The first is that although ASRs of all types may be expectable and highly common--perhaps even universal in the context of sufficiently intense stressors--and that the great majority of persons who experience ASR or COSR recover, everyone who experiences ASR or COSR is at increased risk for PTSD and other behavioral disorders, as well as suicide, endangering others' lives, and potentially catastrophic failure of occupational or social functioning.
Figure 3 is adapted from the first part of the CPG's Module A algorithm for the management of ASR and COSR within the first 4 days after exposure to trauma.
The stressor events that trigger ASR in civilian settings and COSR during military operations share the common features of real or imagined life-threat to self or others, provoking intense physical and emotional responses and loss of control.
Although the intense distress that accompanies ASR and COSR may be internal to the traumatized person, it often manifests in externally observable alterations in appearance and behavior.
The risk for suicide in persons with ASR or COSR is not well studied, but the literature on suicidal ideation and aggression in sub-threshold PTSD is compelling.
The second two COSFA actions--Cover and Calm--are crisis-intervention tools that may be needed infrequently and only briefly, but when they are needed because of a serious ASR or COSR, they are needed immediately.
Abbreviations: ASD = acute stress disorder; CAPS = Clinician-Administered PTSD Scale; COSR
= combat and operational stress reaction; CPG = clinical practice guideline; DOD = Department of Defense; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; GAF = Global Assessment of Functioning; IOM = Institute of Medicine; IPF = Inventory of Psychosocial Functioning; LIFE = Longitudinal Interval Follow-Up Evaluation; M = mean impairment score; OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom; PTSD = posttraumatic stress disorder; QOL = quality of life; SD = standard deviation; VA = Department of Veterans Affairs; WHO = World Health Organization; WHODAS-II = WHO Disability Assessment Schedule II.