Running head: ACUTE STRESS 1

A Discussion and Summary of Acute Stress Response

Varah Siedlecki

Liberty University
Running head: ACUTE STRESS 2

Abstract

Less than 50 years ago Hans Selye, a Nobel Prize laureate, coined the term “stress” to describe

the daily reality of tension or pressure on our mental or physical states. Acute stress is daily

stress magnified to a severe or intense degree, arising in a single moment in response to a

traumatic event. Despite its universal presence, acute stress response has received little if any

systemic consideration, until recently. In attempts to gain a greater understanding, this paper

will provide a brief summary of the multi-faceted considerations of acute stress response, and its

relationship to acute stress disorder (ASD). In examining the personal impact of acute stress,

this discussion will also identify diagnostic guidelines, symptoms, treatment strategies, coping

skills, and known spiritual and professional approaches which may be helpful in dealing with the

effects of stress and trauma.

Keywords: acute stress response, coping strategies, diagnostic guidelines, disorder, dissociation,

PTSD, symptoms, treatment methods

Running head: ACUTE STRESS 3

A Discussion and Summary of Acute Stress Response

It hardly seems only 50 years ago that Hans Selye “coined” the term stress - a term used

to describe a non-specific response to an unlimited realm of demands. Stress has become such

an integrated part of our personal, social, and global awareness; it is difficult to believe only half

a century ago this term did not even exist in the vernacular associated with psychology. For

centuries, the term was used in physics to describe and explain elasticity - the property of a

material that allows it to resume its original size and shape after having been exposed to external

forces. Much in the same way, the term stress is now used in the field of psychology to describe,

and explain the human response to traumatic forces and their influence on human properties of

“elasticity” – better known as “resiliency.” Being that the study of stress on the human organism

is a relatively recent study, much research is still needed to fully understand the multi-faceted

aspects of the human stress response.

It is commonly believed that stress is simply nervous tension, something to be avoided or

managed. In reality stress is a congruent and necessary property of all creation, without which

life would cease to exist; complete freedom from stress is in fact death. Whether in body, mind,

soul, or spirit, whether physical, mental, emotional, social, or financial, stress above all is an

indicator that an imbalance exists - it is a universal expression of reality, it is a God-given

mechanism by which organisms come to recognize correction is needed.

At the onset of an imbalance that creates fear, threat of injury or death, is when the acute

stress response (ASR) occurs, and an adaptation is initiated to restore balance. Our creator has

designed us with this remarkable, internal, and intricate mechanism to ensure our ability to

handle, respond to, and survive the stressors in life. Formerly associated with specific

psychological and physiological processes, the acute stress response (ASR) is commonly
Running head: ACUTE STRESS 4

recognized as the “fight-flight-or freeze” response. ASR has also been identified as acute stress

reaction or shock (Creamer, 2004). For eons, as far back as the pre-historic era, this process of

adaptation, and resiliency to stress has insured the safety and propagation of species. Although

post-modern stressors have changed considerably since the pre-historic era, our psychobiological

acute stress response mechanisms have not changed.

ASR and Acute Stress Disorder

Walter Cannon, M.D., an American physiologist, professor, and chairman of the

Department of Physiology at Harvard Medical was the first to recognize and identify acute stress

response (ASR) in animals at the onset of a perceived threat. In 1915, Cannon coined the term

“fight or flight response.” His work was an expansion on Claude Bernard’s concept of

homeostasis, and later came to be known as the first stage of a General Adaptation Syndrome

(GAS) (Creamer, O’Donnell & Pattison, 2004). Cannon’s theory was that among vertebrates

and other living organisms ASR occurs at the first stage of adaptation to either a physical or

mentally terrifying circumstance or traumatic event.

According to Creamer, O’Donnell and Pattison (2004), Selye built upon Cannon’s ideas,

and went on to identify three stages of the stress response: 1) the alarm stage, 2) the

adaptive/resistance stage, and 3) the exhaustion stage. Stage 1: the alarm stage defines the initial

response when the body first senses danger; Stage 2: describes the attempts of the body to restore

homeostasis; and Stage 3: defines the effects of the stress overload that leads to dysfunction and

destruction. It was Selye who proposed the General Adaptation Syndrome (GAS), which is

commonly referred to as stress response. It is obvious from Selye’s stages that the stress

response is a continuum ranging from an initial healthy tension, to a response demanding

performance, until finally degenerating as a result of the inability to restore homeostasis.

Running head: ACUTE STRESS 5

If homeostasis is not restored tensions increase, performance becomes inhibited, and

degeneration leads to the destruction of identity, personality, and the inability to pursue the

necessary tasks that once comprised the life of a soul. As one travels further along the stress

continuum, one becomes at risk of developing disorders that affect the core being of an

individual. Bessel A. van der Kolk (2007) reports that “exposure to extreme stress affects people

at many levels of functioning: somatic, emotional, cognitive, behavioral and characterological”

(p 183). In the most severe cases, the effects can even cause serious changes in the form and

function of the neurophysiological brain (Yang et al., 2011).

One’s progression along the stress continuum, from a state of distress to more severe

symptoms, is influenced greatly by a number of variables. ASR’s immediate response is just one

of many links in the chain of causality that determines the probability of how far along the stress

continuum one may travel before moving into more serious states of disorder, which include

acute stress disorder (ASD) and PTSD (Post Traumatic Stress Disorder) (Bryant, 2005).

Symptoms and Responses

Not all individuals that experience an ASR will develop ASD or PTSD. This poses a

critical question of why are some individuals resilient in the face of acute stress, while others are

not. Van der Kolk (2007) further postulates if there are specific symptoms that differentiate

those resilient individuals that regain homeostasis from those who respond severely

symptomatic. How an individual behaves, and perceives the threat, is thought to be indicative of

how they will respond. Variability of response is critical to pathological outcomes.

Findings demonstrate that each response is influenced by a complex matrix of biological,

social, temperamental, and experiential influences. The nature of the precipitating event, the

characteristics of the individual, and the nature of the recovery environment all have an
Running head: ACUTE STRESS 6

important bearing on whether the individual will go on to develop ASD or PTSD. Vulnerability

factors that may influence or modify the response to stress include family history of psychiatric

illness, neuroticism as a personality trait, range of social mediators, and the ability to tolerate

traumatic life events (van der Kolk, 2007).

Many studies have explored normal stress reactions, however these may be less relevant

than often assumed, as “they do not deal with the variability of response that is critical to

pathological outcomes” (van der Kolk, 2007, p 171). To date very little systemic research has

been done of ASR, and most studies on ASD have been restricted to samples of several hundred

people, whereas to adequately provide the understanding of the relationship between acute stress

reaction (ASR) and the variety of responses that can occur ideally should include thousands of

participants (Bryant, 2005).

Most of the understanding we have gained in the study of traumatic stress response

comes from the field of neuroscience. Scientific inquiry informs us that once the threat is

perceived to have passed, the body seeks to regain homeostasis, symptoms of hyperarousal

cease, and the body restores normal functioning. A typical pattern for even the most catastrophic

experiences is for the body to find a resolution of symptoms, and return to a pre-stress state of

equilibrium. In the event resolution of the experience is not achieved, the body and mind may

dissociate from the experience. Dissociation allows a person to observe the event as a spectator,

“to experience, no, or only limited, pain or distress; and to be protected from awareness of the

full impact of what has happened” (van der Kolk, 2007, p 192).

Dissociative reactions, during or after the initial stress response may lead to fragmented

encoding, and consolidation of symptoms resulting in acute stress disorder (ASD). Dissociation

is a major predictor that emotional processing of the stressor has been impeded and resolution of
Running head: ACUTE STRESS 7

the experience has failed (Bryant, 2005). Evidence suggests dissociation is an important factor

in ASR since it serves to identify acutely traumatized individuals who may go on to develop

acute stress disorder (ASD), a precursory condition for chronic PTSD (Post Traumatic Stress

Disorder).

Researchers Yitzhaki, Solomon, and Kotler (1991) found that due to ASR’s physiological

and psychological aspects, symptoms experienced are complicated and unstable. ASR can

manifest cognitive, emotional, and behavioral changes as well as somatic symptoms, with severe

ASR resulting in symptoms of mental illness (Shalev, 2002). Symptoms may reduce in severity

with time, but this is not always the case. According to Yang et al. (2011) those with preexisting

conditions, who are suffering from the severe symptoms of ASR are more at risk for developing

ASD or PTSD when encountering stressful events. “This is in contrast to the comparatively

lower risk of PTSD in individuals who have also experienced traumatic events but who have no

or mild manifestations of ASR” (Shalev, 2002, p 533).

Usually symptoms associated with ASR appear within minutes of the stress-inducing

event. Symptoms often present with great variation but typically include withdrawal, agitation,

anxiety, impaired judgment, and depression. These are symptoms commonly present with ASR;

however, in some cases partial or complete amnesia may also be present (Lambert, 2004). In the

next discussion of diagnostic guidelines, a more comprehensive list of symptoms will be

identified for ASR and ASD.

Diagnostic Guidelines

In considering the diagnostic guidelines for ASR, and ASD, it is important to note the

various influences that differentiate the two. Of primary notice are the time-limited reactions

between ASR and ASD. Another significant differentiation is noticed in the intensity and
Running head: ACUTE STRESS 8

severity of symptoms.

Acute stress Disorder (ASD) was introduced into the DSM-IV by the American

Psychiatric Association in 1994, and consists of many symptoms identified for PTSD. Criteria

included a fearful response to experiencing or witnessing a threatening event (American

Psychiatric Association, 1994). In essence, ASD is a diagnosis used to identify acutely

traumatized individuals who are at risk for developing chronic PTSD. This diagnosis chronicles

stress reactions during the commencing four weeks after a trauma, and symptoms must last for at

least 2 days. ASD is characterized as an anxiety disorder that differentiates time-limited

reactions to trauma. Symptoms of ASD include dissociative response, emotional detachment,

temporary loss of memory, depersonalization, and derealization (van der Kolk, 2007).

In 1977, the World Health Organization (WHO) designated ASR in the International

Statistical Classification of Disease, Injuries, and Causes of Death (ICD-9) as “acute reaction to

stress” (WHO, 1977). ASR is a necessary link of obvious interest due to is predictive quality in

identifying subsequent disorders that follow; however, few studies have been conducted on ASR

and its various domains (Brewin, Andrews & Valentine, 2000). In contrast, research into PTSD

has been relatively comprehensive with investigations into symptoms, influencing factors and

methods of treatments (Yang et al., 2011).

To provide an accurate diagnostic guideline for ASR, a much more thorough study of its

various domains, and symptom clusters must be compiled and reviewed. Consequently, Yang et

al. (2011) have developed the Acute Stress Response Scale (ASRS) in attempt to construct a

reliable, and consistent scale to objectively assess, and accurately detect dimensions and

symptom clusters of ASR. ASRS may provide a tool that serves as a diagnostic guideline for

ASR, which at present has no specific diagnostic guideline in the DSM; however, according to
Running head: ACUTE STRESS 9

the International Classification of Diseases, 10th Edition (ICD-10) ASR is a diagnosis given

following the experience of an exceptional mental or physical stressor. Gradus et al. (2010)

presents the following diagnostic guidelines as distinguished for ASR in the ICD-10:

According to the ICD-10 Classification of Mental and Behavioural [sic]

Disorders, Diagnostic Criteria for Research, the symptoms of acute stress reaction

must be present within 1h of the stressful or traumatic event and include one

autonomic arousal symptom (e.g. sweating, heart palpitations or shaking). In

addition, symptoms from three of the following categories must be present: chest

and abdomen symptoms (e.g. difficulty in breathing, feeling of choking or chest

pain), brain and mind symptoms (e.g. feeling dizzy, feeling that objects are unreal

or fear of dying), general symptoms (e.g. numbness or chills), muscle and mental

tension symptoms and other non-specific symptoms (e.g. being easily startled,

difficulty concentrating or irritability). In moderate or severe cases, one may also

exhibit despair or hopelessness, disorientation, withdrawal from social activities,

decreased attention, aggression, or over-activity. Finally, for acute stressors, the

symptoms must begin to diminish within 8h of the event, whereas the symptoms

must begin to diminish within 48h of the event for continuing stressors (pp. 1478-

1479).

Personal Impact

ASR has an immediate impact on the individual, as it is the initial psychobiological

action that prepares an organism to either fight in defense for its survival, flee from the threat in

attempts to establish safety, or freeze in hope that the trauma passes. It is widely held that this

initial response to trauma “is a normal response to an abnormal event” (van der Kolk, 2007, p
Running head: ACUTE STRESS 10

78); still most individuals perceive the physiological changes that occur during the stress

response as a negative experience.

Not only does ASR impact physiology, ASR can impact an individual across several

domains including biological, psychological and social. Within these domains, ASR may impact

existing medical conditions, personality, lifestyle, social systems, family relationships, and

worldviews. ASR may also have an impact and risk factor for completed suicide (Gradus, et al.

2010), since it is comorbid with depression or substance abuse.

One’s response to stress and trauma can lead to a major shift in one’s perceptual

sensitivities, such experiences often are powerful motivating events, which can have a very

positive personal impact for those who have survived the ordeal. Biological and mental acute

stress responses can be distressing and transiently disabling; but more often than not, they

subside without a need for deliberate intervention (Clinton & Ohlschlager, 2002). However, for

those in whom the stress fails to subside, disease states begin to take form as prolonged, multi-

faceted, and complicated disorders develop having a profound personal impact on all concerned.

Acute stress can have a longitudinal impact with consequences that continue indefinitely.

Although ASR usually has an immediate impact within minutes of the stressor, and symptoms

usually disappear within hours or 2-3 days, the impact can cause non-specific physical symptoms

to develop over time even in the absence of immediate perceived symptomatic effects. ASR may

also modify an individual’s vulnerability to subsequent trauma. Unbeknownst to the individual,

a threat or trauma can impact one’s values and beliefs establishing an unconscious, invisible

belief system that ultimately shapes social attitudes and responses (van der Kolk, 2007).

In attempts to gain a greater understanding of the multi-faceted and complicated

considerations of ASR, and the impact it has on a life, we will briefly explore the inner workings
Running head: ACUTE STRESS 11

of the psychobiological mechanism.

Psychobiological Response Mechanism

Acute stress response (ASR) is a type of alarm system inherent within the psychological,

biological, and physiological matrix. It is a protective, internal defense to external stimuli,

allowing us to respond appropriately to the threat of danger. When a threat is perceived, specific

physiological changes occur that prepare the body to respond effectively to the stressor. At the

onset of ASR, the pulse and rate of breathing quickens, the heart begins to race, pupils dilate, and

blood is directed toward the extremities, away from the core organs, to facilitate mobilization. In

addition, adrenaline, cortisol, and other hormones are released in efforts to provide the body with

the energy required to respond to the perceived threat, facilitating a state of hyperarousal

(Clinton & Ohlschlager, 2002).

These physiological changes arouse the sympathetic nervous system, enhancing the

senses, and allowing the body to respond at peak performance, and awareness. Acute stress

response mechanisms are directly related to adaptation, loss, learning, memory-formation, brain

structure and function, and ultimately survival. Activating these psychobiological changes

constitutes major characteristics of ASR. These changes are complex, and involve multi-faceted

mechanisms related to survival. Either these responses serve as adaptive mechanisms that

mediate survival, learning, and adaptation, or the response emerges as a mental disorder (Shalev,

2002).

ASR activates the entire central nervous system sending neural and chemical messages

from the hypothalamus and pituitary, which in turn signals the adrenal glands to release stress

coping hormones. Maintaining homeostasis during ASR is the function of the endocrine system,

while the body’s ability to mobilize begins in the motor area of the brain. The senses necessary
Running head: ACUTE STRESS 12

for perception and evaluation of the threat are brain-mediated as well. The ability to shift

attention, organize thoughts, focus, and respond emotionally or out of impulse are also functions

of the brain. During the initial response, the sympathetic nervous system is activated, and neural

and chemical messages immediately stimulate the body. If the body persists in this state of

hyperarousal, and homeostasis is not restored after the initial threat has ceased, depletion and

exhaustion are inevitable, leading to serious physical, emotional, mental, and spiritual

complications. If treatment is not received, the deteriorating physical conditions of ASR can

eventually destroy the individual from the inside out. Due to the complexity and prevalence of

stress within our postmodern world, it should not be taken lightly.

Treatment, Management, Coping Strategies and

Spiritual and Professional Approaches

Given the pervasiveness and impact of stress in our modern world it is of utmost

importance that an antidote is found. Stress operates on a continuum from minor disequilibrium

to paralysis, and in some cases even death. In treating acute responses, pharmacotherapy targets

the following two distinctions: 1) to reduce current distress, and 2) prevent subsequent stress

disorders. While pharmacotherapy can target symptoms, and putative disease processes, there

are no published randomized controlled studies of pharmacological interventions presently

available. Clinical observations and studies of PTSD are all that recent trauma survivors can rely

on.

Use of benzodiazepines, may reduce anxiety and improve insomnia, but at the risk of

increasing the likelihood of PTSD. Antidepressants have a significant effect on PTSD, while

serotonin reuptake inhibitors are associated with benefitting ASR. Corticotrophin-releasing

hormone receptors that mediate prolonged stress responses may affect the longitudinal course of

ASR (Shalev, 2002); however empirical testing of these ideas is obviously required.
Running head: ACUTE STRESS 13

Cognitive behavioral approaches may be more practical, although it too has its

limitations. A growing body of research suggests that the impacts of cognitive appraisals are a

powerful tool that helps shift negative stress states to more positive ones (Jamieson, Mendes &

Nock, 2013). However, according to Bryant, Moulds & Guthrie (2001) the findings remain

inconclusive and suggest that future studies need to consider the role of specific cognitive

strategies in the maintenance or resolution of ASR.

In 2009 a collaborative study involving the Departments of Psychiatry, Biochemistry,

Biophysics and Behavioral Sciences at the University of California revealed that acute stress

affects the immune system in complex ways, including changing the distribution of cell types,

and is linked to shorter telomeres. “The successful maintenance of telomeres, the protective caps

at the ends of chromosome, is critical to human health” (Epel et al., 2009, p 531). The results of

this study are significant since acute stress is shown to increase cortisol, catecholamines, and

oxidative stress factors, which regulate telomerase activity. Telomerase is a cellular enzyme that

has been linked to age related risk factors, disease, and early mortality. Telomerase is likely a

protective functional response, and may protect cells and/or telomeric DNA from acute stress-

induced mediators such as cortisol or oxidative stress.

This study advances the understanding of the relationship between acute stress and cell

aging in vivo, indicating that like stress-reactive hormones, “telomerase may be dynamic and

responsive to stress, which could have major implications for both research and clinical

applications (Epel et al., 2009). Although the study by Epel et al. (2009) is limited by its sample

size, given that the stress parameters (threat appraisals and changes in cortisol) were correlated

with changes in telomerase activity, it leaves one to question if the possibility of an antidote may

be found in the telomerase enzyme.

Running head: ACUTE STRESS 14

ASR is a challenge with potentially epidemic proportions considering that 21% of

women, and 8% of men who suffer from ASR will go on to develop PTSD. For those with

preexisting trauma experiences the percentages are nearly three times this rate (i.e. rape victims

are 55% more likely to develop PTSD) (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

Affect management, cognitive restructuring, and social integration are all considered components

of effective treatments, yet a broader view must be considered, not just a reduction in

psychopathological symptoms. Coping styles, resilience, social reorganization, and sensitivity

must also be among the tools when considering treatment of ASR (Spiegel, (2005).

Stress management, coping skills, and reduction strategies such as exercise, good

nutrition, developing a social support network, meditation, deep breathing, future visualization,

eye movement desensitization and reprocessing interventions are reported to be beneficial.

Interventions provide comprehensive assessments of the individual’s strengths and resources,

and therapeutic relationships offer thorough collaborative support; however, none of the above

mentioned methods are sufficient when standing alone.

Conclusion

Given the magnitude of crises in the world, there is no simple remedy. Living with stress

has become the new norm; fears, grief, anxiety, anger, resentment, and depression are common

aspects of human life. Gone are the simple ‘good-ole-days’ – the reality we are facing during

these post-modern times are filled with hostility, and danger. Uncertainty pervades the human

arena; all humanity is subject to the provocations of global war and daily tensions of survival,

which the psychobiological post-modern brain is not equipped to deal with.

Stress is unavoidable; it is part of the human experience and affects all dimensions of

being. Those who seek professional care or spiritual counsel may find the needed support to
Running head: ACUTE STRESS 15

better cope with the symptoms of stress. Being attuned to the issues presented in this discussion,

and being familiar with treatment approaches that have been identified as effective for resolving

distress is foundational when dealing with ASR (Koucky, Galovski, Nixon, 2012). Of most

significance, is recognizing that stress can be a catalyst for spiritual growth and stability rather

than an agent of destruction and despair; this is the first step in the healing process.

So many people are suffering, and while there are many ways to respond to stress,

without a solid spiritual hope all the methods of stress management are superficial. Scripture

provides us with a prescription for overcoming stress. In Proverbs 17:22 it states: “A joyful

heart is good medicine, but a crushed spirit dries up the bones (KJV). Joy comes from within; it

is a feeling of contentment and fulfillment that is not based on external circumstances. While we

may get crushed on the outside by people, places, circumstances and events, the key to living in

victory is to learn how to get up on the inside. However, when under stress, finding the strength

to get up is often easier said than done, and it is then we must rely on strength greater than our

own (Nehemiah 8:10).

Research on joy and laughter reflects amazing results, indicating that laughter is good for

the heart and brain; it reduces stress, balances neurotransmitters, helps alleviate insomnia,

corrects depression, reduces pain, and enhances longevity. One study shows that twenty seconds

of belly laughter is equivalent to three minutes on a rowing machine, and ten minutes of laughter

can reduce pain for two hours (Balick & Lee, 2003). According to Keltner & Bonanno (1997),

laughter facilitates the adaptive response to stress by increasing psychological distance from

distress while also enhancing social relations. Laughter releases the tension of acute stress by

reducing stress hormone levels, for this reason keeping a sense of humor is a common

recommendation of stress management experts (Dunbar et al., 2012).

Running head: ACUTE STRESS 16

Ralph Waldo Emerson is credited for stating that: “What lies behind us, and what lies

before us, are small matters compared to what lies within us.” We have been created in the

image and likeness of God (Genesis 1:26-27); we are marvelously and wondrously made (Psalm

139:14). Our Creator has placed within each soul a self-healing quality, an internal resource;

although less tangible than external resources found in therapeutic relationships, medications,

and treatment interventions, it is nonetheless an excellent resource upon which we can rely. This

resource is the Spirit of the Most High. “He is our refuge and strength, an ever-present help in

times of trouble. Therefore we will not fear, though the earth give way and the mountains fall

into the heart of the sea, though its waters roar and foam and the mountains quake with their

surging. There is a river whose streams make glad the city of God, the holy place where the

Most High dwells” (Psalm 46:1-4, NIV) - and in Him, we can rely. Ω
Running head: ACUTE STRESS 17

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders, (4th ed). Washington, DC: Author.

Balick, M., Lee, R. (2003). The role of laughter in traditional medicine and its relevance to the

clinical setting: Healing with ha! Altern There Health Med, 9, 88-91.

Bento, W. (2011). Living with stress as the new norm of the post-modern world: Its

consequences and challenges. Lilipoh: The Spirit of Life

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for

postraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical

Psychology, 68, 748-766.

Bryant, R. A. (2005). Predicting posttraumatic stress disorder from acute reactions. Journal of

Trauma & Dissociation, 6(2), 5-15. Retrieved from:

http://dx.doi.org/10.1300/J229v06n02_02

Bryant, R. A., Moulds, M., & Guthrie, R. M. (2001). Cognitive strategies and the resolution of

acute stress disorder. Journal of Traumatic Stress, 14, 213–219.

doi: 10.1023/A:1007856103389

Clinton, T. C. & Ohlschlager, G. (2002). Competent Christian

Counseling. Colorado: Waterbrook Press.

Creamer, M., O'Donnell, M. L., & Pattison, P. (2004). Acute stress disorder is of limited benefit

in predicting post-traumatic stress disorder in people surviving traumatic injury. Behavior

Research and Therapy, 42, 315-328.

Dunbar, R, Baron, R., Frangou, A., Pearce, E., Van Leeuwen, E., Stow, J., Partridge, G.,
Macdonald, I., Barra, V., & Van Vugt, M. (2012). Social laughter is correlated with an
elevated pain threshold. Proceedings of the Royal Society-B, 279, 1161-1167. doi:
Running head: ACUTE STRESS 18

10.1098/rspb.2011.1373

Epel, E. S., Lin, J., Dhabhar, F. S., Wolkowitz, O. M., Puterman, E., Karan, L., Blackburn, E. H.

(2009). Dynamics of telomerase activity in response to acute psychological stress. Brain,

Behavior, and Immunity, 24, 531-539. doi:10.1016/j.bbi.2009.11.018

Gradus, J. L., Qin, P., Lincoln, A. K., Miller, M., Lawler, E., Sorensen, H. T., & Lash, T. L.

(2010). Acute stress reaction and completed suicide. International Journal of

Epidemiology, 39, 1478-1484. doi:10.1093/ije/dyq112

Jamieson, J. P., Mendes, W. B., Nock, M. K. (2013) Improving acute stress responses: The

power of reappraisal. Current Directions in Psychological Science, 22(1), 51-56. doi

10.1177/0963721412461500, Retrieved from:

http://cdp.sagepub.com.ezproxy.liberty.edu:2048/content/22/1/51

Keltner, D., Bonanno, G. A. (1997). A study of laughter and dissociation: Distinct correlates of

laughter and smiling during bereavement. Journal of Personality and Social Psychology,

73(4), 687-702.

Kessler RC., Sonnega A., Bromet E., Hughes M., & Nelson, C. B. (1995). Posttraumatic stress

disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 52, 1048–1060.

Koucky, E. M., Tara E. Galovski, Reginald D.V., & Nixon (2012). Acute stress disorder:

Conceptual issues and treatment outcomes. Cognitive and Behavioral Practice, 19(3),

437-450. Retrieved from:

(http://www.sciencedirect.com/science/article/pii/S1077722911001155)

Lambert, M.J., (Ed.). (2004). Bergin and Garfield's Handbook of Psychotherapy and Behavioral

Change. New York: Wiley

Sely, H. (1974). Stress without distress. New York: McGraw-Hill.

Running head: ACUTE STRESS 19

Shalev, A. Y. (2002). Acute stress reactions in adults. Biological Psychiatry, 51(7), 532-543.

Retrieved from: (http://www.sciencedirect.com/science/article/pii/S0006322302013355)

Spiegel, D. (2005). Treatment of acute traumatic stress reactions. Journal of Trauma &

Dissociation, 6(2), 101-108. Retrieved from: http://dx.doi.org/10.1300/J229v06n02_09

van der Kolk, B., McFarlane, A., & Weisaeth, L. (2007). Traumatic stress; The effects of

overwhelming experience on mind, body, and society. New York, NY. The Guilford

Press.

Wheeler, K. (2007). Psychotherapeutic strategies for healing trauma. Perspectives in Psychiatric

Care, 43, 132–141. doi: 10.1111/j.1744-6163.2007.00122.x

World Health Organization (WHO). (1977). Manual of the international statistical classification

of disease, injuries, and causes of death (9th revision). Geneva: Author

Yang, Y., Tang, J., Jiang, Y., Liu, X., Sun, Y., Zhu, X., & Miao, D. (2011). Development of the

acute stress response scale. Social Behavior and Personality, 39(5), 713-720. Retrieved

from http://search.proquest.com/docview/878894660?accountid=12085

Yitzhake, T., Solomon, Z., & Kotler, M. (1991). The clinical picture of acute combat stress

reaction among Israeli soldiers in the 1982 Lebanon war. Military Medicine, 156, 193-

197.