Internet Mental Health


Expanded Quality of Life Scale For Acute Stress Disorder

Internet Mental Health Quality of Life Scale

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • After exposure to a severe trauma, developed at least 3 days of specific stress symptoms (e.g., intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, arousal symptoms)

  • The stress-induced symptoms lasted no more than 1 month

  • Causes clinically significant distress or impairment.

  • Has insufficient symptoms to meet the criteria for another mental disorder

  • Is not merely an exacerbation of a preexisting mental disorder

  • Is not due to a medical or substance use disorder.


    Recovery within 1 month (or this diagnosis must be changed)


Occupational-Economic Problems:

  • Causes significant impairment in academic, occupational and/or social functioning

Dissociative Symptoms (Impaired Intellect):

  • Flashbacks: episodes in which the individual feels or acts as if the traumatic event(s) were recurring

  • Disorientation: dissociative symptoms may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings

Reserved, Quiet (Detachment):

  • Social withdrawal

Distressed, Easily Upset (Negative Emotion):

  • Intrusion symptoms: recurrent, involuntary, and intrusive distressing memories, dreams, and flashbacks of the traumatic event(s)

  • Negative mood: persistent inability to experience positive emotions

  • Avoidance symptoms: efforts to avoid distressing memories or external reminders that arouse distressing memories

  • Arousal symptoms: sleep disturbance, irritability, hypervigilance, problems with concentration, exaggerated startle response

Medical Problems:

  • Autonomic signs of panic anxiety (tachycardia, sweating, flushing)

Explanation Of Terms And Symbols

Internet Mental Health Quality of Life Scale

Fear, Generalized Anxiety, Phobia, Panic, Obsession, and Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. The individual may then panic if exposed to snakes. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Normal Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Generalized Anxiety:
    Fear can become excessive, and generalized with excessive anxiety and worry about a number of objects or situations. This anxiety is often associated with avoidance of the feared objects or situations and irritability. Generalized anxiety, especially about distressing memories of the traumatic event, can be very marked in acute stress disorder.

  • Phobia:
    Fear can become excessive, and specifically attached to specific objects or situations (e.g., fear of flying). This phobic fear is out of proportion to the actual danger posed by these feared objects or situations, and the individual desperately tries to avoid whatever triggers the phobia. This phobic fear causes significant distress or disability. Individuals with acute stress disorder can develop intense phobic reactions to reminders of the traumatic event.

  • Panic:
    Phobic individuals can develop a full-blown panic attack if exposed to whatever triggers their phobia. In panic disorder, individuals experience panic attacks that occur spontaneously, and that are not triggered by any phobic stimulus. Individuals with acute stress disorder commonly experience panic attacks in the initial month after trauma exposure that may be triggered by reminders of the traumatic event, or these panic attacks may occur spontaneously.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is a fear-provoking intrusive thought. The recurrent, involuntary, and intrusive distressing memories of traumatic event(s) seen in acute stress disorder could be argued to be obsessions. (Obsessions are defined as: "Recurrent and persistent thoughts, urges, or images that are experienced as intrustive and unwanted and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.") For example, individuals - especially children - may become preoccupied with reminders of their trauma. For example, young children bitten by a dog may become obsessed with dogs and talk about them constantly, and avoid going outside because of their phobic fear of dogs.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. The compulsive substance abuse, gambling or impulsive behavior individuals use to relieve their symptoms of acute stress disorder come close to being compulsive.

Back to top

Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Acute Stress Disorder 308.3

This diagnosis is based on the following findings:

  • Exposed to very upsetting traumatic event(s)

  • Duration of the disturbance was more than 3 days, but less than 1 month

  • This traumatic event caused clinically significant distress or disability (still present)

  • This distress or disability was not due to a substance or another medical condition

  • This distress or disability was not due to a brief psychotic disorder

  • Recurrent, unwanted, distressing memories after this traumatic event (still present)

  • Recurrent distressing dreams after this traumatic event (still present)

  • Dissociative reactions (e.g., flashbacks) after this traumatic event (still present)

  • Intense prolonged psychological or physiological distress when reminded of this traumatic event (still present)

  • Persistent inability to experience positive emotions after this traumatic event (still present)

  • Altered sense of reality after this traumatic event (still present)

  • Inability to remember an important aspect of the traumatic event(s) (still present)

  • Tried hard to avoid thinking about this traumatic event (still present)

  • Tried hard to avoid external reminders associated with this traumatic event (still present)

  • Increased sleep disturbance after this traumatic event (still present)

  • Increased irritability or angry outbursts after this traumatic event (still present)

  • Increased hypervigilance after this traumatic event (still present)

  • Increased problems with concentration after this traumatic event (still present)

  • Exaggerated startle response after this traumatic event (still present)


  • Goal: prevent recurrent, unwanted, distressing memories

  • Goal: prevent recurrent, distressing dreams

  • Goal: prevent dissociative reactions (e.g., flashbacks)

  • Goal: prevent intense prolonged psychological or physical distress when reminded of this traumatic event

  • Goal: overcome inability to experience positive emotions

  • Goal: prevent altered sense of reality

  • Goal: overcome memory loss (dissociative amnesia)

  • Goal: overcome avoidance of thinking about this traumatic event

  • Goal: overcome avoidance of external reminders associated with this traumatic event

  • Goal: prevent sleep disturbance

  • Goal: prevent irritability and angry outbursts

  • Goal: prevent hypervigilance

  • Goal: overcome problems with concentration

  • Goal: prevent exaggerated startle response

Back to top

Acute Stress Reaction F43.0 - ICD10 Description, World Health Organization

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of "daze" with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor - F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.
Dissociative Stupor F44.2 - ICD10 Description, World Health Organization
Dissociative stupor is diagnosed on the basis of a profound diminution or absence of voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch, but examination and investigation reveal no evidence of a physical cause. In addition, there is positive evidence of psychogenic causation in the form of recent stressful events or problems.
Dissociative Amnesia F44.0 - ICD10 Description, World Health Organization
The main feature is loss of memory, usually of important recent events, that is not due to organic mental disorder, and is too great to be explained by ordinary forgetfulness or fatigue. The amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective. Complete and generalized amnesia is rare, and is usually part of a fugue (F44.1). If this is the case, the disorder should be classified as such. The diagnosis should not be made in the presence of organic brain disorders, intoxication, or excessive fatigue.
Dissociative Fugue F44.1 - ICD10 Description, World Health Organization
Dissociative fugue has all the features of dissociative amnesia, plus purposeful travel beyond the usual everyday range. Although there is amnesia for the period of the fugue, the patient's behavior during this time may appear completely normal to independent observers.
Acute Stress Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with acute stress disorder disorder needs to meet all of the following criteria:

  • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others.

    • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

  • Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

    • Intrusion Symptoms

    • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

    • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

    • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

      Ask: "Are you having 'flashbacks,' that is, do you suddenly act or feel as if a stressful experience from the past is happening all over again (for example, you reexperience parts of a stressful experience by seeing, hearing, smelling, or physically feeling parts of the experience)?"

    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

      Ask: "Do you feel very emotionally upset when something reminds you of a stressful experience?"

    • Negative Mood

    • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

      Ask: "Are you losing interest in activities you used to enjoy before having a stressful experience?"

    • Dissociative Symptoms

    • An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective, being in a daze, time slowing).

    • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs).

    • Avoidance Symptoms

    • Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

      Ask: "Do you try to avoid thoughts, feelings, or physical sensations that remind you of a stressful experience?"

    • Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

    • Arousal Symptoms

    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

      Ask: "Are you extremely irritable or angry to the point where you yell at other people, get into fights, or destroy things?"

    • Hypervigilance.

      Ask: "Are you 'super alert,' on guard, or constantly on the lookout for danger?"

    • Problems with concentration.

    • Exaggerated startle response.

      Ask: "Do you feel jumpy or easily startled when you hear an unexpected noise?"

  • Duration of the disturbance is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

  • ("Ask" questions are not part of the DSM-5. Instead, they are inserted from the Severity of Posttraumatic Symptoms - Adult scale.

Back to top

Diagnostic Features

Acute Stress Disorder develops in an otherwise mentally healthy individual in response to an exceptionally traumatic event. Initially there is a dissociative phase (with absence of emotional responsiveness, "being in a daze", derealization, depersonalization, and/or dissociative amnesia). Later the traumatic event is persistently reexperienced (flashbacks), or there is distress on exposure to reminders of the traumatic event. There is marked avoidance of stimuli that arouse recollections of the trauma. There are marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). Acute Stress Disorder causes significant distress or life impairment. Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month. It is not due to a drug, medication, or general medical condition.


Acute Stress Disorder may interfere with sleep, energy levels, and capacity to attend to tasks. This disorder can result in generalized withdrawal from many threatening situations (e.g., medical appointments, absenteeism from work). Half of the individuals who develop Posttraumatic Stress Disorder initially present with Acute Stress Disorder.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.


Prevalence depends on the type of trauma (e.g., 13%-21% of motor vehicle accidents, 19% of assault, 20%-50% for rape or witnessing a mass shooting).


Lasts from 3 days to 1 month. If symptoms persist past 1 month; diagnosis is changed to Posttraumatic Stress Disorder.


Of 1084 consecutive admissions to 5 major trauma hospitals across Australia, 10% developed acute stress disorder (ASD) in the initial month after trauma. At 12-month followup, 10% of the 1084 patients had developed posttraumatic stress disorder (PTSD), and 31% had developed any psychiatric disorder. In terms of those initially diagnosed with ASD, 36% subsequently developed PTSD and 65% developed any psychiatric disorder.


Acute Stress Disorder is triggered by a traumatic event, but there is a higher risk of developing this disorder for those individuals with high levels of Negative Emotion (neuroticism), and an avoidant coping style.

Controlled Clinical Trials Of Therapy

Click here for a list of all the controlled clinical trials of therapy for this disorder.

Effective Therapies

There is evidence that individual trauma focused cognitive behavioural therapy is effective for individuals with acute traumatic stress symptoms compared to both waiting list and supportive counselling interventions. Prolonged exposure therapy has also been found to be effective (with 47% of patients achieving full remission at 6-month followup). Cognitive restructuring therapy has been found to be less effective (with only 13% of patients achieving full remission at 6-month followup). SSRI antidepressant therapy has been shown to be effective in treating posttraumatic stress disorder, acting to reduce its core symptoms, as well as associated depression and disability. Thus this medication should be considered when it appears that the acute stress disorder will last longer than one month.

Ineffective therapies

There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Research has shown that compulsory debriefing of victims of trauma may actually increase the risk of posttraumatic stress disorder and depression. Thus compulsory debriefing of victims of trauma should cease. A more appropriate response could involve a 'screen and treat' model (NICE 2005).

Vitamins, dietary supplements, antianxiety, and antipsychotic medications have not been shown to be effective for this disorder.

A Dangerous Cult

Back to top



Rating Scales

Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These 5 major dimensions of human behavior seem to represent 5 major dimensions whereby our early ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, enthusiastic, and calm.

    Which Dimensions of Human Behavior are Impaired in Acute Stress Disorder?

    Agreeableness Antagonism       Sympathetic, Kind vs. Critical, Quarrelsome
    Conscientiousness Disinhibition       Industrious, Orderly vs. Impulsive, Disorderly
    Openness To Experience Impaired Intellect       Open-Minded, Creative vs. Cognitive Impairment
    Sociability (Extraversion) Detachment       Enthusiastic, Assertive vs. Reserved, Quiet
    Emotional Stability Negative Emotion       Calm, Emotionally Stable vs. Distressed, Easily Upset

The 5 Major Dimensions of Mental Illness

Our website uses the "Big 5 Factors" of personality as major dimensions of mental illness. Each of these 5 dimensions has a healthy side and an unhealthy side. The Big 5 Factors are: Agreeableness, Conscientiousness, Openness to Experience, Sociability (Extraversion), and Emotional Stability. Our website adds an additional factor, Physical Health. However, our discussion will primarily focus on the traditional "Big 5 Factors".

The Following Pictures Are of The International Space Station

Agreeableness (Sympathetic, Kind)
Description: Agreeableness is synonymous with cooperation and social harmony; whereas Antagonism is synonymous with competition and aggression. The Agreeableness dimension measures the "good vs. bad" behaviors that are central to the concept of LOVE and JUSTICE.
Descriptors: Sympathetic, kind, appreciative, affectionate, soft-hearted, warm, generous, trusting, helpful, forgiving, pleasant, good-natured, friendly, cooperative, gentle, unselfish, praising, sensitive
MRI Research*: Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
Antagonism (Critical, Quarrelsome)
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Conscientiousness (Industrious, Orderly)
Description: Conscientiousness is synonymous with being industrious and orderly; whereas Disinhibition is synonymous with being impulsive and disorderly. The Conscientiousness dimension measures the "self-controlled vs. disinhibited" behaviors that are central to the concept of SELF-CONTROL.
Descriptors: Self-disciplined, achievement-oriented, industrious, competent, reliable, responsible, orderly, deliberate, decisive
MRI Research*: Conscientiousness was associated with increased volume in the lateral prefrontal cortex, a region involved in planning and the voluntary control of behavior.
"I do a thorough job. I want everything to be 'just right'. I want every detail taken care of."
"I am careful."
"I am a reliable hard-worker."
"I am organized. I follow a schedule and always know what I am doing."
"I like order. I keep things tidy."
"I see that rules are observed."
"I do things efficiently. I get things done quickly."
"I carry out my plans and finish what I start."
"I am not easily distracted."
Rigid Perfectionism (Excessive Conscientiousness)
"Even though it drives other people crazy, I insist on absolute perfection in everything I do."
"I simply won't put up with things being out of their proper places."
"People complain about my need to have everything all arranged."
"People tell me that I focus too much on minor details."
"I have a strict way of doing things."
"I postpone decisions."
Disinhibition (Impulsive, Disorderly)
* Irresponsibility:
"I've skipped town to avoid responsibilities."
"I just skip appointments or meetings if I'm not in the mood."
"I'm often pretty careless with my own and others' things."
"Others see me as irresponsible."
"I make promises that I don't really intend to keep."
"I often forget to pay my bills."
* Impulsivity:
"I usually do things on impulse without thinking about what might happen as a result."
"Even though I know better, I can't stop making rash decisions."
"I feel like I act totally on impulse."
"I'm not good at planning ahead."
* Distractibility:
"I can't focus on things for very long."
"I am easily distracted."
"I have trouble pursuing specific goals even for short periods of time."
"I can't achieve goals because other things capture my attention."
"I often make mistakes because I don't pay close attention."
"I waste my time ."
"I find it difficult to get down to work."
"I mess things up."
"I don't put my mind on the task at hand."
* Risk Taking:
"I like to take risks."
"I have no limits when it comes to doing dangerous things."
"People would describe me as reckless."
"I don't think about getting hurt when I'm doing things that might be dangerous."
* Hyperactivity:
"I move excessively (e.g., can't sit still; restless; always on the go)."
"I'm starting lots more projects than usual or doing more risky things than usual."
* Over-Talkativeness:
"I talk excessively (e.g., I butt into conversations; I complete people's sentences)."
"Often I talk constantly and cannot be interrupted."
* Elation:
"I feel much more happy, cheerful, or self-confident than usual."
"I'm sleeping a lot less than usual, but I still have a lot of energy."
("Conscientiousness vs. Disinhibition" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Open To Experience (Open-Minded, Creative)
Description: Open to Experience is synonymous with being open-minded and creative; whereas Closed to Experience is synonymous with being closed-minded and uncreative. The Openness to Experience dimension measures the "open-minded vs. closed-minded" behaviors that are central to the concept of WISDOM. Open-minded people ask why, are willing to challenge something that doesn't seem right, to listen to other people's opinions, and to be ever-ready to accept new truths, if the evidence is there. They are creative, flexible, and holistic in their thinking. They never stop questioning.
Descriptors: Wide interests, imaginative, intelligent, original, insightful, curious, sophisticated, artistic, clever, inventive, sharp-witted, wise
MRI Research*: Openness To Experience did not have any significant correlation with the volume of any brain structures. (This could suggest that "Openness To Experience", as defined here, is more a function of culture rather than of brain neurobiology.)
Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
"I am original, and come up with new ideas."
"I am curious about many different things."
"I am quick to understand things."
"I can handle a lot of information."
"I like to solve complex problems."
"I have a rich vocabulary."
"I think quickly and formulate ideas clearly."
"I enjoy the beauty of nature."
"I believe in the importance of art."
"I love to reflect on things."
"I get deeply immersed in music."
"I see beauty in things that others might not notice."
"I need a creative outlet."
Closed To Experience (Closed-Minded, Uncreative)
"I prefer work that is routine."
"I have difficulty understanding abstract ideas."
"I avoid philosophical discussions."
"I avoid difficult reading material."
"I learn things slowly."
"I have few artistic interests."
"I seldom notice the emotional aspects of paintings and pictures."
"I do not like poetry."
"I seldom get lost in thought."
"I seldom daydream."
Cognitive Impairment
* Memory Impairment:
"I have difficulty learning new things, or remembering things that happened a few days ago."
"I often forget a conversation I had the day before."
"I often forget to take my medications, or to keep my appointments."
* Impaired Reasoning or Problem-Solving:
"My judgment, planning, or problem-solving isn't good."
"I lack creativity or curiosity."
* Eccentricity:
"I often have thoughts that make sense to me but that other people say are strange."
"Others seem to think I'm quite odd or unusual."
"My thoughts are strange and unpredictable."
"My thoughts often don’t make sense to others."
"Other people seem to think my behavior is weird."
"I have several habits that others find eccentric or strange."
"My thoughts often go off in odd or unusual directions."
* Unusual Beliefs and Experiences:
"I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
"I've had some really weird experiences that are very difficult to explain."
"I have seen things that weren’t really there."
"I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
"I sometimes have heard things that others couldn’t hear."
"Sometimes I can influence other people just by sending my thoughts to them."
"I often see unusual connections between things that most people miss."
* Perceptual Dysregulation:
"Things around me often feel unreal, or more real than usual."
"Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
"It's weird, but sometimes ordinary objects seem to be a different shape than usual."
"Sometimes I feel 'controlled' by thoughts that belong to someone else."
"Sometimes I think someone else is removing thoughts from my head."
"I have periods in which I feel disconnected from the world or from myself."
"I can have trouble telling the difference between dreams and waking life."
"I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
"Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
"People often talk about me doing things I don't remember at all."
"I often can't control what I think about."
"I often see vivid dream-like images when I’m falling asleep or waking up."
("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Sociability (Enthusiastic, Assertive)
Description: Sociability is synonymous with being outgoing, enthusiastic and assertive; whereas Detachment is synonymous with being reserved and quiet. The Sociability (Extraversion) dimension measures the "approach vs. avoidance" behaviors that are central to the concept of SOCIABILITY and LEADERSHIP.
Descriptors: Enthusiastic, assertive, active, energetic, outgoing, outspoken, dominant, forceful, show-off, sociable, spunky, adventurous, noisy, bossy
MRI Research*: Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
Attention Seeking (Excessive Sociability)
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
Detachment (Reserved, Quiet)
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
* Anhedonia (Lack of Pleasure):
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
* Restricted Affectivity:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Emotional Stability (Calm, Emotionally Stable)
Description: Emotional Stability is synonymous with being calm and emotionally stable; whereas Negative Emotion is synonymous with being distressed and easily upset. The Emotional Stability dimension measures the "safety vs. danger" behaviors that are central to the concept of COURAGE.
Descriptors: Stable, calm, relaxed, contented
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
Negative Emotion (Distressed, Easily Upset)
Description: Degree to which people experience persistent negative emotions (anxiety, anger, or depression) and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotional instability, anxiety, irritability, depression, rumination-compulsiveness, self-consciousness, vulnerability
MRI Research*: Negative Emotion was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
* Anxiousness:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
* Depression:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

The "Big 5 Factors" of Personality as Shown In Dogs

The same "Big 5 Factors" of personality found in humans can be found in dogs. This makes sense because dogs, like humans, are a social species.

Agreeableness ("Friend")
Dog is friendly towards unfamiliar people.
Dog is friendly towards other dogs.
When off leash, dog comes immediately when called.
Dog willingly shares toys with other dogs.
Dog leaves food or objects alone when told to do so.
Antagonism ("Foe")
Dog is dominant over other dogs.
Dog is assertive with other dogs (e.g., if in a home with other dogs, when greeting).
Dog behaves aggressively towards unfamiliar people.
Dog shows aggression when nervous or fearful.
Dog aggressively guards coveted items (e.g., stolen item, treats, food bowl).
Dog is quick to sneak out through open doors, gates.

Conscientiousness ("Self-Controlled")
Dog works at tasks (e.g., getting treats out of a dispenser, shredding toys) until entirely finished.
Dog works hard all day herding or pulling a sleigh (if a "working dog" on the farm or in the snow). *
Dog is curious.
Disinhibition ("Disinhibited")
Dog is boisterous.
Dog seeks constant activity.
Dog is very excitable around other dogs.

Open To Experience ("Open-Minded")
Dog is able to focus on a task in a distracting situation (e.g., loud or busy places, around other dogs).
Closed To Experience ("Closed-Minded")
Dog is slow to respond to corrections.
Dog ignores commands.
Dog is slow to learn new tricks or tasks.

Sociability ("Approach")
Dog is attention seeking (e.g., nuzzling, pawing or jumping up on family members looking for attention and physical contact).*
Dog seeks companionship from people.
Dog is affectionate.
Detachment ("Avoidance")
Dog is aloof.
Dog gets bored in play quickly.
Dog is lethargic.

Emotional Stability ("Safety")
Dog tends to be calm.
Dog is relaxed when greeting people.
Dog is confident.
Dog adapts easily to new situations and environments.
Negative Emotion ("Danger")
Dog is anxious.
Dog is shy.
Dog behaves fearfully towards unfamiliar people.
Dog exhibits fearful behaviors when restrained.
Dog avoids other dogs.
Dog behaves fearfully towards other dogs.
Dog behaves submissively (e.g., rolls over, avoids eye contact, licks lips) when greeting other dogs.
Modified from Jones, A. C. (2009). Development and validation of a dog personality questionnaire. Ph.D. Thesis. University of Texas, Austin.

* New items added by Phillip W. Long MD

Notice the Personality Differences Between Dogs and Humans

Dogs and humans are strikingly similar on 4 of the "Big 5 Factors" of personality. However, dogs and humans are quite different on the "Conscientiousness" factor - because the canine brain isn't designed to organize work projects. That's why dogs don't build dog houses.

Two of the "Big 5 Factors" of dog personality are clearly a function of dogs being a social species that forms social hierarchies: (1) the "Agreeableness" factor describes "friend vs. foe" behaviors, and (2) the "Sociability" factor describes "approach vs. avoidance" behaviors.

The "Openness to Experience" describes the ability to learn from experience. The "Emotional Stability" factor describes "safety vs. danger" behaviors.

The Brain and the "Big-5 Factors" of Human and Dog Personality

It could be that the "Big-5 Factors" of personality represent some extremely basic brain functions. For example, when a young man approaches a young woman, she must: (1) decide whether he is friend or foe ["Agreeableness"], (2) decide if this represents safety or danger ["Emotional Stability"], (3) decide whether to approach or avoid him ["Sociability"], (4) decide whether to be self-controlled or disinhibited ["Conscientiousness"], and (5) learn from this experience ["Openness to Experience"].

Back to top

World Health Organization Acute Stress Disorder Treatment Guidelines

World Health Organization Grief Treatment Guidelines

World Health Organization Stress Symptoms

World Health Organization Acute Stress Interventions

Treatment Guidelines


Treating Patients With Acute Stress Disorder and Posttraumatic Stress Disorder - Summarized From APA Guideline (2004)

Effective Psychological Treatment

All effective psychological treatments for Anxiety Disorders incorporate one or more of the following: (1) cognitive exposure (mentally facing the fear), (2) behavioral exposure (physically facing the fear), (3) correcting maladaptive coping (eliminating the negative thinking and superstitious behaviors associated with the fear), and (4) reducing stressors (reducing health/economic/occupational/social stressors using a problem-solving approach).

  • Cognitive prolonged exposure:
    This involves the emotional and detailed recounting of the traumatic memory in the temporal order in which the events unfolded, including one's thoughts and feelings, either in one's imagination while giving a running commentary on what one visualizes, or in writing. This is usually repeated until the recounting no longer evokes high levels of distress, and until the trauma memories are experienced as memories rather than something happening all over again.
    • Cognitive prolonged exposure should wait 2 to 3 weeks after trauma exposure before starting to ensure that safety and decreased arousal are first established.
    • May speed recovery and prevent Posttraumatic Stress Disorder when this therapy is given over a few sessions beginning 2 to 3 weeks after trauma exposure.
    • Prolonged exposure has been shown to be more effective than cognitive behavioral therapy (CBT)

  • Behavioral exposure to avoided situations:
    This involves real-life confrontation with now safe situations that the person avoids because they are associated with the trauma and evoke strong emotions or physical reactions (e.g., driving a car again after being involved in an accident; using elevators again after being assaulted in an elevator). Repeated exposures help the person realise that the feared situation is no longer dangerous and that the anxiety about it does not persist for ever.
    • Behavioral exposure should wait 2 to 3 weeks after trauma exposure before starting to ensure that safety and decreased arousal are first established.

  • Eye movement desensitization and reprocessing (EMDR)
    This treatment uses recall and verbalization of traumatic memories of an event, as well as multiple brief, interrupted exposures to traumatic material. Research has shown that factors other than eye movements are responsible for EMDR's therapeutic effect.
    • EMDR has demonstrated efficacy similar to other forms of cognitive behavioral therapy (CBT)

  • Psychoeducation and support
    Both appear to be helpful as early interventions to reduce the psychological sequelae of exposure to mass violence or disaster.

Ineffective Psychological Treatment

  • Psychological Debriefing:
    • There is no evidence that psychological debriefing is effective in preventing Posttraumatic Stress Disorder or improving social and occupational functioning.
    • May increase symptoms, especially when used with groups of unknown individuals with widely varying trauma exposures or when administered early after trauma exposure and before safety and decreased arousal are established.

Pharmacological Treatment

  • Antidepressant Medication:
    Selective serotonin reuptake inhibitor (SSRI), tricyclic, and monoamine oxidase inhibitor (MAOI) antidepressant medication are recommended as first-line medication treatment for Acute Stress Disorder.

  • Benzodiazepines:
    • May be useful in reducing anxiety and improving sleep.
    • Carry a high risk for dependence.
    • Benzodiazepine withdrawal may worsen symptoms.

Treatment - Summarized From U.S. Department of Defense, Veterans Affairs Guideline (2010)

Strength of Recommendations Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Major Recommendations

Management of Acute Stress Disorder and Prevention of Posttraumatic Stress Disorder

  1. Assessment and Triage
    1. Trauma Exposure (within the past 30 days)

      Acute Stress Reaction (ASR) is a transient condition that often develops in response to a traumatic event. Traumatic events are events that cause a person to fear that he/she may die or be seriously injured or harmed. These events also can be traumatic when the person witnesses them happening to others. Such events often create feelings of intense fear, helplessness, or horror for those who experience them. The traumatic events that can lead to an acute stress reaction are of similar severity to those involved in PTSD.

      Combat or Operational Stress Reaction (COSR) is an acute stress reaction of service members during Ongoing Military Operations. COSR specifically refers to a reaction to high-stress events and potentially traumatic event exposure. This reaction is not attributed to an identified medical/surgical condition that requires other urgent treatment (a service member can have COSR concurrent with minor wounds/illnesses).

    1. Assess Briefly Based on General Appearance and Behavior


      Identify individuals who may be at risk for endangering themselves or others due to emotional distress or functional incapacity.


      1. Identification of a patient with ASR symptoms is based on observation of behavior and function; there is insufficient evidence to recommend a specific screening tool.
      2. Individuals exhibiting the following responses to trauma should be screened for ASR:
        1. Physical: exhaustion, hyperarousal, somatic complaints (gastrointestinal [GI], genitourinary [GU], musculoskeletal [MS], cardiovascular [CV], respiratory, nervous system [NS]), or symptoms of conversion disorder
        2. Emotional: anxiety, depression, guilt/hopelessness
        3. Cognitive/mental: amnestic or dissociative symptoms, hypervigilance, paranoia, intrusive re-experiencing
        4. Behavioral: avoidance, problematic substance use.
      1. Individuals who experience ASR should receive a comprehensive assessment of their symptoms to include details about the time of onset, frequency, course, severity, level of distress, functional impairment, and other relevant information.
      2. Assess for capability to perform routine functions.

      Assessment Specific to COSR

      1. Assess service member's functional status, to include:
        1. Any changes in productivity
        2. Co-worker or supervisor reports of recent changes in appearance, quality of work, or relationships
        3. Any tardiness/unreliability, loss of motivation, or loss of interest
        4. Forgetful or easily distracted
        5. Screening for substance use
      1. Document symptoms of COSR and obtain collateral information from unit leaders, coworkers, or peers about stressors, function, medical history, and absence or impairment in operation or mission.
      2. Consider the service member's role and functional capabilities and the complexity and importance of his/her job.
    1. Unstable, Dangerous to Self or Others, or Need for Urgent Medical Attention


      Protect individuals who may be at risk for endangering themselves or others due to emotional distress or functional incapacity.


      1. Address acute medical/behavioral issues to preserve life and avoid further harm by:
        1. Providing appropriate medical/surgical care or referring to stabilize
        2. Evaluating the use of prescribed medications
        3. Preventing possible biological or chemical agent exposure
        4. Managing substance intoxication or withdrawal
        5. Stopping self-injury or mutilation
        6. Addressing inability to care for oneself.
      1. Arrange a safe, private, and comfortable environment for continuation of the evaluation:
        1. Assess danger to self or others (e.g., suicidal or homicidal behavior)
        2. Establish a working treatment alliance with the patient
        3. Maintain a supportive, non-blaming, non-judgmental stance throughout the evaluation
        4. Assist with the removal of any ongoing exposure to stimuli associated with the traumatic event
        5. Minimize further traumas that may arise from the initial traumatic event
        6. Assess and optimize social supports
        7. Secure any weapons and explosives
      1. Legal mandates should be followed:
        1. Reporting of violence, assault
        2. Confidentiality for the patient
        3. Mandatory testing
        4. Attending to chain of evidence in criminal cases (e.g., rape, evaluation)
        5. Involuntary commitment procedures if needed
      1. Carefully consider the following potential interventions to secure safety:
        1. Find safe accommodation and protect against further trauma
        2. Voluntary admission if suicidal
        3. Restraint/seclusion only if less restrictive measures are ineffective
        4. Provide medications managing specific symptoms as needed (e.g., sleep, pain)
      1. Educate and "normalize" observed psychological reactions to the chain of command.
      2. Evacuate to next level of care if unmanageable, if existing resources are unavailable, or if reaction is outside of the scope of expertise of the care provider.
    1. Ensure Basic Physical Needs Are Met


      Ensure that trauma-exposed persons with acute stress symptoms have their basic needs met.


      1. Acute intervention should ensure that the following needs are met:
        1. Safety/security/survival
        2. Food, hydration, clothing, hygiene, and shelter
        3. Sleep
        4. Medications (i.e., replace medications destroyed/lost)
        5. Education as to current status
        6. Communication with family, friends, and community
        7. Protection from ongoing threats/toxins/harm. If indicated, reduce use of alcohol, tobacco, caffeine, and illicit psychoactive substances.
      1. Provide Psychological First Aid to:
        1. Protect survivors from further harm
        2. Reduce physiological arousal
        3. Mobilize support for those who are most distressed
        4. Keep families together and facilitate reunion with loved ones
        5. Provide information and foster communication and education
        6. Use effective risk communication techniques

      Interventions Specific for Members of Pre-existing Group (e.g., COSR)

      1. Treat according to member's prior role and not as a "patient."
      2. Assure or provide the following, as needed:
        1. Reunion or ongoing contact with group/unit
        2. Promote continuity with established relationships (e.g., primary group)
        3. Respite from intense stress
        4. Comfortable environment (e.g., thermal comfort)
        5. Consider psychoeducation and discussion in a group format
        6. Assign job tasks and recreational activities that will restore focus and confidence and reinforce teamwork (limited duty).
    1. Person Has Trauma-Related Symptoms, Significant Impaired Function, or Diagnosis of ASD


      Identify patients who have excessive post-traumatic stress symptoms or significant distress impaired function, or are diagnosed with ASD.


      1. Acutely traumatized people, who meet the criteria for diagnosis of ASD, and those with significant levels of post-trauma symptoms after at least two weeks post-trauma, as well as those who are incapacitated by acute psychological or physical symptoms, should receive further assessment and early intervention to prevent PTSD.
      2. Trauma survivors, who present with symptoms that do not meet the diagnostic threshold for ASD, or those who have recovered from the trauma and currently show no symptoms, should be monitored and may benefit from follow-up and provision of ongoing counseling or symptomatic treatment.
      3. Service members with COSR who do not respond to initial supportive interventions may warrant referral or evacuation.
    1. Assess Medical and Functional Status


      Obtain complete history, physical examination, relevant laboratory tests, and assessment of functioning to determine course of treatment.


      1. Medical status should be obtained for all persons presenting with symptoms to include:
        1. History, physical examination, and a neurological examination
        2. Use of prescribed medications, mood or mind-altering substances, and possible biological or chemical agent exposure
        3. A mini-mental status examination (MMSE) to assess cognitive function if indicated.
      1. The history and physical examination findings should lead the provider to other assessments as clinically indicated. Based on the clinical presentation, assessment may include:
        1. Screen for toxicology if the symptom presentation indicates
        2. Radiological assessment of patients with focal neurological findings or possible head injury
        3. Appropriate laboratory studies to rule out medical disorders that may cause symptoms of acute stress reactions (e.g., complete blood count [CBC], chemistry profile, thyroid studies, human chorionic gonadotropin [HCG], electrocardiogram [EKG], electroencephalogram [EEG])
      1. A focused psychosocial assessment should be performed to include assessment of active stressors, losses, current social supports, and basic needs (e.g., housing, food, and financial resources).
      2. A brief assessment of function should be completed to evaluate: 1) objectively impaired function based on general appearance and behavior; 2) subjectively impaired function; 3) baseline level of function (LOF) vs. current LOF; and 4) family and relationship functioning.
    1. Assess Pre-Existing Psychiatric and Medical Conditions


      Identify patients at risk for complications.


      1. Assess patients for pre-existing psychiatric conditions to identify high-risk individuals and groups.
      2. Assure access and adherence to medications that the patient is currently taking.
      3. Refer patients with pre-existing psychiatric conditions to mental health specialty when indicated or emergency hospitalization if needed.
    1. Assess Risk Factors for Developing ASD/PTSD


      1. Trauma survivors who exhibit symptoms or functional impairment should be screened for the following risk factors for developing ASD/PTSD:

        Pre-traumatic Factors

        1. Ongoing life stress
        2. Lack of social support
        3. Young age at time of trauma
        4. Pre-existing psychiatric disorders, or substance misuse
        5. History of traumatic events (e.g., motor vehicle accident [MVA])
        6. History of PTSD
        7. Other pre-traumatic factors, including: female gender, low socioeconomic status, lower level of education, lower level of intelligence, race (Hispanic, African-American, American Indian, and Pacific Islander), reported abuse in childhood, report of other previous traumatization, report of other adverse childhood factors, family history of psychiatric disorders, and poor training or preparation for the traumatic event.

        Peri-traumatic or Trauma-related Factors

        1. Severe trauma
        2. Physical injury to self or others
        3. Type of trauma (combat, interpersonal traumas such as killing another person, torture, rape, or assault convey high risk of PTSD)
        4. High perceived threat to life of self or others
        5. Community (mass) trauma
        6. Other peri-traumatic factors, including: history of peri-traumatic dissociation.

        Posttraumatic Factors

        1. Ongoing life stress
        2. Lack of positive social support
        3. Bereavement or traumatic grief
        4. Major loss of resources
        5. Negative social support (shaming or blaming environment)
        6. Poor coping skills
        7. Other post-traumatic factors, including: children at home and a distressed spouse.
  1. Treatment
    1. Provide Education and Normalization/Expectancy of Recovery


      Help trauma survivors cope with ASR/COSR by providing information that may help them manage their symptoms and benefit from treatment.


      1. All survivors should be given educational information to help normalize common reactions to trauma, improve coping, enhance self-care, facilitate recognition of significant problems, and increase knowledge of and access to services. Such information can be delivered in many ways, including public media, community education activities, and written materials.
    1. Initiate Brief Intervention


      To lessen the physical, psychological, and behavioral morbidity associated with acute stress reaction (ASR), hasten the return to full function (duty), and reduce the risk for development of ASD or PTSD following a traumatic event.


      The following treatment recommendations should apply for all acutely traumatized people who meet the criteria for diagnosis of ASD, and for those with significant levels of acute stress symptoms that last for more than two weeks post-trauma, as well as those who are incapacitated by acute psychological or physical symptoms.

      1. Continue providing psychoeducation and normalization.
      2. Treatment should be initiated after education, normalization, and Psychological First Aid has been provided and after basic needs following the trauma have been made available.
      3. There is insufficient evidence to recommend for or against the use of Psychological First Aid to address symptoms beyond 4 days following trauma. [I]
      4. Survivors who present symptoms that do not meet the diagnostic threshold of ASD or PTSD should be monitored and may benefit from follow-up and provision of ongoing counseling or symptomatic treatment.
      5. Recommend monitoring for development of PTSD using validated symptom measures (e.g., PTSD Checklist, other screening tools for ASD/PTSD).
      6. Psychotherapy:
        1. Consider early brief intervention (4 to 5 sessions) of cognitive-based therapy (CBT) that includes exposure-based therapy, alone or combined with a component of cognitive re-structuring therapy for patients with significant early symptom levels, especially those meeting diagnostic criteria for ASD. [A]
        2. Routine formal psychotherapy intervention for asymptomatic individuals is not beneficial and may be harmful. [D]
        3. Strongly recommend against individual Psychological Debriefing as a viable means of reducing ASD or progression to PTSD. [D]
        4. The evidence does not support a single session group Psychological Debriefing as a viable means of reducing ASD or progression to PTSD, but there is no evidence of harm (Note: this is not a recommendation pertaining to Operational Debriefing). [D]
        5. Groups may be effective vehicles for providing trauma-related education, training in coping skills, and increasing social support, especially in the context of multiple group sessions. [I]
        6. Group participation should be voluntary.
      1. Pharmacotherapy:
        1. There is no evidence to support a recommendation for use of a pharmacological agent to prevent the development of ASD or PTSD. [I]
        2. Strongly recommend against the use of benzodiazepines to prevent the development of ASD or PTSD [D]
    1. Acute Symptom Management


      1. Symptom-specific treatment should be provided after education, normalization, and basic needs are met.
      2. Consider a short course of medication (less than 6 days), targeted for specific symptoms in patients post-trauma
        1. Sleep disturbance/insomnia
        2. Management of pain
        3. Irritation/excessive arousal/anger
      1. Provide non-pharmacological intervention to address specific symptoms (e.g., relaxation, breathing techniques, avoiding caffeine) to address both general recovery and specific symptoms (sleep disturbance, pain, hyperarousal, or anger).

    L1. Facilitate Spiritual Support


    1. Ensure patient access to spiritual care when sought.
    2. Assess for spiritual needs.
    3. Provide opportunities for grieving for losses (providing space and opportunities for prayers, mantras, rites, and rituals and end-of-life care, as determined important by the patient).

    L2. Facilitate Social Support

    1. Immediately after trauma exposure, preserve an interpersonal safety zone protecting basic personal space (e.g., privacy, quiet, personal effects).
    2. As part of Psychological First Aid, reconnect trauma survivors with previously supportive relationships (e.g., family, friends, unit members) and link with additional sources of interpersonal support.
    3. Assess for impact of PTSD on social functioning.
    4. Facilitate access to social support and provide assistance in improving social functioning, as indicated.
  1. Re-assessment
    1. Reassess Symptoms and Function


      Identify patients with persistent traumatic stress symptoms, related dysfunction, or additional treatment needs.


      1. Assessment of the response to the acute intervention should include an evaluation for the following risk factors:
        1. Persistent or worsening traumatic stress symptoms (e.g., dissociation, panic, autonomic arousal, cognitive impairment)
        2. Significant functional impairments (e.g., role/work, relationships)
        3. Dangerousness (suicidal or violent ideation, plan, and/or intent)
        4. Severe psychiatric co-morbidity (e.g., psychotic spectrum disorder, substance use disorder or abuse)
        5. Maladaptive coping strategies (e.g., pattern of impulsivity, social withdrawal, or other reactions under stress)
        6. New or evolving psychosocial stressors
        7. Poor social supports
      1. Follow-up after acute intervention to determine patient status should include the following:
        1. Patient does not improve or status worsens – continue management of PTSD (see Module B below) in consultation or referral to PTSD specialty care or mental health provider. Recommend involvement of the primary care provider in the treatment. Patients with multiple problems may benefit from a multi-disciplinary approach to include occupational therapy, spiritual counseling, recreation therapy, social work, psychology, and/or psychiatry.
        2. Patient demonstrates partial improvement (e.g., less arousal, but no improvement in sleep) – consider augmentation or adjustment of the acute intervention and follow up within 2 weeks.
        3. Patient recovers from acute symptoms – provide education about acute stress reaction and contact information with instructions for available follow-up if needed.
  1. Follow-up
    1. Persistent (>1 Month) or Worsening Symptoms, Significant Functional Impairment, or High Risk for Development of PTSD


      Identify patients with PTSD or high risk for developing PTSD who may benefit from PTSD treatment.


      1. Individuals who fail to respond to early interventions should be referred for PTSD treatment when they have:
        1. Worsening of stress-related symptoms
        2. High potential or new-onset potential for dangerousness
        3. Development of ASD/PTSD
        4. Maladaptive coping with stress (e.g., social withdrawal, alcohol use)
        5. Exacerbation of pre-existing psychiatric conditions
        6. Deterioration in function
        7. New onset stressors
        8. Poor social supports.
      1. Primary Care provider should consider initiating therapy pending referral or if the patient is reluctant or unable to obtain specialty services.
      2. Primary Care provider should continue evaluating and treating co-morbid physical illnesses and addressing any other health concerns, as well as educating and validating the patient regarding his/her illness.
    1. Monitor and Follow-Up


      1. Follow-up should be offered to individuals who request it or to those at high risk of developing adjustment difficulties following exposure to major incidents and disasters, including individuals who:
        1. Have ASD or other clinically significant symptoms stemming from the trauma
        2. Are bereaved
        3. Have a pre-existing psychiatric disorder
        4. Require medical or surgical attention
        5. Were exposed to a major incident or disaster that was particularly intense and of long duration
      1. Primary Care providers should follow-up with patients about issues related to trauma in an ongoing way. Patients with initial sub-threshold presentation are at increased risk of developing PTSD and may need symptom-specific management.

Back to top

Self-Help Resources For Acute Stress Disorder

Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning the day in the morning, then assessing these plans in the evening has been shown to increase health and happiness. There is an additional benefit from doing a weekly review of your life satisfaction.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.

International Space Station (For Meditation)

Planning My Day (5-Minute Meditation Video)

Planning My Day (Picture)

Reviewing My Day Or Week (5-Minute Meditation Video)

Life Satisfaction Scale (Video)

Healthy Social Behaviors Scale (Video)

Mental Health Scale (Video)

Why We All Need to Practice Emotional First Aid

The Philosophy Of Stoicism (5 minute video)

Stoicism 101 (52 minute video)

The Roman emperor and Stoic philosopher Marcus Aurelius ruled from 161 to 180 A.D.

An Example Of Mindfulness Meditation (10 minute video)

In the 5th century BCE, Buddha spent 6 years of his life mastering mindfulness meditation. He then decided to look beyond meditation. Buddha concluded that simply emptying the mind of thought is calming, but otherwise it accomplishes little - since "You return to the same world". Instead, Buddha taught that we should change our world by seeking enlightenment through practicing compassion, and living a calm, peaceful, happy life.

7-Minute Workout Is All You Need To Get Back Into Physical Shape

Click Here For More Self-Help

Back to top

  • The best summary on bad research is given by Laura Arnold in this Tedx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes

Research Topics

Acute Stress Disorder - Latest Research (2016-2017)

Cochrane Review (The best evidence-based, standardized reviews available)

No evidence of effectiveness:
  • Multiple session early psychological interventions for prevention of post-traumatic stress disorder (2009) (This review evaluated the results of 11 studies that tested a diverse range of psychological interventions aimed at preventing PTSD. The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used.)

Back to top

Internet Mental Health © 1995-2017 Phillip W. Long, M.D.