Stress Related Disorders and their Management

What is stress?

Stress is defined as a psychological process initiated by events that threaten, harm, or challenge an organism, exceeding available coping resources. It is characterized by psychological responses directed towards adaptation.

It's a situation that arises from physical and/or mental positive or negative pressure, overwhelming adaptive capacities.

Stressful events often trigger psychiatric disorders.

However, not all reactions to stressful events are abnormal.

Grief, for example, is a normal reaction to the stressful experience of bereavement.

There is also a normal pattern of reaction to a dangerous or traumatic event, such as a car accident (anxiety & restlessness for a few hours).

Some individuals, however, may experience more serious and prolonged symptoms, indicating an abnormal reaction.

Making a separation between normal and abnormal reactions to stressful events in terms of severity or duration is, however, difficult. In practice, the division is arbitrary.

Response to Stressful Events:

Has three components:

1. An emotional response, with somatic accompaniments.
2. A coping strategy.
3. A defense mechanism.

Emotional and somatic responses could either be anxiety responses with autonomic arousal causing apprehension, irritability, tachycardia, etc., OR depressive responses with pessimistic thinking, anergia, etc.

Anxiety responses are generally associated with events that pose a threat, while depressive responses are usually associated with events that involve separation or loss.

Symptoms, however, are less severe than those of anxiety or depressive disorders.

Coping Strategies:

They are conscious responses that serve to reduce the impact of stressful events, making it possible to maintain normal performance at the time, though not always in the longer term.

They are of 2 types: problem-solving strategies and emotion-reducing strategies.

Problem-solving strategies include:

• Seeking help
• Obtaining information or advice
• Solving problems
• Confrontation

Emotion-reducing strategies include:

• Ventilation of emotion
• Evaluation of the problem
• Positive reappraisal of the problem
• Avoidance of the problem

Note: They are not always adaptive. Therefore, it isn’t enough to possess the ability to use coping strategies but also the ability to judge which strategy should be used in particular circumstances.

Coping mechanisms used repeatedly become coping styles.

Defence Mechanisms:

Responses of which the person is unaware (unconscious processes).

Different types.

• Most frequent ones are repression, denial, displacement, projection, and regression.

Response to a stressful life event is modified by present circumstances and by past experience (Brown & Harris 1978).

Some current circumstances make a person more vulnerable to stressful life events, e.g., lack of a confidant with whom to share problems.

Such circumstances are called vulnerability factors.

Vulnerability can be increased by previous experience also, e.g., experience of losing a parent in childhood may make a person more vulnerable in adult life to stressful events involving loss.

Classification of Reactions to Stressful Events:

• ICD-10 and DSM-IV reactions to stressful experiences are classified into three(3) groups:

1. Acute reactions to stress: Acute stress reaction (ICD-10) & Acute stress disorder (DSM-IV).
2. Post-traumatic stress disorder
3. Adjustment disorder

These are immediate and brief responses to sudden intense stressors in a person who doesn’t have another psychiatric disorder at the time.

Acute Stress Reaction (ICD-10): Response should start within an hour of exposure to the stressor & begins to diminish after not more than 48 hours.

Acute Stress Disorder (DSM-IV): Onset should be after experiencing the distressing event & the condition lasts for at least 2 days but for no more than 4 weeks.

Stressor in both cases must be of an exceptional nature, and for DSM-IV, actual or threatened injury to self or others has occurred.

Epidemiology

Rates in the population are unknown.

Rates of acute stress disorder reported among survivors of motor vehicle accidents is 13% (Harvey & Bryant, 1998).

In victims of violent crime, it’s 19% (Brewin et al, 1999), and among the witnesses of a mass shooting, it was 33% (Classen et al, 1998).

People who develop Acute Stress Disorder are more likely to experience subsequent PTSD (Brewin et al, 2003).

However, around 50% of those who eventually develop PTSD after a trauma do not meet criteria for Acute Stress Disorder soon after it.

Symptoms

The core symptoms of an acute psychological response to stress are anxiety or depression.

Both, however, occur together often as stressful events most times combine danger & loss, e.g., RTA.

Other symptoms include:

• Numbness or feeling dazed
• Difficulty in remembering the whole sequence of events
• Insomnia
• Restlessness
• Poor concentration
• Physical symptoms of autonomic arousal

Most frequent coping strategy used is avoidance, and the most frequent defense mechanism is denial.

These, however, recede as anxiety diminishes.

In DSM-IV, the diagnosis of Acute Stress Disorder requires marked symptoms of anxiety or increased arousal, re-experiencing the event, impaired social functioning, and 3 of 5 dissociative symptoms:

• A sense of numbing or detachment
• Reduced awareness of the surroundings (“being in a daze”)
• Derealization
• Depersonalization
• Dissociative amnesia

In ICD-10, 2 symptoms required for the moderate form & 4 for the severe form from a list of 7, which are:

• Withdrawal from expected social interaction
• Narrowing of attention
• Apparent disorientation
• Anger & verbal aggression
• Despair & hopelessness
• Inappropriate or purposeless activity
• Uncontrollable & excessive grief

Note: ASR & ASD are used only when the person was free from these symptoms immediately before the impact of the stressful event. Otherwise, the response is classified as an exacerbation of pre-existing psychiatric disorder.

PTSD Diagnostic Criteria Comparison

DSM-5 (2013)	ICD-11 (2018)
A. Exposure to actual or threatened death, serious injury, or sexual violence	Exposure to an extremely threatening or horrific event or series of events
B. Intrusions C. Avoidance D. Changes in cognitions and mood E. Arousal & reactivity	Re-experiencing Avoidance Persistent perceptions of heightened current threat
F. Duration more than 1 month G. Clinically significant distress or impairment of function H. Due to event, not due to physiological effects of a substance or medical condition	Must last for at least several weeks Significant impairment in personal, family, social, educational, occupational, or other important areas of functioning

Etiology

Mainly events that can provoke an acute response to stress.

Examples include RTA, physical assault or rape, sudden discovery of a serious illness.

However, not all people exposed to the same stressful situation develop the same degree of response.

This variation suggests that differences in constitution, previous experience, coping styles may play a part in aetiology.

Management

Watchful waiting with a follow-up appointment in about a month. In most cases, stress reactions will resolve with time.

Psychotherapy (brief trauma-focused cognitive-behavioral therapy) may be needed in cases where the stressful event is that which cannot be easily discussed, e.g., rape, or if the response is prolonged or severe.

Anxiolytics/hypnotics may be indicated if anxiety is severe or when sleep is severely disrupted.

This is an intense, prolonged & sometimes delayed reaction to an intensely stressful event.

Extreme stressors that may cause this include natural disasters such as flood, earthquakes, man-made calamities such as major fires, fatal RTA or the circumstances of war, rape or serious physical assault on the person.

However, not everyone exposed to the same extreme stressor develops PTSD, therefore, personal predisposition plays a part.

Clinical features of PTSD can be divided into 3 groups:

a) Hyperarousal

• Persistent anxiety
• Irritability
• Insomnia
• Poor concentration

b) Intrusions

• Intense intrusive imagery
• Flashbacks
• Recurrent distressing dreams

c) Avoidance

• Difficulty in remembering stressful event at will
• Avoidance of reminders of the events
• Detachment
• Inability to feel emotion (numbness)
• Diminished interest in activities

Other features include depressive symptoms, feelings of guilt, dissociative symptoms & depersonalization.

It may also present as deliberate self-harm or substance abuse, which have developed as maladaptive coping strategies.

In DSM IV, PTSD cannot be diagnosed until at least a month of symptomatology has elapsed; until then, the condition is regarded as acute stress disorder.

Symptoms of PTSD may, however, begin soon after the stressful event or after an interval usually of days, occasionally of months, though rarely more than 6 months.

Can occur at any age & can affect anyone.

In DSM-5, the stressor criterion is more explicit with regard to how an individual experienced traumatic events; direct, witnessed, or experienced indirectly.

Has 4 symptom clusters. Avoidance cluster divided into avoidance & persistent negative alterations in cognition & mood.

Etiology

The necessary cause of PTSD is an exceptionally stressful event.

It is, however, not necessary that the person should have been physically harmed or threatened personally. Those involved in other ways may develop the disorder.

Intentional acts of interpersonal violence, in particular sexual assault, & combat are more likely to lead to PTSD than accidents or disasters.

Men tend to experience more traumatic events in general than women, but women experience more events that are likely to lead to PTSD e.g. rape, domestic violence.

Women are also more likely to develop PTSD in response to a traumatic event than men.

Genetic factors: Risk of PTSD is increased by a family history of psychiatric disorder which may reflect genetic factors (Koenen et al., 2002).

Neurobiological factors: Dysregulation of HPA axis with general increase in lability following environmental stress.

Smaller volume of the hippocampus.

Fear conditioning: Sensory cues related to the stressful situation.

Cognitive theories: Normal processing of emotionally charged information is overwhelmed so memories persist in an unprocessed form in which they intrude into conscious awareness.

Predisposing Factors

• Personal history of mood & anxiety disorder
• Previous history of trauma
• Female gender
• Neuroticism
• Lower intelligence
• Lack of social support
• Extreme severity & close proximity of the individual’s exposure to the traumatic event.

Maintaining Factors

• Negative appraisal of early symptoms
• Avoidance of reminders of the traumatic situation
• Suppression of intrusive memories, which is known to make them more likely to recur.

Differential Diagnosis

• Stress-induced exacerbations of previous anxiety or mood disorder.
• Acute stress disorders (distinguished by time course).
• Adjustment disorders (distinguished by a different pattern of symptoms).
• Enduring personality changes after a catastrophic experience.

Management

History should include inquiries about the nature & duration of symptoms, previous personality & psychiatric history.

Feelings of anger & thoughts of self-harm are common & a risk assessment may be needed.

Emotional support to encourage recall of traumatic events in mild cases.

CBT in severe & long-standing cases.

Medications shouldn’t be the first line unless the patient expresses a preference for it or if psychotherapy is not available.

Anxiolytics should be avoided because of dependence.

Antidepressants such as SSRIs, TCAs & MAOIs have shown efficacy in clinical trials.

However, drug treatment has been shown to have lower effect when compared to psychotherapy.

In cases of significant comorbid depressive disorder, then antidepressant treatment should be considered an adjunct to psychotherapy.

Prognosis

Many cases are persistent.

About half will recover within a year.

Up to a third, however, do not recover even after many years.

Psychological reactions arising in relation to adapting to new circumstances, e.g., divorce or separation, a major change of work, migration, birth of a handicapped child, onset of a terminal illness, sexual abuse.

Clinical Features:

• Anxiety
• Worry
• Poor concentration
• Depression
• Irritability
• Symptoms of autonomic arousal; palpitations, tremor
• Aggressive behavior
• Episodes of DSH or misuse of alcohol

Onset & Course

Onset is more gradual than that of an acute reaction to stress.

Social functioning is impaired.

Impairment in social functioning, as well as the intensity of distress, distinguishes it from normal adaptive reactions.

Its course is also more prolonged.

Epidemiology

Prevalence in the community is unknown.

In a study of medical patients referred for psychiatric evaluation, 12% met criteria for adjustment disorder.

27% prevalence in another study in patients attending a stroke unit.

Etiology

Stressful conditions are the necessary cause of an adjustment disorder.

Individual vulnerability, however, is important.

This seems to vary from person to person & may relate in part to previous experiences.

Diagnosis

Diagnosis is not made when diagnostic criteria for another psychiatric disorder are met.

Diagnosis is made by excluding anxiety or depressive disorder.

The disorder should have started soon after the change of circumstances for the diagnosis to be made.

Both ICD-10 & DSM-IV require that the disorder starts within 3 months & ICD-10 indicates that it starts within 1 month usually.

Reaction should be related to & in proportion to the stressful experience.

Treatment

Designed to help the patient resolve the stressful problems if possible & to aid the natural processes of adjustment.

This is done by reducing denial & avoidance of the event, encouraging problem-solving & discouraging maladaptive coping responses.

Anxiety can be reduced by encouraging the patient to talk about it & express feelings.

Anxiolytics or hypnotics may, however, be needed for a few days.

Problem-solving counseling & supportive psychotherapy are effective.

Essential feature is a disruption of the usually integrated functions of consciousness, memory, identity, or perception.

This disturbance may be sudden or gradual, transient or chronic.

Types

• DSM-IV
• Dissociative amnesia
• Dissociative fugue
• Dissociative identity disorder
• Depersonalization disorder
• Dissociative disorder NOS
• ICD-10
• Dissociative amnesia
• Dissociative fugue
• Multiple personality disorder
• Dissociative disorder NOS
• Dissociative stupor
• Trance & possession disorders
• Ganser’s syndrome

ICD-11	DSM-5
Dissociative neurological symptom disorder Dissociative amnesia Depersonalization-derealization disorder Trance disorder Possession trance disorder Complex dissociative intrusion disorder Dissociative identity disorder Other dissociative disorder	DID Dissociative amnesia, including dissociative fugue Depersonalization-derealization disorder Other specified dissociative disorder Unspecified dissociative disorder
DSM Diagnostic and Statistical Manual, ICD-International Classification of Diseases, DID-Dissociative identity disorder

Dissociative Amnesia

Inability to recall important personal memories, usually of stressful nature, that is too extensive to be explained by normal forgetfulness.

Dissociative amnesia occurs alone & during the course of other dissociative disorders & of PTSD, acute stress disorder & somatization disorder.

Diagnosis is made only when these other conditions are not present.

The amnesia may be circumscribed for a single recent traumatic event OR

It could be an inability to recall long periods of childhood.

It should be distinguished from amnesia having a medical cause.

Dissociative Fugue

Extremely rare.

There is loss of memory (amnesia) coupled with wandering away from the person’s usual surroundings.

These people usually deny all memory of their whereabouts during the period of wandering & some deny knowledge of personal identity.

Must be distinguished from organic disorders such as epilepsy & substance intoxication.

Dissociative Identity Disorder

A.k.a Multiple Personality Disorder.

There are sudden alternations between two patterns of behavior, each of which is forgotten by the patient when the other is present.

One pattern is, however, the person’s normal personality while the other contrasts, often strikingly with the normal.

There could be more than one additional personality at times.

Etiology

Role of severe trauma.

Iatrogenic factors - use of hypnosis.

Diagnosis

• Presence of two or more distinct identities or personality states.
• At least two of these identities recurrently take control of the person’s behavior.
• Inability to recall important personal info that is too extensive to be explained by normal forgetfulness.
• The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

Ganser’s Syndrome

Very rare condition with 4 features:

• Giving ‘inappropriate answers’ to questions designed to test intellectual functions
• Psychogenic physical symptoms
• Hallucinations
• Apparent clouding of consciousness

Not every individual exposed to a stressful event comes down with a disorder.

Individual vulnerability comes into play.

Present circumstance and past experience are very important in predicting who develops an abnormal reaction.

Symptoms shouldn’t meet the diagnostic criteria for depression or anxiety.

Psychotherapy is the mainstay of treatment.