Abstract

There are a compilation of many years of empirical evidence that has sought to diagnosis and treat stress and the extreme forms it. The evidence which has, persistently, perplexed scientists are the common stress reactions that are experience by normal functioning people and by those who are, actually, diagnosed with stress disorders. This research will examine acute stress response as it relates to all people who experience trauma or emotional events. The evidence brought forth by this research will define acute stress reaction and acute stress disorder, list the symptoms, and describe the differences between the two. The diagnosing criteria as described by the DSM-IV will be described, as well the history of its inclusion. This study will, also, compare and contrast different available treatments for acute stress disorder and the prevention of the disorder. Finally, a look into the necessary components needed to help people cope with the effects of trauma, will be examined from a professional and spiritual perspective.
Keywords: Stress, acute-stress reaction, acute-stress disorder, trauma, treatment, prevention.

Acute Stress Response: The Reaction and Disorder When people experience traumatic or emotionally taxing events, there is much to be said concerning what happens when people aren’t treated for the short term and long term effects of these traumatic circumstances. However, in more recent years, evidence points to a series of normal effects of trauma that are, immediately, experienced by all trauma victims. All people experience traumatic events at some point in their lives, but the responses are displayed in different and unique ways “that reflect individual physiological and psychological states” (Yang, Y. et al, 2011, p. 714). The immediate reaction to traumatic events is called acute stress response. “Acute stress response refers to a series of physiological and psychological responses generated after stressful events, that are manifested mainly by cognitive, emotional, and behavioral changes as well as somatic symptoms”( p. 714). Acute stress response (ASR) also, called fight are trauma victims’ normal responses to abnormal events or situations (American Association for Christian Counselors). Acute stress responses (ASRs) results are “unstable and variable” (Yang et al., 2013, p.1).
Acute Stress Response and the Nervous System In the 1920’s, American neurologist and physiologist, Walter Cannon, interpreted the chain of quick and simultaneous reactions occurring within the body to mobilize its resources to deal with dangerous circumstance as “acute stress response”. In response to acute stress the “sympathetic nervous system regulates a broad range of visceral functions and, during extreme emotional or physical states, activates both the cardiovascular and adrenal catecholamine systems for homeostatic adjustments” (Jansen, A., Nguyen, X., Karpitskiy, V., Mettenleiter, T., & Loewy, A., 1995, 644). The central nervous system (CNS) neurons responsible for dual activation of these involuntary responses are believed to be controlled “by a common set of central command neurons that provides dual projections to the sympathetic outflow systems that control the heart and adrenal gland” (Jansen et al., p. 644). These autonomic changes results in rapid increase of the heart rate, blood pressure and breathing rate. These two biological concepts that make the acute stress response are also known as the fight-or-flight response in regard to its preparation of the body to stand and fight or flee the immediate threat (Brown and Fee, 2002, p.1594). Once the threat is gone, it takes between 20 to 60 minutes for the body to return to its pre-arousal levels. Though, Cannon’s biological ideas are still taught as “a basic principle of autonomic function, it has not been possible to define the command neurons and CNS circuits responsible for this response, because of the technical limitations” (Jansen et al., p. 644).
Acute Stress Reaction
Acute stress reactions is a “diagnosis given immediately following the experience of an exceptional mental or physical stressor” (Gradus et al., 2010, p. 1578). “The biology of the responses to extreme events is complex. It involves mechanisms related to survival, learning, memory-formation, loss, and socially modulated re-adjustment and adaptation” (Shalev, 2002, p.532). Resnick et al (1992) report that the “early responses to adversity primarily reflect the intensity of the stressor” (as cited by Shalev, p. 533). According to Breslau and Davis (1995); True et al (1993), early responses, also, “reflect the effects of inherited and acquired vulnerability” (as cited by Shalev, p. 533). Grinker and Spiegel refer to acute stress responses as a ‘‘passing parade of every type of psychological and psychosomatic symptom’’ (as cited by Yang et al. p.1).
More Symptoms Though, acute stress reactions are indicative to major disasters, accidents, and events such as serious illness and death, these responses can’t be, automatically, declared positive or negative. “Acute stress reactions to trauma as a spectrum include anxiety, dissociative, and depressive symptoms. The course of these symptoms may vary, with fluctuations between intrusion (“positive”) and avoidance/ numbing/dissociative (“negative”)…” (Spiegal, 2005, p. 101). The aftermath of a critical incident leaves many people in a state of high stress. The acute stress reactions that are due to these traumatic experiences result in “physiological and psychological responses” (Campbell & Ehlert, 2012, p. 1111).
Research has discovered that acute stress responses “ranged from slightest to most severe in the following order: cognitive changes, physiological responses, emotional responses, behavioral changes, psychiatric symptoms” (Yang et al., 2013, p.8). It is, also, impossible to know, exactly, what symptoms will be manifest themselves in any individual who experiences trauma, but the time-frame of the biological responses can be predicted and described. “These extend from fragments of seconds (for defense reflexes such as auditory startle), seconds (for sympathetic activation), minutes (for engagement of the hypothalamic–pituitary–adrenal axis), hours (for early gene expression), days (for memory consolidation), and months (for putative alterations of brain structures)” (Shalev, 2002, p. 532). Laboratory stressors such as the Trier Social Stress Test (TSST) induce reliable stress responses, which are mainly assessed for biological parameters such as cortisol”( Campbell & Ehlert, 2012, p. 1111). Physiological responses have a mission; as an indicator of the severity of the stressor and to exert some of the energy to decrease the severity of the stress at hand (Yang et al., 2013).
Table 1. illustrates a sample list of the normal acute stress reactions manifested as a result of trauma as described by the American Association for Christian Counselors. The normalcy of the immediate reactions to abnormal events has attributed to the complication of proper diagnosis and misdiagnosis of acute trauma disorders such as Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD). The distinct characteristic of Acute Stress Response (ASR), according the International Classification of Diseases (ICD), is “transient reaction that can be evident immediately after the traumatic event and usually resolves within 2–3 days after a trauma” (Bryant, Friedman, Spiegel, Ursano, & Strain, 2011, p. 803). ICD further describes ASR’s as related to “dissociative (daze, stupor, amnesia) and anxiety (tachycardia, sweating, flushing) reactions (p.804). The logical assumption to encompass this method will allow treatment for acute distress that “may warrant intervention (e.g., sleep disturbance) but does not attempt to predict subsequent disorder” (p.804).
Table 1. Acute Stress Symptoms
Physical Cognitive Emotional Behavioral Spiritual
• Vacant stare
• Rapid heart beat
• Chills
• Vomiting • Confusion in thinking
• Memory impairment
• Difficulty making decisions • Shock
• Anger
• Despair
• Panic
• Helplessness • Withdrawal
• Disturbed eating pattern
• Disruptive sleeping schedule
• Poor hygiene • Feeling abandoned or betrayed by God
• Lack of hope
• Lack of spirit of thankfulness
• Difficulty praying

Acute Care for Stress Relief
The human response to a traumatic event can be very intense and momentarily debilitating because the psychological homeostasis of balance, order, and structure has been disrupted (American Association for Christian Counselors). Nonetheless, these reactions and their symptoms are, clinically, normal. Professional and Lay caregivers must take care not to attempt to diagnosis or treat the onset of these immediate reactions as a sign of deeper rooted problems. Furthermore, caregivers should not mistake the lack of a need for clinical diagnosis as a sign that trauma victims have no immediate needs. Victims of trauma are, rarely, aware, of their need of someone who can render psychological first aid known as acute care (AACC). The first goal of acute care is to come along side and give support for those who have experienced trauma. Caregivers should stabilize trauma victims by reassuring them that their immediate feelings are quite normal (AACC). “At a time of intense emotional reaction, it is…helpful to have the presence of others to lend security, order, and a sense of objective reality to balance their subjective…jumbled reality” (Freeman, 2005, p. 128).
One of the most important immediate needs of many trauma victims is spiritual reassurance. Psychological first aid or acute care includes reminding people that “God is our refuge and strength, an ever present help in trouble” Psalm 46:1 and to meditate on Psalm 18:2, “The LORD is my rock, and my fortress, and my deliverer; my God, my strength, in whom I will trust; my buckler, and the horn of my salvation, and my high tower”.
Acute Stress Disorder
The diagnosis of Acute Stress Disorder (ASD) found its inclusion into the DSM-IV described as a “posttraumatic reaction that occurs two to twenty-eight days following a trauma and involves symptoms of intrusion, avoidance, hyper-arousal and dissociation” (Suliman, Troeman, Stein, & Seedat, 2013, p. 277). By the DSM-IV’s definition, acute stress responses occur before acute stress disorder can take place (Bryant et al., 2011, p. 804). According to Bryant and Harvey, a main reason that acute stress disorder (ASD) has been added into the “Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) was to identify acute posttraumatic stress reactions that are pre-cursors of chronic Posttraumatic stress disorder”( as cited in Bryant, Moulds & Guthrie, 2000p. 61). Another, equally, important reason for acute stress disorder’s inclusion as a separate disorder is to describe acute stress response (ASR) because there has been “…much evidence in the literature of a range of distressing responses in the aftermath of trauma, including posttraumatic anxiety, mood disturbances, sleep problems, other physical and psychological symptoms” (Bryant et al., 2011, p. 803). Table 2 outlines the DSM-IV diagnostic criteria for Acute Stress Disorder.

Due to the current association of acute stress disorder with posttraumatic stress disorder and acute stress response, it is natural that its diagnostic criterion focuses on anxiety and disassociation. Acute stress disorder is marked by “re-experiencing and marked avoidance and hyperarousal” (Cardena & Carlson, 2011, p. 247) and three dissociative symptoms. The theoretical perspective purposes that dissociative responses will impair trauma victims and disable their ability to process affect and memories about the traumatic event which, in return, paralyzes the recovery process (Bryant et al, 2011). “From an empirical perspective, there is much evidence that peritraumatic dissociative reactions are very common, including emotional numbing, altered time sense, reduction in awareness of one’s surroundings, depersonalization, and amnesia” (p. 805). Butler et al. contend that “The dissociative symptoms emphasized in ASD have been shown to play a role in the immediate as well as long-term stress responses to traumatic events” ( as cited in Koucky, Galovski & Nixon, 2012,p. 439). More importantly, many studies have concluded that peritraumatic dissociation is a precursor for identifying PTSD.
ASD as it Relates to PTSD As mentioned above, acute stress disorder plays an integral role in predicting and diagnosis of PTSD as result of overlapping criterion and parameters for start and end durations. It must be, empirically, noted that there are deep parameters between acute stress disorder and posttraumatic stress disorder in which a PTSD diagnosis can occur during the final stage (four weeks) duration of ASD (Cardena & Carlson, 2011). “A bigger difference in symptom criteria between the two diagnoses is the ASD criterion for three dissociative symptoms, whereas none are needed for PTSD” (p. 247). Another controversial distinction of the criterion is that “distress and/or dysfunction is more elaborate in ASD than in PTSD” (p. 248). In many recent studies, researchers have shown that ASD “demonstrates significant predictive validity in identifying cases that go on to develop PTSD” (Koucky et al., 2012, p. 439). Harvey and Bryant (1998) studied a sample from a group of “motor vehicle accident survivors (n=71), and concluded that 78% of ASD positive participants met criteria for PTSD at 6-month follow-up. The same study group evaluated a similar motor vehicle accident sample (n=50) and found that 80% of cases that met initial criteria for ASD went on to develop PTSD at 2-year follow-up” (as cited in Koucky et al., 2012, p. 439).
Treatments for Acute Stress Disorder The predictive power of ASD for PTSD can’t be overlook. One of the main goals of the treatment process during acute stress disorder is to identify precursors that lead to PTSD and to, possibly, prevent diagnosis of PTSD. When considering treatment for acute stress disorder it is important to keep in mind the parameters which separates it from acute stress response (ASR) and posttraumatic stress disorder (PTSD). “The assessment and containment of distress are major components of early treatment…” (van, McFarlane, Weisaeth, 2007, p. 480) as well as comprehension that “various treatment strategies need to be systematically assessed for their relative effectiveness…”(p. 480). Research indicates that “Any intervention that has the power to help has the power to hurt” (Spiegel, 2012, p. 102). “Normal recovery should be assumed and explored, such that benevolent but untimely interventions will not do harm” (Shalev, 2002, p.600).
Debriefing
Contrary to past assessment and poor implementation, debriefing has become one of the most effective methods for “mitigating the effects of exposure to trauma” (AACC) and keeping people “healthy and in service” (AACC). Debriefing is usually a one-time and up to ninety minute group stabilization process. In particular, Critical Incident Stress Debriefing (CISD) is a debriefing process that “addresses full range of impairment caused by a crisis, particularly focusing on relationships, family, friends, and God” (AACC). Debriefing utilizes early intervention, are multimodal and multicomponent (AACC). Debriefing has access to different active ingredients and “these components are used at the appropriate time with the right target group” (AACC). The toxicity of past debriefing has come in the form of poor interaction and support with trauma victims. Debriefing counselors have been known to inform people with acute stress disorder that they may suffer deeper or future emotional problems “In the immediate aftermath of trauma, the last thing trauma victims want or need to hear is the prediction of future difficulties. The present ones are quite enough. Indeed such predictions may induce rather than prevent certain emotional reactions” (Spiegel, 2012, p. 104). Debriefers must, also, be aware of that debriefing has the potential of “stirring up emotional reactions without providing any means for restructuring the meaning of the emotional experiences and traumatic events, enhancing skill at regulating emotional response, or providing a supportive social environment for managing the emotion” (p. 104).
Diffusing
Diffusing is another immediate action response tool that can be used to assess and screen victims of trauma. Diffusing is a time sensitive tool that places victims with like experience and symptoms together for immediate alleviation or balance of symptoms (AACC).
Cognitive Behavioral Therapy (CBT) Cognitive Behavioral Therapies are vital intervention measures that can drastically assist in the stabilization of victims diagnosed with acute stress disorder. Cognitive restructuring allow traumatized victims who have developed acute stress disorder to “examine their memories and experiences from a new point of view, allowing them to find new meaning in the experience” (Spiegel, 2012, p. 106). For example, Spiegel (1996), Spiegel (1997), Classen (1996) have supporting evidence that cognitive behavioral therapy will help victims “come to recognize their good fortune in surviving the trauma, to acknowledge something they did to protect themselves or others, or to realize that they were not responsible for the traumatic event that befell them” (as cited in Spiegel, 2012, p. 104). “Effective techniques in this domain range from simple information provision to profound cognitive restructuring” (p. 104). “Cognitive behavioral treatments have repeatedly demonstrated efficacy in resolving the symptoms of ASD. Specifically, treatments including the CBT components of psychoeducation, imaginal exposure, in-vivo exposure, cognitive restructuring, and progressive muscle relaxation have demonstrated success based on the current literature (Koucky et al., 2012, p. 448). Table 3 illustrates the positive results of cognitive therapy as an immediate response to victims of acute stress disorder.

Pharmacology Studies point to evidence of the value of drugs during the four week duration period acute stress disorder. Treatments should be utilized to alleviate acute trauma not as a predictor or indicator of deeper trauma or future diagnosis of PTSD (Watson, Friedman, Ruzek, Norris, 2002). Drugs such as serotonin reuptake inhibitors (SSRIs), beta-adrenergic blockers, alph-adrenergic agonists, and benzodiazepines have been found to be beneficial (van et al., 2007).

Finding Christ within Acute Stress Responses One of the profound symptoms of those diagnosed with acute stress disorder is the temporary loss of spiritual connection or even lack of faith in God (AACC). A distinct emotion that is manifested when victims are in a state of acute stress is guilt. True guilt comes from God and can be described as “shame free” guilt that is meant to transform those who are affected by it (AACC). During times of acute stress, by God’s design, most people have propensity to be “traumatized and resilient at the same time” (AACC). The small percentage of people who are thrust into acute stress disorder are not lost or hopeless. Dr. Scalise is confident that “God whispers to us in our pleasures, speaks to us in our consciousness, but shouts to us in our pain…” (AACC). Caregivers are commissioned to demonstrate God’s healing grace by coming alongside those who have been traumatized and reassuring them that God is with them in their time of pain. “But he lifted up our illnesses, he carried our pain;” Isaiah 53:4.
Conclusion
When people experience traumatic events beyond their control the sensory perceptions, may, sometimes, overload and cause cognitive functioning to become impaired. Acute stress disorder (ASD) is a posttraumatic stress reaction that occurs two to four weeks after the trauma. Symptoms of (ASD), typically, manifests itself through cognitive, behavioral, emotional, biological, and spiritual disruptions. As of date, many people who suffer with ASD have a high rate of, later receiving a PTSD diagnosis. ASD symptoms are instrumental in accurately predicting symptoms of the onset of PTSD. DSM-IV has been criticized for the rigid criterion to diagnose ASD as opposed to PTSD. Research supports evidence that make it vital to interject early intervention care is provided in order to prevent further distress including PTSD. A better understanding and more research of Acute Stress Disorder (ASD) will be necessary to, possible prevent subsequent PTSD diagnosis.

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