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Acute Stress Disorder a Handbook of Theory, Assessment, And Treatment UpLoaDeD by LeaDeR DrVetTox (January 2009)

Acute Stress Disorder a Handbook of Theory, Assessment, And Treatment UpLoaDeD by LeaDeR DrVetTox (January 2009)

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Published by Ivana Hadzivanova

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Published by: Ivana Hadzivanova on Apr 23, 2012
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THE
EMERGENCE
OF
ACUTESTRESS DISORDER
The psychological problems that arise from extreme trauma have beendocumented in literature since the time
of
Homer (Alford,
1992).
Theearly writings have described the anguish caused by distressing memories
and
elevated anxiety in a wide range of trauma survivors. Despite thisawareness
of
the psychological aftermath
of
trauma, our understanding ofposttrauma reactions has varied considerably over the years. Interestingly,the conceptualization of trauma response has often been influenced
by
thesocial and ideological movements
of
the day. For example, in the 19thcentury, there was considerable debate over the functional or organic basesof
traumatic
neurosis
or
railway spine.
In
keeping with prevalent schools
of
thought at the time, some theorists argued that such reactions resulted frommolecular changes in the central nervous system (Oppenheim,
1889),
whereas others held that they were a function
of
anxiety (Page, 1895).Some years later, the diagnosis
of
shell shock became fashionable (Mott,1919) because ascribing stress reactions to organic factors permitted anacceptable attribution for poor military performance (van der Kolk, 1996a).Similarly, we need to understand the current conceptualization
of
acutestress disorder (ASD) in the context of popular ideological developmentsin modem psychiatry.One
of
the most influential developments in the current conceptu-alization of
ASD
was the work conducted at the Salpitriire in Paris.
Al-
3
 
though this school
of
thought commenced
100
years ago, its powerful
in-
fluence
on
modern psychiatry has
only
occurred
in
the last
20
years. Thisearly theorizing represents the precursor of current proposals of trauma-induced dissociation (Nemiah,
1989;
van der Kolk
&
van der Hart,
1989).
Charcot
(
1887)
proposed that traumatic shock could evoke responses thatwere phenomenologically similar to hypnotic states. Charcot
held
thatoverwhelmingly aversive experiences led
to
a dissociation that involvedprocesses observed in both hysteria and hypnosis. Janet
(1907)
continuedthis perspective
by
arguing that trauma that was incongruent with existingcognitive schema led to dissociated awareness. Janet believed that
by
split-ting
off
traumatic memories from awareness, individuals could minimizetheir discomfort. The price for this dissociation, however, was a loss inpsychological functioning because mental resources were not available forother processes. Accordingly, Janet argued that adaptation
to
a traumaticevent involved integrating the fragmented memories into awareness.
De-
spite the immediate influence
on
his contemporaries, Janet’s influence wasshort-lived until the renaissance of dissociation in the 1980s. Indeed, itwas these early theorists who provided the basic rationale for the presentdiagnosis of
ASD.
Increased interest in acute stress reactions developed during the
20th
century as a result of
both
wartime and civilian traumas. In one of theearliest studies
of
acute stress, Lindemann
(
1944)
documented the acutereactions of survivors of the Coconut Grove fire
in
Boston in
1942.
Heobserved that
the
acute symptoms reported
by
survivors included avoidance
of
“the
intense distress connected to the grief experience.
.
,
the expres-sion of emotion
. . .
disturbed pictures
.
.
.
a sense
of
unreality
,
. .
ncreasedemotional distance from other people
. . .
and waves of discomfort” (pp.
141-143).
In
general, however, much of the early interest in acute trau-matic stress reactions came from military sources. Acute stress reactionswere reportedly common in troops from both World War
I
and World War
I1
(Kardiner, 1941; Kardiner
&
Spiegel,
1947).
The acute psychologicalafermath of battle, subsequently known as
combat
stress
reaction
(CSR), wasthe most studied instance
of
acute stress. This is not surprising consideringthat
CSR
was observed in more than
20%
of
US
troops in World War
I1
(Solomon, Laor,
&
McFarlane,
1996).
CSR
is a poorly defined constructthat
is
marked
by
its variability and fluctuating course (Solomon, 1993a).Its symptoms include anxiety, depression, confusion, restricted affect, irri-tability, somatic pain, withdrawal, listlessness, paranoia, nausea, startle re-actions, and sympathetic hyperactivity (Bar-On, Solomon, Noy,
&
Nardi,
1986;
Bartemeier,
1946;
Grinker,
1945).
Inherent in many of the earlynotions of
CSR
was the assumption that stress symptoms were transientreactions to an extreme stress. That is, they were
not
recognized as psy-chopathological reactions because
they
were observed in troops who werenot regarded as having a predisposition to psychiatric disorders. These mil-
4
ACUTE STRESS DISORDER
 
itary opinions played a significant role in shaping
the
early diagnosticthinking
of
both
the World Health Organization
(WHO)
and
the
Amer-ican Psychiatric Association after World War
11.
In
1948,
WHO
adoptedthe Armed Forces’ categorizations when it integrated mental disorders intothe sixth revision
of
the
International Statistical Classification
of
Diseases,Injuries, and Causes
of
Death (ICD-6).
Similarly, in
1952,
the AmericanPsychiatric Association developed the
Diagnostic and Statistical Manual
of
Mend Disorders (DSM)
on the basis
of
existing conceptualizations withinthe Veterans Administration and the Armed Forces.
A
major effect
of
thisinfluence was that initial diagnostic categorizations regarded acute stressreactions as temporary responses in otherwise normal individuals (Brett,
1996).
Exhibit
1.1
contains a summary of the development of diagnosticcategories relevant to traumatized people in both
ICD
and
DSM.
The de-scriptions
of
acute trauma reactions in
ICD-6
to
ICD-9
(World HealthOrganization,
1977)
all shared the assumption that acute stress reactionswere transient reactions
in
nonpathological individuals. During the sameperiod
of
time, the American Psychiatric Association used variable termsto describe acute stress reactions. The first edition
of
DSM
(AmericanPsychiatric Association,
1952)
classified acute posttrauma responses under
gross stress
reaction,
and longer lasting reactions were subsumed under
the
anxiety
or
depressive
neuroses.
In
DSM-11
(American Psychiatric Associa-tion,
1968),
ongoing reactions were similarly categorized, but
transient
sit-
uational disturbance
was used
to
describe an acute posttrauma response. Themajor changes occurred in
DSM-111
(American Psychiatric Association,
1980),
in which the diagnosis of
posttraumatic
stress
disorder
(PTSD)
was
EXHIBIT
1.1
Diagnostic Categories for Traumatic Stress Reactions
ICD DSMICD-6
(1948)
Acute situational maladjustment
ICD-8
(1969)
ICD-9
(1977)
ICD-
7
0
(1 992)
Transient situational disturbanceAcute stress reactionAcute stress reactionPosttraumatic stress disorderEnduring personality change aftertrophe experience
DSM
(1 952)
Gross stress reactionsAdult situational reactionAdjustment reactionAdjustment reactionPosttraumatic stress disorderAcute stress disorderPosttraumatic stress disorder
DSM-I1
(1 968)
DSM-Ill, DSM-Ill-R
(1980, 1987)
DSM-IV
(1 994)
catas-
Note. ICD
=
lnternational Statistical Classification of Disease
(published by the
World
HealthOrganization);
DSM
=
Diagnostic and Statistical Manual of Mental Disorders
(published by theAmerican Psychiatric Association).
EMERGENCE
OF
ASD
5

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