther
(2001)
D.L. Delahanty et al.
Initial posttraumatic urinary cortisol levels predict subsequent PTSD symptoms in motor vehicle accident victims
Biol Psychiatry
(2000)
A. Ehlers et al.
A cognitive model of posttraumatic stress disorder
Behav Res Ther
(2000)
I.M. Engelhard et al.
A longitudinal study of “intrusion-based reasoning” and posttraumatic stress disorder after exposure to a train disaster
Behav Res Ther
(2002)
R. Guthrie et al.
Attempting suppression of traumatic memories over extended periods in acute stress disorder
Behav Res Ther
(2000)
V. Holeva et al.
Prevalence and predictors of acute stress disorder and PTDS following road traffic accidentsThought control strategies and social support
Behav Ther
(2001)
R. Noyes et al.
Depersonalizaton in response to life-threatening danger
Compr Psychiatry
(1977)
K. Smith et al.
The generality of cognitive bias in acute stress disorder
Behav Res Ther
(2000)

Creamer MC, O’Donnell ML, Pattison P (in press): The relationship between acute stress disorder and posttraumatic...

C.V. Dancu et al.

Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape

J Trauma Stress

(1996)

D.L. Delahanty et al.

Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents

J Consult Clin Psychol

(1997)

A. Ehlers et al.

Psychological predictors of chronic PTSD after motor vehicle accidents

J Abnorm Psychol

(1998)

S.A. Falsetti et al.

Frequency and severity of panic attack symptoms in a treatment seeking sample of trauma victims

J Trauma Stress

(1997)

A. Feinstein

Posttraumatic stress disorderA descriptive study supporting DSM-III-R criteria

Am J Psychiatry

(1989)

E.B. Foa et al.

Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims

J Consult Clin Psychol

(1995)

A. Freinkel et al.

Dissociative symptoms in media witnesses of an execution

Am J Psychiatry

(1994)

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Acute responses to stressEarly predictors of posttraumatic stress disorder

Abstract

Introduction

Section snippets

Acute stress reactions

The natural course of psychological adaptation

Acute stress disorder

The evidence for acute stress disorder

The future of acute stress disorder

Acute symptoms and chronic PTSD

How do we improve early identification of PTSD?

What is the optimal approach for predicting PTSD?

Future directions

Acknowledgements

Behav Res Ther

Clin Psychol Rev

Behav Res Ther

Biol Psychiatry

Behav Res Ther

Behav Res Ther

Behav Res Ther

Behav Ther

Compr Psychiatry

Behav Res Ther

Behav Res Ther

Behav Res Ther

Predicting PTSD in victims of violent crimeThe role of shame, anger and blame

J Abnorm Psychol

The experience of a mental health team involved in the early phase of a disaster

Aust N Z J Psychiatry

Emergency room vital signs and PTSD in a treatment seeking sample of motor vehicle accident victims

J Trauma Stress

Acute stress disorder and posttraumatic stress disorder in victims of violent crime

Am J Psychiatry

Hypnotizability in acute stress disorder

Am J Psychiatry

Initial post-traumatic stress responses following motor vehicle accidents

J Trauma Stress

Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury

Am J Psychiatry

Delayed-onset posttraumatic stress disorderA prospective study

Aust N Z J Psychiatry

A prospective study of psychophysiological arousal, acute stress disorder and posttraumatic stress disorder

J Abnorm Psychol

Treatment of acute stress disorderA comparison of cognitive-behavioral therapy and supportive counseling

J Consult Clin Psychol

Treating acute stress disorderAn evaluation of cognitive behavior therapy and counseling techniques

Am J Psychiatry

A prospective examination of delayed onset PTSD secondary to motor vehicle accidents

J Abnorm Psychol

Hypnotizability and traumatic experienceA diathesis-stress model of dissociative symptomatology

Am J Psychiatry

Dissociative reactions to the San Francisco Bay Area earthquake of 1989

Am J Psychiatry

Psychobiologic mechanisms of posttraumatic stress disorder

Arch Gen Psychiatry

Reaction to traumaA cognitive processing model

J Abnorm Psychol

Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape

J Trauma Stress

Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents

J Consult Clin Psychol

Psychological predictors of chronic PTSD after motor vehicle accidents

J Abnorm Psychol

Frequency and severity of panic attack symptoms in a treatment seeking sample of trauma victims

J Trauma Stress

Posttraumatic stress disorderA descriptive study supporting DSM-III-R criteria

Am J Psychiatry

Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims

J Consult Clin Psychol

Dissociative symptoms in media witnesses of an execution

Am J Psychiatry

Acute responses to stress
Early predictors of posttraumatic stress disorder