EVIDENCE-BASED ANSWER
COGNITIVE BEHAVIORAL THERAPY (CBT) THAT EMPHASIZES EXPOSURE-BASED TREATMENT is the most effective intervention for adults with acute stress disorder (ASD) (strength of recommendation [SOR]: B, meta-analysis of limited-quality randomized controlled trials [RCTs]).
Exposure-based therapy reduces symptoms in adults with ASD more than CBT that focuses on cognitive restructuring; both therapies are better than no treatment at all (SOR: B, a limited-quality RCT).
Avoid drug treatment within 4 weeks of appearance of symptoms, unless distress is too severe to be managed with psychological treatment alone (SOR: C, consensus guideline).
Evidence summary
ASD refers to a constellation of psychological symptoms that can occur within 4 weeks after a traumatic event.1 (For more on ASD, see http://psychcentral.com/disorders/acute-stress-disorder-symptoms/.) Patients with symptoms that persist beyond 4 weeks or develop after 4 weeks are diagnosed with post-traumatic stress disorder (PTSD). Approximately 12.5% of people who experience a traumatic event develop ASD, and 10% develop PTSD, although not all patients who develop PTSD have preceding ASD.2 Early identification and treatment of ASD can decrease the percentage of patients who go on to develop PTSD.2
Exposure-based therapy works better than cognitive restructuring
A 2009 meta-analysis of small, limited-quality RCTs noted that CBT based on re-exposure to memories of the traumatic event, when started within 3 months of the event, is more effective than supportive counseling for adults with ASD; supportive counseling is more effective than no treatment at all.3
Exposure-based therapy reduces subsequent PTSD symptoms in adults with ASD more than cognitive restructuring.2 Exposure-based CBT attempts to decrease unrealistic anxiety by challenging anxiety-provoking thoughts, situations, activities, and people that are not fundamentally dangerous.4 Both exposure-based therapy and cognitive restructuring are better than no treatment at all.3
A small 2008 RCT evaluated the effect of weekly 90-minute CBT sessions with daily homework activities that were started within 1 month after a motor vehicle accident or nonsexual assault for patients with ASD.2 Only 33% of patients who received exposure-based therapy had PTSD symptoms 6 weeks after starting treatment, whereas 63% of the cognitive restructuring group and 77% of untreated patients had PTSD at the 6-week follow-up.2
Medication shows no clear benefit over CBT
A 2007 meta-analysis of mixed-method trials concluded that medication should not be substituted for CBT, which is more effective.5 The evidence showed no clear benefit for pharmacologic treatment; medication was as effective as placebo, but with higher drop-out rates.5