Analog scale measures stress in ED trauma patients.

CHICAGO -- Israeli investigators have developed a visual analog scale to measure the intensity of acute stress reaction symptoms in the emergency department.

The scale is similar in design to the widely used Wong-Baker Faces Pain Rating Scale, and accurately predicted the level of emotional reactions weeks after a traumatic event in two studies.

The new scale is the first to measure acute stress reaction symptoms occurring right after a traumatic event, Dr. Ilan Kutz explained at the annual meeting of the International Society for Traumatic Stress Studies. Instruments are available to measure acute stress disorder, but the disorder is typically diagnosed after the first 4 weeks. It's likely that no scale has been developed to measure acute stress reaction symptoms because "it's considered a normative response and so fleeting that people never bothered to attach much attention to it," he said.

Dr. Kutz and his associates developed more than a dozen questionnaires in an attempt to tackle such assessment issues as how to weight various symptoms (for example, hyperarousal vs. disassociation), how to categorize symptom intensity, and who should conduct the assessment and when. In the end, none of the measures were brief or simple to interpret.

"So we designed, out of a bit of despair, another kind of scale taken from the pain visual analog scale that says distress is something the patient and the clinician can point to," said Dr. Kutz, Meir Hospital, Tel-Aviv, Israel.

The 10-point acute stress reaction visual analog scale (ASR-VAS) includes five faces, ranging from a frowning and tearful face representing "extreme distress" to a smiling face for "no distress." The scale was tested by more than 1,000 Israeli clinicians with no training in acute stress reaction and found to be a simple and intuitive measurement for what the patient was experiencing, with a high interrater reliability, he said.

Dr. Kutz and Rachel Dekel, Ph.D., of Bar Ilan University in Ramat-Gan, Israel, then asked 23 victims of a terrorist attack and their clinicians to use the ASR-VAS to rate the intensity of distress within 30 minutes of arrival in the ED and 3-6 hours later after a clinical intervention.

As expected, patients rated their level of distress somewhat higher on arrival than did clinicians (7.4 points vs. 6 points), and the rating given by both groups had significantly decreased upon the patients' release (6.4 vs. 5), she said at the meeting.

Telephone interviews were conducted by a social worker 4 weeks after the event using the Stanford Acute Stress Reaction Questionnaire and again 4-5 months later using the Post-Traumatic Stress Disorder (PTSD) Inventory.

A high positive correlation was observed between the ASR-VAS level of distress upon arrival and the level of distress at the two follow-up interviews. Dr. Dekel said.

In an effort to replicate their findings, a second study with the same protocol was conducted in 62 patients, aged 18-70 years, who experienced a motor vehicle accident but did not require surgery. The patients were subdivided into three groups based on their ASR-VAS scores: 18 "resilient" patients arrived and left the hospital with a score below 5; 23 "adaptive" patients arrived with a score above 5, but experienced a 30% drop or more at release; and 21 "nonadaptive" patients whose score was above 5 at arrival and failed to decrease by 30% or more at discharge.

The nonadaptive group had significantly higher levels of distress on the 4-point Stanford questionnaire 4 weeks after the accident (2.11 points), compared with the adaptive (1.15 points) and resilient (0.69 points) groups, Dr. Dekel reported. The difference was not significant between nonadaptive and adaptive groups.

At 4 months, PTSD symptom levels were also significantly higher in the nonadaptive group than in the resilient group, and trended higher in the adaptive group, compared with the resilient group.

Because of the small size of the subgroups, it was not statistically possible to determine if the scale could predict who will develop long-term distress after a trauma, but it can be used with 90% confidence to predict those who are unlikely to develop distress, she said.

Dr. Dekel acknowledged that the studies were limited by their small size, the use of telephone interviews, and the potential for car accident victims to be seeking secondary gains through insurance compensation.

Although these early findings should be interpreted with care, Dr. Kutz and Dr. Dekel concluded that the scale would be a useful tool in mass casualty events.

The investigators reported no conflicts of interest or funding support for the studies.