stress disorders

STRESS ,HEALTH & COPING د.وليد عزيز العميدي

The stress : Refers to experiencing events that are perceived as endangering one’s physical or psychological wellbeing.These events are usually referred to as stressors .People’s reactions to these stressors are termed stress responses.
Characteristics of stressful events:
? Some events are major changes affecting large no. of people , others are major changes in the life of an individual, some are daily hassles.
? Some are acute ,some are chronic.

Events that are perceived as stressful usually fall into one or more of the following categories:
1. Traumatic events.
2. Uncontrollable events.
3. Unpredictable events.
4. Major changes in life circumstances.
5. Internal conflicts.


Responses to stressful events :
• Emotional response , with somatic complaints : the responses are of 2 kinds : anxiety response with autonomic arousal leading to apprehension , irritability , tachycardia and dry mouth .they are usually associated with events that pose a threat .
While depressive response with pessimistic thoughts and reduced physical activity associated with events that involve separation or loss.
• Coping strategy : serve to reduce the impact of stressful event , thus attenuating the emotional and somatic response .
Coping strategies are of 2 kinds :
- Problem solving strategies: seeking help from another person , obtaining informations or advice , making implementing plans to deal with problems and confrontation .
- Emotion reducing strategies : ventilation of emotion , evaluation of the problem , positive reappraisal of the problem and avoidance of the problem.
• Defense mechanisms : are unconscious responses to external stressors as well as to anxiety arising from internal conflict .
The most frequent mechanisms are repression , denial , displacement , projection and regression .
How stress affects health?
? Emotional stress plays an important role in more than half of all medical problems.
? Chronic stress can lead to physical disorders such as: ulcers, high blood pressure, and heart disease.
? It impairs immune system.
? Psycho-physiological (psychosomatic) disorders: are physical disorders in which emotions are believed to play a central role. Examples : asthma, hypertension, ulcers, colitis, and rheumatoid arthritis.

Classification of reaction to stressful events :
? Acute stress disorder .
? PTSD.
? Adjustment disorder :
- With depressed mood .
- With anxiety .
- With mixed anxiety and depressed mood.
- With disturbance of conduct .
- With mixed disturbance of emotions and conduct .
- Unspecified.

? Acute reaction to stress: immediate and brief response to sudden intense stressors in a person who does not have another psychiatric disorder at the time .
ICD- 10 definition of acute stress reaction that the response should start within an hour of exposure to the stressor and begins to diminish after not more than 48 hr.
DSM-IV definition : the condition should lasts for at least 2 days and for no more than 4 wks. ( more prolonged response).

? The core symptoms of acute stress reaction are depression or anxiety , avoidance is the most frequent coping strategy , while the most frequent defense mechanism is denial .
? In DSM-IV the diagnosis of acute stress disorder requires marked symptoms of anxiety or increased arousal , re-experiencing of the event and 3 of the following dissociative symptoms : - numbing or detachment.
- derealization.
- - depersonalization.
- - dissociative amnesia.

? The principle components of psychological first aid:
- comfort and consolation.
- - Protection from further threat and distress.
- - immediate physical care.
- - helping reunion with loved ones.
- - sharing the experience.
- - facilitating the sense of being in control.

? Post-traumatic stress disorder (PTSD) : this term denotes an intense , prolonged , and sometime delayed reaction to an intensely stressful event.
The essential features of PTSD are :
- Hyperarousal : persistent anxiety , irritability , insomnia and poor concentration.
- Intrusions : intense intrusive imagery , flashbacks and recurrent distressing dream.
- Avoidance : difficulty in recalling stressful events at will , avoidance of reminders of the events , detachment , numbness and diminished interest in activities.
- Onset and course : symptoms of PTSD may begin very soon after the stressful event or after an interval usually of days , but occasionally of months , though not more than 6 months . In DSM-IV PTSD can not diagnosed until at least a month of symptomatology has elapsed , until then the condition is regarded an acute stress disorder .
- DSM-IV has 2 criteria not present in ICD-10 : symptoms must have been present for at least a month and must cause significant distress or impaired social functioning.

Epidemiology:
? Estimates of the PTSD in the general population are mainly from USA.
? The lifetime prevalence ranges from about 10 to 12 percent among women and 5 to 6 percent among men.
? Although PTSD can appear at any age, it is most prevalent in young adults, because they tend be more exposed to precipitating situations.
? Children can also have the disorder.
? The lifetime prevalence is significantly higher in women, and a higher proportion of women go on to develop the disorder.
? Historically, men s trauma was usually combat experience, and women s trauma was most commonly assault or rape.
? The disorder is most likely to occur in those who are single, divorced, widowed, socially withdrawn, or of low socioeconomic level.
? The most important risk factors, however, for this disorder are the severity, duration, and proximity of a person s exposure to the actual trauma.
? A familial pattern seems to exist for this disorder, and first-degree biological relatives of persons with a history of depression have an increased risk for developing PTSD following a traumatic event.

Comorbidity :
? Comorbidity rates are high among patients with PTSD, with about two thirds having at least two other disorders.
? Common comorbid conditions include depressive disorders, substance-related disorders, other anxiety disorders, and bipolar disorders.
? Comorbid disorders make persons more vulnerable to developing PTSD.
?
Neurobiological abnormalities in PTSD :

? HPA axis : evidence for low plasma cortisol levels and increased sensitivity to dexamethason suppression . Increased levels of CRH in CSF .
? Noradrenaline : increased sympathetic tone , increased startle response .
? Brain imaging : smaller volume of hippocampus , overactivity of amygdala to traumatic psychological stimuli .

Treatment
? Counselling : provide emotional support , encourage recall of traumatic events to integrate them into patient`s experience .
? CBT :
- Information about the normal response to severe stress and importance of confronting situations and memories related to traumatic events.
- Self monitoring of the symptoms.
- Exposure to situations that are being avoided.
- Recall of images of traumatic events , to integrate these with the rest of patient`s experience
- Cognitive restructuring .
- Anger management.
? Medications : anxiolytic drugs should be avoided because prolonged use may lead to dependence .
Paroxetine , TCA or mirtazapine should be considered for treatment of PTSD ( NICE guideline ).

Adjustment disorder : the term refers to psychological reactions arising in relation to adapting to new circumstances . such circumstances include divorce and separation , a major change of work and abode , such as transition from school to university or migration and the birth of handicapped child.
Clinical features : the symptoms of an adjustment disorder include anxiety , worry , poor concentration , depression and irritability , together with physical symptoms caused by autonomic arousal such as palpitations and tremor. The onset is more gradual than that of an acute reaction to stress and the course is more prolonged . usually the social functioning is impaired.
Both ICD-10 and DSM-IV require that the disorder starts within 3 months.

Treatment : treatment is designed to help the patient resolve the stressful problems and to aid the natural processes of adjustment , this is done by reducing denial and avoidance of stressful events , encouraging problem solving and discouraging maladaptive coping responses.