REACTION TO STRESSFUL EXPERIENCES

By- Dilki Punchihewa

WHAT IS STRESS?

our reaction to events, environmental or internal, that are associated with substantial adaptive demands that exceed our adaptive resources.

Normal response to stressful events

1. Somatic response 2. Emotional response 3. Psychological response

ICD-10

1. Acute stress reaction2. Post traumatic stress disorder (PTSD)3. Adjustment disorder

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days.

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

(ICD-10)

ACUTE STRESS REACTION

Can present with….• Emotional response-anxiety, low mood, irritability, emotional ups and downs,

poor sleep, poor concentration, wanting to be alone.

• Somatic symptoms- – A thumping heart (palpitations)– Feeling sick (nausea)– Chest pain– Headaches– Tummy (abdominal) pains– Breathing difficulties

• Dissociative symptoms- emotional numbness and being in a daze, difficulty in recalling the event, detached from others and surrounding, recurrent dreams or flashbacks

• Coping stratergies – avoidance, maladpative coping responses

• Symptoms must start within 1 hour of the stressor

• Symptoms should being to diminish within 48 hours

• Clinical picture should change over time with no one symptom lasting for more than few hours.

Differential diagnosis

• PTSD • Adjustment disorder • Brief psychotic episode • Dissociative disorder • Organic disorder

POST TRAUMATIC STRESS DISORDER

Develops after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened.

• Symptoms must occur with 6 months of the event (ICD-10)• Lasting for more than 4 weeks • Symptoms similar to Acute stress reaction • Dissociative symptoms MUST be present • In addition - intrusions - depressive symptoms

• PTSD is commonly seen in trauma like rape, exposure to combat during war, sexual molestation,

being kidnapped or held hostage etc.

presentation…

• Risk factors for PTSD ‒ Females ‒ Children and older adults ‒ Ethnic minorities ‒ Family or personal history of psychiatric

illness ‒ Low intelligence‒ Child abuse ‒ Low self esteem ‒ Exposure to previous trauma ‒ Lack of social support

Differential diagnosis

• Acute stress disorder • Adjustment disorder • Depressive disorder • Anxiety disorder • Obsessive compulsive disorder • Brief psychotic disorder • Substance induce disorder

ADJUSTMENT DISORDER • Adjustment refers to Psychological reaction involved in

adapting to new circumstances. • It will be considered abnormal if distress

‒ Is greater that what is expected in a particular stressful event

‒ Has impairment of social functioning ‒ Is close in time to the life change ‒ Not severe enough to diagnose another psychotic illness

• There are no specific symptoms

• Usually present with mild symptoms of anxiety, depression, emotional and behavioral disturbances

• Symptoms must present within 1 month of the stressor

• Once the stressor is terminated symptoms doesn’t persist for more than additional 6 months

• When making the diagnosis always think1. Does the patient have a diagnosable mental disorder 2. If there is a diagnosable mental disorder, does it fit the

criteria for another condition better than those for adjustment disorder.

• Common situations….‒ Divorce or separation ‒ Change in job ‒ Home situation ‒ Newly married ‒ Birth of a child ‒ Transition between school and university

• Risk factors ‒ Young people ‒ Females ‒ Past experience of stressful event ‒ Low self esteem

Differential diagnosis

• Acute stress disorder or PTSD• Mood disorder • Anxiety disorder • Grief reaction • Organic disorder

• Majority will recover within few months without any interventions

• Some may progress in to more serious psychiatric illness

Acute stress reaction PTSD Adjustment disorder • Investigations to exclude organic

causes

• General measures 1. provide emotional

support 2. provide practical

support 3. help with residual

problems

• Psychological treatment 1. encourage recall 2. develop more affective

coping strategies 3. debriefing 4. CBT

• Pharmacological 1. Short term Anxiolytics

(3-5 days)2. Antidepressants - SSRI

• Exclude organic causes

• General measures 1. Provide emotional,

practical and social support

2. Educate about PTSD 3. Help with associated

guilt, anger and grief

• Psychological 1. Watchful waiting 2. Trauma focused cognitive

behavioral therapy 3. Eye movement

desensitization and reprocessing

• Pharmacological 1. Short term

benzodiazepine 2. Antidepressants

• Recover spontaneously with help of family and friends

• If treatment needed

Main aim is to reduce acute symptoms caused by the stressor

• General measures 1. Practical support to

manage stressors 2. Information about

adjustment disorder

• Psychological 1. Supportive brief

psychotherapy and problem solving

• Pharmacological 1. Short term Anxiolytics2. Antidepressants

MANAGEMENT