Acute stress disorder is the symptom presentation in the first month after trauma exposure. DSM-5 requires the trauma exposure criterion (same as PTSD) plus at least 9 symptoms from a list of 14 across five categories (intrusion, negative mood, dissociation, avoidance, arousal). Duration: 3 days to 1 month. After 1 month, the diagnosis transitions to PTSD if symptoms persist.
The 1-month gate: roughly half of patients with acute stress disorder progress to PTSD; roughly half resolve naturally. Early identification predicts who may need structured intervention; natural recovery is the more common outcome.
What works for early intervention: psychological first aid (safety, stabilization, basic needs, connection), watchful waiting with monitoring, brief trauma-focused CBT for high-risk patients (those with severe initial symptoms, prior trauma history, or psychiatric comorbidity), social support, treatment of acute insomnia and anxiety, addressing acute medical needs.
What does not work — and may harm: Critical incident stress debriefing (CISD), once routine after group trauma, is no longer recommended. Multiple RCTs showed no PTSD-preventive effect and possible harm in some subgroups. Forced re-exposure to traumatic content within hours to days, in a group setting, before natural processing has occurred, appears to consolidate rather than alleviate traumatic memory.
Pharmacologic considerations: avoid benzodiazepines in the acute period — multiple studies suggest they may impair natural fear extinction and worsen PTSD outcomes. Short-term treatment of acute insomnia with non-benzodiazepine agents reasonable. Beta-blockers (propranolol) acutely after trauma have been studied for prevention of memory consolidation — mixed evidence, not yet standard of care.
The clinical approach: in the first weeks after trauma, focus on basic needs (safety, sleep, food, supportive connection), monitor symptoms, identify high-risk patients for structured intervention. The majority of patients recover with time and support; the minority who don't deserve close attention. Modern early intervention is less about doing something aggressive and more about creating conditions for natural processing while identifying those who need more.
When you encounter a patient in the first month post-trauma, the temptation may be to "do something" therapeutic — but for many patients, the right intervention is watchful support. For high-risk patients, brief structured trauma-focused intervention may help prevent PTSD. The clinical judgment is who needs what, and natural recovery remains the most common path.