| Psychological Reaction to Stress | | | | develop: |
| | | | | - in the aftermath of man-made as opposed to natural |
| Introduction: | | | | disaster |
| Stressful events or adverse ‘life events' are known | | | | - if there are long-term stressful consequences to deal |
| to contribute to the aetiology of many psychiatric | | | | with, such as bereavement, disability, court case, loss |
| disorders, including mood disturbance and anxiety | | | | of home or job, |
| disorders. | | | | - If there is a history of mental illness |
| Generally, the individuals affected have some | | | | - If there is lack of social support, skills. |
| vulnerability to the mental illness as a result of genetic | | | | Treatment of PTSD include: (Bio-psycho-social) |
| factors, childhood experiences, or drug or alcohol | | | | - v Biological: Medications, depending on the |
| abuse. The stress may precipitate an episode of | | | | presentation. SSRI are licensed, but in general treat |
| illness. Hoses with high vulnerability may become ill in | | | | depending on the symptomology ( i.e. intrusive thoughts |
| the absence of stressful event, or with a relatively | | | | treat as OCD, anxiety symptoms treat as GAD, |
| minor stress. In contrast the reactions to stress | | | | depressive symptoms ,treat as Depressive disorder) |
| described here are a direct consequence of the | | | | - v Psychological: CBT is effective and has strong |
| stressful event, and would not arise without it. Three | | | | evidence base. Debriefing is controversial and there is |
| types of disorders will be described: | | | | evidence for and against although at current time its |
| | | | | use is diminishing. EMDR (Eye Movement |
| - Acute stress reaction | | | | Desensitization Reprocessing) is affective and is |
| - Post -traumatic stress disorders (PTSD) which | | | | commonly a choice in specialized PTSD clinics. |
| occurs in response to exceptionally severe stress | | | | Supportive therapy is useful. |
| - Adjustment disorders which occur at the time of a | | | | - v Social: social support including patient's finance, |
| life change or following a stressful event. | | | | work, accommodation and social network are |
| It is normal to react to stress in an emotional way. | | | | extremely important. |
| The disorders described here are considered to be | | | | 3. Adjustment Disorders: |
| abnormal reactions to stress either because the | | | | Are abnormal response to significant life changes, such |
| reaction is extreme or prolonged, or because it | | | | as a bereavement, marital separation, redundancy or |
| prevents the individual from functioning at home or | | | | starting a new job or college. The abnormal response |
| work in their usual way. An abnormal reaction to | | | | takes the form of an emotional disturbance, with |
| stress may occur because of the nature of the | | | | symptoms of anxiety, depressed mood or feeling |
| stressor, or the resources of the individual to cope with | | | | unable to cope. The symptoms are not severe enough |
| it, and often a combination of the two Control over | | | | to merit a diagnosis of depressive disorder or anxiety |
| events | | | | disorders, but must interfere with the patient's ability to |
| The stressor may be unusually intense, such as a | | | | function normally at home, work or in social situations |
| combat situation or a natural disaster. Less intense | | | | before a diagnosis can be made |
| events may be made more stressful by a long | | | | Adjustment disorders usually begin within a month of |
| duration, or by a lack of control over events. Individual | | | | precipitating event, and in most cases resolve within six |
| coping abilities are influenced by personality | | | | month, simple psychological and social treatment, such |
| characteristics and previous experiences of stress and | | | | as providing the patient with support, an opportunity to |
| methods of coping with it. Stressful events are | | | | talk about their feelings and a practical problem-solving |
| generally more difficult to cope with if they arise | | | | approach are often all that is required. |
| against a background of social difficulties, lack of social | | | | Bereavement: |
| support or even physical illness (remember the | | | | Loss of a close relative or friend is always an |
| bio-psycho-social model, for causation and | | | | extremely stressful event that will inevitably provoke a |
| management). | | | | marked emotional response. This is, of course, entirely |
| 1. Acute Reaction to Stress: | | | | normal, and the majority cope with their grief without |
| This disorder is rarely seen by mental health | | | | any professional help. |
| professionals, but may present to primary health care | | | | The normal grieving process: (e.g. death of a husband) |
| (PHC). It is short-lived, with symptoms settling within | | | | - Shock. Feeling numb ‘I can't believe he's gone' |
| hours or at most couple of days (ICD-10). The | | | | - Anger. ‘why did he leave me when I needed him' |
| symptoms are severe, often with an initially dazed | | | | - Searching. For his face in a crowd, and vivid dreams |
| state, followed by a variety of reactions from stupor | | | | that he is alive again |
| to marked agitation. Panic attacks are common. The | | | | - Guilt. ‘if only I had called the doctor earlier' |
| stress that precipitates an acute stress reaction is | | | | - Sadness. With many of the features of depression |
| often an overwhelmingly traumatic physical or | | | | - Acceptance. Gradual return to normal life |
| psychological experience, such as an assault, accident | | | | Needless to say, that the process above is simplified. |
| or bereavement. In most cases no treatment is | | | | Some individuals will ‘skip a stage', others will not |
| required as the symptoms settle spontaneously | | | | follow the above order and some will go back to a |
| (depending on the individual). If medical help is sought, a | | | | previous stage. |
| short course of BDZ or propranolol (a ? blocker) is an | | | | Bereavement can closely resemble depressive illness |
| appropriate treatment; with support. | | | | with persistent low mood, insomnia, loss of appetite |
| 2. Post- Traumatic Stress Disorders (PTSD): | | | | and thoughts of hopelessness and guilt. The only |
| PTSD occurs in response to an extremely stressful | | | | treatment required, however, is support, an opportunity |
| event, beyond the realms of usual experience that | | | | to talk and reassurance that it is part of a normal |
| would be distressing to most people. This might include | | | | process of adjustment that will gradually improve. |
| a serious accident or assault in which the life of the | | | | Abnormal grief: |
| individual or their family is threatened, or man-made or | | | | Grief is considered to be abnormal if: |
| natural disaster. | | | | - There is a considerable delay before it begins. For |
| There is often a delay of days or weeks before the | | | | example, a mother of two young children felt unable to |
| symptoms begin, although generally the disorder is | | | | grieve after the death of her mother because she did |
| established within six months of the stressor and runs | | | | not want to distress the children. She put all thoughts |
| a chronic, fluctuating course. The range of symptoms | | | | of her mother to the back of her mind, and got on with |
| that are found could be arranged under three broad | | | | life until 18 month later she becomes extremely |
| headings: | | | | depressed, tearful and felt life was no longer worth |
| - v Avoidance behaviour: | | | | living after the death of her pet. The suppressed grief |
| - Avoids reminders of trauma | | | | for her mother was finally expressed, but at an |
| - Loss of interest in normal activities | | | | inappropriate time. |
| - Detachment from family and friends | | | | - Symptoms are very intense. For example, an elderly |
| - v Re-experiencing the trauma: | | | | man, distressed after the sudden death of his wife, |
| - Intrusive recollections | | | | became increasingly concerned with his own death. He |
| - Nightmares | | | | began to believe that his insides were rooting away |
| - Flashbacks | | | | and that he would die soon (Coatard's syndrome- a |
| - Distress at encountering any reminder of the trauma | | | | severe form of depression). Theses nihilistic delusions |
| - v Anxiety: | | | | required inpatient psychiatric treatment. |
| - Automatic arousal | | | | - Symptoms are very prolonged. It is difficult to apply |
| - Insomnia | | | | fixed time limit on normal grief, as it will vary depending |
| - Irritability | | | | upon the individual and the circumstances of the |
| - Poor concentration | | | | bereavement. Generally , however, the most intense |
| - Exaggerated startle response | | | | feeling of grief will be beginning to resolve, and normal |
| The anxiety symptoms are prominent, and this may | | | | activities will be resumed by about six month. Grief |
| demonstrate itself with irritability, wariness and an | | | | may become stuck at one stage of the process, for |
| exaggerated startle reflex. Insomnia is common, with | | | | example there may be prolonged feelings of |
| difficulties in both falling asleep (anxiety) and staying | | | | numbness and shock, and an inability to accept the |
| asleep or waking up early (depression). Nightmares are | | | | reality of the loss |
| common. Recurrent thoughts about the traumatic | | | | An Abnormal grief reaction is more likely to arise if: |
| event are characteristic of PTSD. Vivid memories | | | | - Ø The death was sudden |
| come to mind repeatedly despite attempts to block | | | | - Ø The relationship with the dead person was overly |
| them out, and these are often accompanied by the | | | | dependent or difficult in some way |
| emotions that were experienced at the time. Very | | | | Bereavement therapy is a brief form of |
| intense and distressing flashbacks can occur, that can | | | | psychotherapy which focus specifically upon the |
| feel though the trauma is happening or about to | | | | bereavement, encourage the individual to talk through |
| happen again. Any reminders of the trauma are | | | | the events leading up to and following the death in |
| avoided, and this can result in social isolation. | | | | detail, and guiding them through the normal grief |
| Depressive disorder is a common co-morbidity, and | | | | process, for example by encouraging ventilation of |
| substance misuse may be an effort to cope with the | | | | feeling of anger and guilt |
| symptoms. | | | | Other psychological treatments include support groups, |
| The presence of extreme stress is the key aetiological | | | | CBT and IPT (Inter Personal Therapy). |
| factor in PTSD (remember the vulnerability to mental | | | | References: |
| illness diagram). The greater the stress, the more likely | | | | 1. Stevens L, Rodin. Psychiatry: An illustrated colour |
| it is that PTSD will develop. | | | | text, Churchill Livingstone 2001 |
| There is some evidence that it is more likely to | | | | 2. Steple D. |