Reaction to stressful situations

Dr.Harim Mohsin

Introduction

This category differs from others in that it includes disorders identifiable not only on grounds of symptomatology and course but also on the basis of one or other of two causative influences -• an exceptionally stressful life event producing an acute stress

reaction, or • a significant life change leading to continued unpleasant

circumstances that result in an adjustment disorder.

Components of response to stress

• 1-an emotional response with somatic accompaniments e.g anxiety• 2-a coping strategy- seeking help, problem solving,

ventilation, avoidance, substance use, aggression etc• 3-a defense mechanism- repression, projection, sublimation

etc.

Classification of Reactions to stressful experience

ICD-10

Acute stress reactionPTSDAdjustment disorder•Brief depressive disorder•Mixed anxiety and depressive disorder•Predominant disturbance of other emotions•Mixed disturbance of emotions and conduct•Other specified symptoms

DSM-4

Acute stress disorderPTSDAdjustment disorder•With depressed mood•With anxiety•With disturbance of conduct•With mixed disturbance of emotions and conduct•Unspecified

Types

• Acute Stress reaction• Post traumatic stress disorder• Adjustment disorder

Acute stress reaction

• A transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress and which usually subsides within hours or days.

Acute Stress Reaction

• Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions

• The symptoms show great variation but typically they include an initial state of "daze", with some narrowing of attention, inability to comprehend stimuli, and disorientation.

• This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present.

• The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within 2-3 days (often within hours).

• Partial or complete amnesia for the episode may be present.

Diagnosis• In ICD-10- • Moderate 2/7 and severe 4/7 of the following symptoms:• Withdrawal from expected social interactions• Narrowing of attention• Apparent disorientation• Anger and verbal aggression• Despair and hopelessness• Inappropriate or purposeless activity• Uncontrollable and excessive grief

Management

• Planning for disaster- • Immediate and appropriate response to psychological effects of major

disaster according to decided priority needs of adults, children and team members. • Psychological assistance for victims of disaster by Alexander (2005):• Comfort & consolation, Protection from threat/distress, immediate

physical care, Reunion with loved ones, Sharing experiences, Linking survivors with support, Identifying those who need help further.

Management

• Debriefing : After disaster counseling has taken the form known as debriefing or Critical incident stress debriefing (CISD) individually/group. • Facts- victim relates what happened• Thoughts- describe their thoughts after event• Feelings- emotions associated with incident• Assessment- take stock up of responses• Education- Counselor offers information about stress response and

management.

Management

• Follow up after 1 month, identify subjects likely to develop PTSD. • Offer psychotherapy to those without social support (friends,

family) or confidentiality issues (rape)• Incase of depression, insomnia or anxiety medication should

be prescribed.

Post-Traumatic Stress disorder

• This arises as a delayed and/or protracted response to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or other crime).

Clinical picture

Hyperarousal Intrusions Avoidance

Persistent anxietyIrritabilityInsomnia

Poor concentration

Intense intrusive imagery

‘flashbacks’Recurrent distressing

dreams

Difficulty recalling stressful events at will

Avoidance of reminder of eventsDetachmentNumbness

Diminished interest in activities

PTSD- Diagnosis

• Symptoms begin soon after stressful event, after days or months but rarely after 6 months. • PTSD can’t be diagnosed until 1 month of symptomatology

has passed. Until then it is classified as acute stress reaction. • Many cases are persistent; about half recover within 1 year

but 1/3 don’t recover even after many years.

Predisposing factors

• Individual factors that increase vulnerability to development include:• Personal history of mood/anxiety disorders• Previous history of trauma• Female gender• Neuroticism• Lower intelligence• Poor social support

Treatment

• Counseling • Emotional Support, Encourage recall to integrate the events

into the patient’s experience and facilitate working through associated emotions. There might be feelings of guilt, purposelessness and other concerns in cases of rape or personal assault which would need addressing.

Treatment

• Cognitive-behavioral treatment• When symptoms are severe or long-standing CBT is most appropriate. • The components of treatment:• Information about the normal response to severe stress and importance of confronting situations and

memories related to traumatic events. • Self-monitoring of symptoms• Exposure to situations that are being avoided• Recall of images of the traumatic events • Cognitive restructuring through the discussion of evidence for and against the appraisals and

assumptions• Anger management for people who still feel angry about the traumatic events and their causes.

Medication

• Anxiolytics should be avoided if diagnosis of PTSD has been established as they may lead to dependence. • A number of antidepressants have shown efficacy in clinical

trials, SSRIs, SNRIs, TCAs, and MOAIs. There are also preliminary data supporting Mirtazipine and augmentation with atypical antipsychotics.

Adjustment disorders

• States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event (including the presence or possibility of serious physical illness). • The stressor may have affected the integrity of an individual's social network

(through bereavement or separation experiences) or the wider system of social supports and values (migration or refugee status). The stressor may involve only the individual or also his or her group or community.

Diagnosis• The manifestations vary but none of the symptoms is of sufficient

severity or prominence in its own right to justify a more specific diagnosis. • These include depressed mood, anxiety, worry (or a mixture of these), a feeling

of inability to cope, plan ahead, or continue in the present (social/occupation) situation, and some degree of disability in the performance of daily routine. • The individual may feel liable to dramatic behaviour or outbursts of violence, but

these rarely occur. However, conduct disorders (e.g. aggressive or dissocial behaviour) may be an associated feature, particularly in adolescents.• In children, regressive phenomena such as return to bed-wetting, babyish

speech, or thumb-sucking are frequently part of the symptom pattern.

Diagnosis

• The onset is usually within 1 month of the occurrence of the stressful event or life change, and the duration of symptoms does not usually exceed 6 months. • If the symptoms persist beyond this period, the diagnosis

should be changed according to the clinical picture

Diagnosis •  Brief depressive reaction• A transient, mild depressive state of duration not exceeding 1 month.

• Prolonged depressive reaction• A mild depressive state occurring in response to a prolonged exposure to a stressful

situation but of duration not exceeding 2 years.

• Mixed anxiety and depressive reaction• Both anxiety and depressive symptoms are prominent, but at levels no greater than

specified in mixed anxiety and depressive disorder or other mixed anxiety disorder

• With predominant disturbance of other emotions• The symptoms are usually of several types of emotion, such as anxiety,

depression, worry, tensions, and anger. Symptoms of anxiety and depression may fulfil the criteria for mixed anxiety and depressive disorder or other mixed anxiety disorder but they are not so predominant that other more specific depressive or anxiety disorders can be diagnosed. • This category should also be used for reactions in children in which

regressive behaviour such as bed-wetting or thumb-sucking are also present.• With predominant disturbance of conduct• The main disturbance is one involving conduct, e.g. an adolescent grief

reaction resulting in aggressive or dissocial behaviour.

Treatment

• Designed to help patients resolve the stressful problems and aid natural process of adjustment. • Encourage problem solving, discourage maladaptive coping

strategies, facilitate communication. Occasionally medications (anxiolytic or hypnotic) might be needed.

Thank you