Differential diagnoses

Both ICD-10 and DSM-IV require that the symptoms are not merely an exacerbation of a pre-existing disorder. In addition, a number of alternative diagnoses need to be considered.

Post-traumatic stress disorder

In ICD-10, PTSD is conceptualized as an alternative diagnosis of acute stress reactions. The definitions of acute stress reaction and PTSD differ in terms of the stressor criterion (exceptionally stressful life event vs. exceptionally threatening or catastrophic event), the time course (symptoms start to diminish within 48 h versus no time limit), and symptom pattern (PTSD, but not acute stress reaction, includes involuntary re-experiencing the traumatic event).

In DSM-IV, acute stress disorder can be distinguished from PTSD by the time-frame covered by the diagnoses. Acute stress disorder refers to the period from 2 days to 1 month post-trauma, after which a diagnosis of PTSD can be considered. The primary difference between the symptom criteria for acute stress disorder and PTSD in DSM-IV is the former's emphasis on dissociative reactions.

Adjustment disorder

This diagnosis covers a wide range of emotional or behavioural symptoms indicative of distress, which are judged to be out of proportion to the stressor experienced. This broad coverage can be contrasted with (1) the specific set of symptoms described by the acute stress disorder and acute stress reaction criteria, and (2) the stipulation that the stressor involves both a threat to life and a subjective response of fear for the acute stress disorder and an exceptional stressor in the case of acute stress reaction.

Brain injury

A number of acute stress disorder symptoms overlap with symptoms of brain injury including reduced awareness, depersonalization, derealization, irritability, and concentration difficulties. (15) While results from neuropsychological and neurological investigations may assist in the differential diagnosis, there appear to be a group of individuals with a mild head injury for whom there are no known tools to differentiate whether the disturbance is due to brain injury or acute stress disorder, or whether both are present.

Brief psychotic disorder

When there is one or more psychotic symptoms present after experiencing an extreme stressor, the brief psychotic disorder diagnosis should be considered. Dissociative disorders

Given the emphasis on dissociative symptoms in acute stress disorder, it needs to be distinguished from dissociative amnesia and depersonalization disorder. The criteria for these diagnoses stipulate that if the amnesia or depersonalization can be accounted for by acute stress disorder then a dissociative disorder cannot be diagnosed (see lCMPteL5,2,4).

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