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Acute Stress Disorder After Burn Injury: A Predictor of Posttraumatic Stress Disorder?

From the Department of Psychiatry and William Randolph Hearst Burn Center, The New York Presbyterian Hospital, New York, NY.

Address reprint requests to: JoAnn Difede, The New York Presbyterian Hospital, 525 E. 68th Street, Box 200, New York, NY 10021. Email: jdifede{at}med.cornell.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVES: The principal goals of this study were to determine whether ASD predicted chronic PTSD and whether dissociation is more characteristic of the acute-trauma period than PTSD symptoms.

METHODS: Eighty-three hospitalized adult burn patients were assessed with structured interviews and self-report measures within 2 weeks of injury and again at least 6 months postburn.

RESULTS: Nineteen percent had ASD. Dissociative symptoms were not more common or more severe than PTSD symptoms. Thirty-six percent had chronic PTSD. While ASD predicted chronic PTSD, meeting the symptom criteria for PTSD within 2 weeks postburn also predicted chronic PTSD.

CONCLUSIONS: Our data support the inclusion of an ASD diagnosis in the DSM, which would allow the diagnosis of symptoms in the first month posttrauma as a psychiatric disorder but questions whether dissociation is more characteristic of the acute trauma period than the PTSD symptom clusters.

Key Words: acute stress disorder, • burn injury, • posttraumatic stress disorder, • trauma.

Abbreviations: PTSD = posttraumatic stress disorder;; ASD = acute stress disorder;; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Until the release of the DSM-IV, the immediate aftermath of a traumatic event was accepted as a normal reaction to an overwhelming event. The conceptualization of acute reactions to trauma as a normal response was supported by a widely held theoretical view of posttrauma reactions that suggested that alternating intrusive and avoidant PTSD symptoms represented normal information processing of an event overwhelming to one’s cognitive structures (1). In contrast, the DSM-IV includes the diagnosis of ASD, which may be made as early as 3 days following the traumatic event (2). Comprised of dissociative, intrusive, avoidant, and arousal symptoms, the formulation of ASD emphasizes dissociative symptoms. To be diagnosed with ASD, one must experience at least three of five possible dissociative symptoms but only one intrusive, avoidant, and arousal symptom. In contrast, a diagnosis of PTSD requires the presence of at least one intrusive symptom and three avoidant and two arousal symptoms, each of which must persist for at least 1 month (2). Three of the dissociative symptoms included in the ASD diagnosis (depersonalization, derealization, and time distortion/daze) are new to the DSM-IV, the other two (numbing, amnesia) have been previously classified as avoidant symptoms within the PTSD diagnosis.

ASD was added to the DSM-IV, at least in part, on the basis of retrospective studies that documented the presence of dissociative symptoms, including derealization, depersonalization, emotional numbing, and a reduction of awareness in one’s surroundings following various types of accidents (3). The DSM-IV committee’s decision to create a new diagnostic category to describe acute psychological reactions to severe trauma instead of modifying the time criteria for PTSD appears predicated on the assumption that the symptoms developing immediately following a traumatic event differ from those symptoms persisting over time or occurring later, ie, the intrusive, avoidant, and arousal symptoms integral to PTSD (3–6). Speigel and colleagues (3) have argued that a dissociative syndrome characterized by depersonalization, derealization, and psychic numbing is prominent immediately following a traumatic stressor (3, 5). To that end, those dissociative symptoms not already included in the PTSD diagnosis as part of the avoidant symptom cluster were added to the DSM-IV formulation of ASD. To our knowledge, however, the superiority of the ASD criteria compared with the PTSD symptom criteria in describing the phenomenology of acute posttraumatic stress reactions has not been firmly established. Bryant and Harvey reviewed the evidence for the current diagnostic classification of ASD and concluded that there was a lack of empirical evidence to support the current formulation (7). They noted that the emphasis on dissociative symptoms was based on a widely held theoretical view that trauma causes dissociation; moreover, the studies cited to support the current formulation of the ASD diagnosis asked participants to recall their immediate trauma response many months or years after the event, which may have introduced a retrospective reporting bias.

Since ASD is a relatively new diagnostic entity, there has been little opportunity to develop, validate, and use assessment measures of ASD and conduct studies of acute response to trauma to address these issues. Three studies (5, 8, 9) have documented self-reported dissociative symptoms immediately following various traumas, such as the Loma Prieta earthquake, Oakland firestorms, and shooting deaths in a San Francisco office building, using a self-report measure of ASD, the Stanford Acute Stress Reaction Questionnaire. These studies provide initial support for the presence of dissociative symptoms in the immediate aftermath of trauma. However, their lack of assessment of PTSD symptoms and use of only self-report measures precludes any conclusion about whether dissociative symptomatology was more characteristic of the acute posttrauma period than intrusive, avoidant, and arousal PTSD symptoms. These studies also suggest that dissociative symptoms do predict a diagnosis of PTSD but do not address the issue of whether one of the other symptom clusters would be a better predictor of PTSD.

To our knowledge, very few studies have used a clinical assessment of ASD. Brewin and colleagues reported that 19% of crime victims had ASD (10), while Bryant and Harvey found that 14% of patients developed ASD following mild traumatic brain injury (11). These studies also suggest that a diagnosis of ASD predicts chronic PTSD (10, 11). Only Brewin and colleagues (10) addressed the question of whether dissociative symptoms were more characteristic of the posttrauma period than PTSD symptoms, concluding that the DSM-IV diagnosis had internal coherence but that their data did not suggest that dissociative symptoms were better predictors of PTSD than the other symptom clusters.

	Burn Injury

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Burn injury has occupied a unique role in the trauma literature. Beginning with the work of Cobb and Lindemann in 1943 (12, 13) documenting acute psychological responses to the Cocoanut Grove fire, studies of burn injury have offered perspectives that have helped validate the idea that trauma has mental health consequences. In a seminal descriptive study, Cobb and Lindemann describe dissociation, reexperiencing, avoidance, and acute grief in those people hospitalized for burns following the Cocoanut Grove fire (12). More recent studies have documented that up to 45% of adults who were hospitalized for their burn injury have PTSD 1 year later (14, 15) and that severity of intrusive and avoidant PTSD symptoms within 1 week of injury predict chronic PTSD (16).

Given the differing criteria for ASD and PTSD and the limited data to guide the formulation of DSM-IV criteria, the primary goal of this investigation was to document the frequency and severity of ASD and PTSD symptoms in a traumatized sample within 2 weeks of the traumatic event using both well-validated self-report measures and clinical interviews and to test the hypotheses that dissociative symptoms would be the best predictors of a diagnosis of ASD at the time of the trauma and of PTSD at least 6 months postburn. We also sought to document the frequency of the ASD and PTSD diagnoses in the acute and chronic poststressor periods. In light of the assumptions about the prominence of dissociation in the acute posttrauma phase, we were particularly interested to learn if dissociative symptoms were more common, more severe, and better predictors of an ASD diagnosis and therefore more characteristic of the acute posttrauma response period than the intrusive, arousal, and avoidant symptoms that comprise a PTSD diagnosis. The second aim of this study was to determine if ASD or any of its component symptom clusters predicted PTSD at least 6 months postinjury. We were especially interested to learn if dissociative symptoms would be the best predictors of PTSD.

	METHODS

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Subjects
Eighty-three hospitalized burn patients participated in this study within 2 weeks of their injury. Sixty-six percent were male and 34% were female, with an average age of 42.0 + 15.2 years. Typical of urban burn centers (17), slightly more than half of the sample represented ethnic minorities; 33% (27) were black, 18% (15) were Hispanic, 42% (35) were Caucasian. Fifty percent (42) of the burns were caused by flame, 41% (34) were scald burns, while 9% (7) were electrical/chemical. The average total body surface area burned (TBSA) was 10.5 ± 7.4%. Thirty-nine percent of all burns were work related.

Twenty-four percent of our sample had a psychiatric history according to SCID DSM-IV diagnostic criteria. Of these, 14.0% (12) had a history of substance abuse, 14.0% (12) had a history of a mood disorder, and 9.3% (10) had an anxiety disorder. Additionally, 14.0% met criteria for a current DSM-IV diagnosis other than ASD at the time of their injury. Of these, 4.6% (5) had a current diagnosis of substance abuse, 2.3% (2) had a mood disorder, and 7.0% (6) had an anxiety disorder. Consistent with recent epidemiological studies of trauma (18, 19), 70% of our sample had a trauma history. Of these, 13% had previously been hospitalized for burns.

Procedure
Every adult patient admitted to the burn center was approached within the first 2 weeks of hospitalization for informed consent. After complete description of the study to the subjects, written informed consent was obtained. Consenting, English speaking patients who scored 20 or above on the Mini Mental Status Exam (20) participated in the assessment, which consisted of three well-validated self-report measures of psychopathology and a clinical interview.

Fifty-nine of 83 subjects, or 71%, who completed the self-report battery and clinical interviews while hospitalized were available for follow-up. The follow-up interview occurred no earlier than 6 months postburn (to be consistent with studies that suggest PTSD becomes a chronic condition by 6 months postinjury). The average time since the burn injury for the T2 interview was 8.0 ± 1.5 months. There were no differences between those who were and those who were not available for follow-up on any of the self-report or clinical measures at baseline nor were their any differences on sociodemographic or burn characteristics. At follow-up, the entire battery of self-report and clinical interviews was readministered.

Ten percent of those approached refused to participate in the study. Refusers did not differ from participants with respect to sociodemographic characteristics (age, race, gender, marital status) or characteristics of the burn injury (total body surface area burned, etiology).

Measures
General psychiatric symptoms were measured with the Brief Symptom Inventory (BSI) (21); intrusive and avoidant PTSD symptoms were measured by the Impact of Events Scale (IES) (22); and ASD symptoms were assessed with the Stanford Acute Stress Reactions Questionnaire (SASRQ) (5, 8, 9). Doctoral-level psychologists blind to the self-report responses evaluated the subjects for 1) psychopathology using the Structured Clinical Interview for DSM-IV (SCID) (23, 24), 2) ASD and PTSD using the SCID and the Clinician-Administered PTSD Scale (CAPS) (23, 25), and 3) traumatic events history using a structured screening interview (26) that inquired, in a yes/no format, if the participant has ever witnessed or experienced any of 13 traumatic events, including natural disasters; a serious accident or injury; a sudden, life-threatening illness; military combat or military service in a war zone; the death of a friend/family member in an accident or by murder; the sudden, unexpected death of a close family member; assault with a weapon; assault without a weapon; childhood physical abuse; childhood sexual abuse; unwanted sexual contact coerced by verbal threat, physical force, or threat of force; or any other traumatic event.

An ASD diagnosis was determined by scoring the CAPS intrusive, avoidant, and arousal PTSD clusters according to the F1I2 rule (27) and the SCID-ASD cluster according to the SCID scoring criteria, which require the presence of three dissociative symptoms to meet the symptom criteria. The CAPS scoring rules determine what frequency/intensity combination is required to count a symptom as present. The CAPS score for each symptom is obtained by adding the frequency to the intensity rating. The authors of the CAPS have formulated several different rules (27). The original working rule, the F1I2 rule, described in the CAPS manual (27), considers an item a symptom if the frequency score is one or greater and the intensity score is two or greater. To be consistent with DSM-IV ASD criteria for these symptom groups, participants had to have at least one symptom in each of the three PTSD clusters and at least three dissociative symptoms on the ASD-SCID module to receive a diagnosis of ASD.

Every 10th clinical interview was corated for interrater reliability. Interrater reliability equaled .93. (Cohen’s kappa) for the final diagnoses of ASD and of PTSD during the inpatient phase; interrater reliability was also .93 (Cohen’s kappa) for a final diagnosis of chronic PTSD.

Information pertaining to the burn, including total body surface area burned (TBSA), degree of burns, areas burned, and pain medication usage, was collected from the hospital record.

Pain medication usage data.
Because opiate use could affect reporting of dissociative symptoms such as feeling in a daze and time distortion, we documented pain medication usage for all the patients enrolled in our study and examined the data for possible associations with dissociative symptoms. For the first 70 subjects, we calculated the average daily morphine equivalents used (ADME) over their entire hospitalization (or a maximum of 14 days since the maximum time to interview was 2 weeks postburn.) We used standard factors to convert other drugs used (eg, Levorphenol, Percocet, Tylenol #3, Demerol) into morphine equivalents. The ADME used over the entire hospitalization correlated significantly (r = .9, p < 0.001) with the ADME used over the 2 days preceding the research interviews. To streamline data collection in the remaining cases, we conducted our analyses based on the 2-day ADME for all participants. There were no significant correlations between average daily morphine dose equivalents and dissociative symptoms. Correlations between ADME and dissociative symptoms were as follows: amnesia (r = .09), reduction of awareness (r = .17), depersonalization (r = .12), derealization (r = .06), numbing (r = .0008), and dissociative total (r = .12).

Data Analysis
Data analyses were conducted in four steps. First, preliminary analyses were conducted to examine the relationship between sociodemographic variables (eg, gender), characteristics of the burn injury (eg, TBSA), and pain medication usage with ASD. Second, descriptive statistics were done to document the frequency and severity of ASD symptoms both by clinical interview and self-report. We were also interested to know how many participants would meet the PTSD symptom criteria, the time criteria not withstanding, within 2 weeks of injury. Third, we determined whether there was a difference in self-report of subjective distress by diagnosis. Finally, using logistic regression analysis, we attempted to predict PTSD classification from a diagnosis of ASD as well as from the component ASD symptom clusters.

	RESULTS

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Preliminary Analyses: Sociodemographics, Characteristics of the Burn Injury, and Acute Stress Disorder
Neither sociodemographic characteristics (ie, gender, race, and age) nor characteristics of the burn injury (ie, TBSA, etiology) were associated with self-report of ASD symptoms or PTSD symptoms or a diagnosis of ASD while hospitalized or PTSD at least 6 months postburn (T2). Neither psychiatric history nor trauma history were associated with self-reported ASD symptoms, self-reported PTSD symptoms, or a diagnosis of ASD while hospitalized or PTSD at T2.

Acute Stress Disorder
Self-report of ASD symptoms.
As shown in Table 1, the most frequently endorsed ASD symptom (as measured by the SASRQ), reported by 76% of participants, was difficulty falling asleep and staying sleeping. Five symptoms were endorsed by 50% or more of our sample: timelessness, avoiding both thoughts and feelings of their burn injury, difficulty falling asleep and staying sleeping, and restlessness.

To specifically test the hypothesis that dissociative symptoms would be the best predictors of PTSD at T2, a forward stepwise logistic regression analysis was conducted. To be consistent with ASD criteria, meeting criteria for one avoidant, one intrusive and one arousal symptom was entered as one variable on step one and meeting criterion for three dissociative symptoms was entered as one variable on step 2. As shown in Table 8, the dissociative symptoms added to the ASD diagnosis contributed significantly to the predictive value of the model. This model correctly classified 75% of those with PTSD and 90% of those without PTSD, with an overall accuracy rate of 83%. However, if the model is changed and the PTSD criteria (of one intrusive, three avoidant, and two arousal symptoms) are substituted for the ASD criteria of one intrusive, one avoidant, and one arousal symptom on step 1, dissociative symptoms do not contribute significantly to the model and are dropped in step 2. Without dissociative symptoms, this model correctly classifies 100% of those without PTSD and 62.5% of those with PTSD at T2, with an overall accuracy rate of 82%.

	DISCUSSION

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

Our results are similar to those of the few other studies that used clinical assessments to evaluate participants according to the current ASD diagnostic criteria. This similarity is noteworthy because the trauma populations studied differ. First, the percent of adult burn patients reporting ASD is consistent with these reports of ASD following motor vehicle accidents (11) and criminal assault (10). Second, as in the present study, more patients in these studies reported symptoms from the arousal cluster during the acute trauma period than from the other symptom groups (10, 11). Finally, as in our study, these studies also present data, discussed below, that could lead one to question the assumption that dissociation is the most critical feature of the acute trauma period.

In light of the DSM-IV criteria emphasizing dissociative symptoms, one might expect that, as compared with other symptom clusters, dissociative symptoms would be more common, more severe, and thus more characteristic of the posttrauma period than PTSD symptoms. Dissociative symptoms might also be expected to be the best predictors of an ASD diagnosis. Our data suggest that dissociative symptoms are an integral component of the acute-trauma period postburn but are not more characteristic of this phase than the intrusive, avoidant, and arousal symptoms that comprise a PTSD diagnosis. Dissociative symptoms were not more common than intrusive and avoidant PTSD symptoms. As noted earlier, arousal symptoms, most particularly sleep difficulties and irritability, were most common. Similar to Brewin and colleagues’ study (10), the positive and negative predictive validity of the four symptom clusters did not differ substantially. A diagnosis of ASD was no more likely to be made if dissociative symptoms were present than if intrusive, avoidant, or arousal symptoms were present. Moreover, the diagnostic criteria for PTSD and ASD identified essentially the same group of acutely burned patients. Only one more person was diagnosed with PTSD, the time criteria not withstanding, than with ASD. Additionally, both diagnoses identified those patients who reported clinically significant subjective distress. Consistent with theoretical arguments, dissociative symptoms did predict PTSD 6 months postburn. However, a diagnosis of PTSD 2 weeks postburn, the time criteria notwithstanding, also predicted chronic PTSD.

Because ASD is a new diagnosis, formulated without the benefit of prospective longitudinal studies, it is important to evaluate the current diagnostic criteria in light of data from such studies to determine if revisions would be advisable. The pattern of evidence emerging from longitudinal prospective studies raises the question of whether it would be parsimonious to use the same diagnostic criteria for both the acute and chronic posttrauma periods. By increasing the number of symptoms required for the intrusive, avoidant, and arousal symptom clusters in the ASD diagnosis to be consistent with the current PTSD symptom criteria while retaining the dissociative symptoms added to the current ASD criteria, a unified set of diagnostic criteria could be created. The current study, as well as those of Bryant and Harvey (11) and Brewin et al. (10) provide empirical support for such a change. Each of these studies suggested that the predictive validity of the intrusive, avoidant, and arousal symptom clusters was improved for the acute trauma period if the symptom number was increased to be consistent with the criteria for the PTSD diagnosis. If a unified set of symptom criteria was created, then the time criteria might be changed to reflect an acute trauma period and a chronic trauma period to be consistent with studies showing that acute PTSD symptoms resolve spontaneously in a subset of trauma patients by 3 months (31). Several recent studies (5, 8–10) have prospectively documented the presence of the dissociative symptoms (ie, depersonalization, derealization, time distortion/reduction in awareness of surroundings) that were included in the original ASD diagnostic formulation. Thus, these symptoms appear to be a valid part of the diagnosis and should probably remain in any future revisions of the ASD criteria. What is less clear is whether these symptoms persist over time and should therefore be added to the diagnostic criteria for PTSD. To further address the persistence question, future studies should prospectively assess those dissociative symptoms, added to the DSM-IV ASD diagnosis, throughout the longitudinal course of trauma. Though there are too few studies yet to draw firm conclusions about revision of the ASD criteria, our study and others (10, 28) provide initial evidence that revisions might be warranted.

Finally, in the absence of prospective data, given the emphasis on dissociative symptoms in the current DSM-IV formulation of ASD, it is likely that clinicians will expect dissociative symptoms to be most salient. The persistence of such assumptions could lead to the underdiagnosis of ASD, as clinicians may fail to recognize it in those individuals who do not have the expected pattern of symptoms. Yet, the underdiagnosis of ASD may have particularly important clinical implications given the growing body of data suggesting that ASD predicts PTSD and in light of evidence that early intervention may ameliorate and perhaps even prevent chronic PTSD (28–30).

	ACKNOWLEDGMENTS

TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
This work was supported by grants to the first author from the National Institute of Mental Health (Grant MH56338) and the Aaron Diamond Foundation. The authors would like to acknowledge their indebtedness to the late Samuel Perry, MD, a pioneer in work with burn patients, who served as a consultant to this project prior to his death.

Received for publication July 2, 2001.

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TOP ABSTRACT INTRODUCTION Burn Injury METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 

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