acute stress disorder 急性应激障碍

“Acute stress disorder (ASD) was first introduced in DSM-IV and significantly updated in DSM-5. The DSM-5 definition includes exposure to a Criterion A potentially traumatic events（PTE）, as described previously in the PTSD criteria.” (“New oxford textbook of psychiatry”, 2020, p. 823) 急性应激障碍( acute stress disorder，ASD )最早出现在DSM – IV中，并在DSM – 5中得到显著更新。DSM – 5的定义包括暴露于标准A的创伤性事件，如前所述的PTSD标准。

“The key difference between PTSD and ASD is time and markers of distress. ASD is defined as distress occurring after 3 days, but within 1 month of a Criterion A PTE. Further, ASD requires nine or more symptoms in the five major categories of intrusion, negative mood, dissociative, avoidance, and arousal symptoms (DSM-5). Consistent with other mental health disorders, the symptoms must cause clinically significant distress or functional impairment.” (“New oxford textbook of psychiatry”, 2020) PTSD和ASD的关键区别在于时间和痛苦的标记。ASD定义为3 d后发生，但在A标准创伤性事件后1个月内发生。进一步，ASD要求在闯入、负性情绪、分离、回避和唤醒症状( DSM-5 ) 5个大类中出现9个及以上症状。与其他精神健康障碍一致，该症状必须引起临床上显著的困扰或功能损害。

“DSM-III did not permit a trauma-related diagnosis prior to 1- month post-traumatic event exposure, perhaps due to the normative symptoms associated with experiencing traumatic events. The introduction of ASD as a mental health disorder within DSM-IV allowed for individuals who have marked distress due to a PTE within 1 month of the PTE to receive clinical services that may potentially decrease distress and the development of PTSD. However, the DSM-IV definition of ASD gave excessive weight to dissociative symptoms. Although other symptoms, including anxiety and arousal, were part of the diagnosis, individuals needed three or more dissociative symptoms in order to meet the criteria. In fact, several other acute symptoms are associated with the development of PTSD, rather than only peritraumatic dissociation.” (“New oxford textbook of psychiatry”, 2020, p. 823) 美国精神障碍诊断与统计手册第3版( DSM-III ) 不允许在创伤后事件暴露1个月前进行创伤相关诊断，可能是由于经历创伤事件相关的规范症状。在DSM – IV中引入ASD作为精神健康障碍[，允许在PTE后1个月内因创伤性事件而感到明显痛苦的个体接受可能减少痛苦和PTSD发展的临床服务。然而，DSM – IV对ASD的定义赋予分离症状过多的权重。尽管包括焦虑和觉醒在内的其他症状是诊断的一部分，但个体需要三个或更多的分离症状才能达到标准。事实上，其他几个急性症状与PTSD的发展有关，而不仅仅是创伤分离状况。

“When developing DSM-5, several critiques regarding DSM-IV definitions of ASD were considered, including questioning the predictive value of ASD in predicting the development of PTSD, differentiating ASD from other mental health disorders, the utility of ASD to enhance early intervention, and the general utility of the ASD diagnosis. These critiques have been described elsewhere in more detail, but recommendations for DSM-5 primarily focused on the broadening of symptoms to remove DSM-IV’s unjustified emphasis on dissociative symptoms.” (“New oxford textbook of psychiatry”, 2020, p. 823) 在制定DSM – 5时，考虑了对DSM – IV中ASD定义的一些批评，包括质疑ASD对PTSD发展的预测价值，区分ASD与其他精神健康障碍，ASD对加强早期干预的效用，以及ASD诊断的一般效用。这些批评已在其他地方进行了更详细的描述，但对DSM – 5的建议主要集中在症状的拓宽，以消除DSM – IV对分离症状的不合理强调。

“The DSM-5 definition of ASD differs from that of the DSM-IV definition in several ways. Firstly, the definition of a PTE was updated to be consistent with the new definition of a PTE, as described in PTSD. The most marked change in symptom presentation was the elimination of DSM-IV’s requirement of three or more dissociative symptoms, while giving greater weight to a broader set of symptoms in DSM-5. Although DSM-5 does recognize that some people may experience dissociative symptoms, others may now meet ASD criteria without a single dissociative symptom. In other words, there has been a shift in our understanding of ASD from a predominantly dissociative disorder to one that includes a greater variability in symptom presentation.” (“New oxford textbook of psychiatry”, 2020, p. 823) ASD的DSM – 5定义与DSM – IV定义在多个方面存在差异。首先，对创伤性事件的定义进行了更新，使其与PTSD所描述的创伤性事件的新定义相一致。症状呈现方面最显著的变化是取消了DSM – IV对3个及以上分离症状的要求，同时对DSM – 5中更广泛的一组症状赋予了更大的权重。虽然DSM – 5的确认识到有些人可能会经历分离症状，但其他人现在可能符合ASD标准，没有单一的分离症状。换句话说，我们对ASD的理解发生了转变，从以分离障碍为主转变为包括症状表现的更大变异性。

“Preliminary evidence suggests that both DSM-IV and DSM-5 criteria have equal predictive value related to the development of PTSD, but DSM-5 criteria have greater specificity, compared to DSM-IV criteria . According to DSM-5, there are higher rates of ASD among individuals who have experienced interpersonal PTEs (20–50%), compared to non-interpersonal PTE (<20%) . Therefore, ASD is quite common and should be regularly assessed for among populations who have experienced recent PTEs. Although ASD is not always predictive of PTSD, individuals with ASD (and those without) should also be assessed for PTSD if they continue (or develop) significant symptoms of distress or impairment 1 month following a PTE.” (“New oxford textbook of psychiatry”, 2020, p. 823) 初步证据表明DSM – IV和DSM – 5标准对PTSD的发生具有相同的预测价值，但DSM – 5标准比DSM – IV标准具有更高的特异性。根据DSM – 5，与经历过非人际创伤性事件 ( < 20 % ) 相比，经历过人际创伤性事件的个体中ASD的患病率更高( 20-50 % )。因此，ASD是相当常见的，应定期在经历过近期PTE的人群中进行评估。虽然ASD并不总是预测PTSD，但如果ASD (以及那些没有)的个体在创伤性事件后1个月继续(或出现)显著的痛苦或损伤症状，也应该评估PTSD。