Stress – UpToDate

1 In a patient presenting with a symptom that could be attributed to stress (e.g., headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.

Acute Stress

Physical Response Emotional Response 
  1. ↑ACTH, epi + norepi, glucocorticoids and endorphins
  2. ↓Insulin+ reproductive hormones (est, prog, test)
  3. ↑Cognition + memory
  4. ↓Pain sensation
  5. ↑Energy stores mobilized, heartrate, metabolic rate, bp, resp rate

 

  1. Denial (defense mechanism) & Disbelief
  2. Shock
  3. Anger & Fear 
  4. Anxiety & Restlessness
  5. Confusion & Forgetfulness
  6. Self-doubt

Chronic Stress

Physical Response  Emotional Response  Behavioural Response
  1. Gl upsetSleep disturbances
  2. Headaches
  3. Lethargy
  4. Muscle + Back pain
  5. ↓libido
  6. ↓Immune response
  7. ↑risk developing mood disorder (GAD, MDD)
  8. ↑serum cholesterol
  9. ↑blood pressure
  10. ↑platelet aggregation
  11. ↑risk of cardiovascular events
  12. ↑risk of DM related complications and metabolic syndrome
  1. Mental blocksHopelessness, frustration
  2. Boredom
  3. Reduced feelings of empathy
  4. Chronic fatigue
  5. Anger, cynicism, pessimism
  6. Depression
  7. Nervousness
  8. Self-hate
  9. Guilt

 

  1. Mistakes or judgment errorsImpulsiveness
  2. Inappropriate or aggressive communication
  3. Apathy
  4. Increased drug or alcohol use
  5. Withdrawal, isolation
  6. édifficulty maintaining healthy life style (diet, exercise, sleep)
  7. Disordered eating

 

 


2 In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).

  • Stress: any demand on the body, mind and spirit to perform. Function is maintained and coping is adaptive.
  • Distress: Coping and adaptation processes fail to return an organism to physiological and/or psychological homeostasis.
  • Coping: Behavioral response to reduce stress in non-detrimental way. Function maintained.
  • Not coping: Appreciable decline in social, work, economic, family functioning and/or maladaptive coping (ETOH, substances, smoking, social withdrawl, etc)
    1. Assess function (all domains): school, family, relationships, work, health behaviors (exercise, diet, sleep), substance use, sexual function, psychological health
    2. Identify maladaptive/deleterious coping strategies/behaviors

3 main ways people cope with stress (can be adaptive or maladaptive)

  • Task-oriented: analyze situation and take action to deal directly with situation.
  • Emotion-oriented: address feelings and find social supports.
  • Distraction-oriented: use activities or work as distraction.

3 In patients not coping with stress, look for and diagnose, if present, mental illness (e.g., depression, anxiety disorder).

Stress has high comorbidity with anxiety, depression and psychoses

Screen for following:

  1. MDD
  2. Eating disorders
  3. GAD
  4. Panic Disorder
  5. Phobias
  6. Acute Stress disorder (symptoms of PTSD with onset before 4 weeks and duration < 4 weeks) g. PTSD

Diagnostic Criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:
  1. The person experienced, witnessed, or was confronted with an event or events thatinvolved actual or threatened death or serious injury, or a threat to the physical integrityof self or others.
  2. The person’s response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
  1. Intrusive distressing recollections(young children, repetitive play)
  2. Nightmares
  3. Flashbacks/hallucinations
  4. Intense psychologic/physiologic distress at exposure to cues resembling the event.
   
C. Avoidance of stimuli associated with the trauma + numbing of general responsiveness
D. Persistent symptoms of increased arousal (irritable, hypervigilant,↑startle,↓ [ ]
E. Duration is more than one month.
F. Causes clinically significant distress or impairment in function.

 Prognosis: Spontaneous improvement, lasts 36 months (treatment), 64 months (no treatment), > 1/3 never fully recover

(+) prognosis if: Rapid engagement of treatment, early/ongoing social support, avoidance of retraumatization,good premorbid function, and absence of psychiatric disorders or substance abuse.

Comorbidity Men (%) Women (%)
Alcohol abuse or dependence 51.9 27.9
Drug abuse or dependence 34.5 26.9

Treatment:

  1. NO! Exposure therapy and psychotherapy to relive experiences =(BAD)
  2. Behavioural and cognitive therapy (enroll families in therapy as well)
  3. SSRI (sertraline, Fluvoxamine, paroxetine) ↓ numbing, avoidance, hyperarousal
  4. Clonidine/Risperidone may ↓ intrusive recollections, nightmares, hypervigilance and outbursts of anger
  5. Benzos: ↓ anxiety but no impact on core symptoms (↑substance abuse = avoid benzos)

4 In patients not coping with the stress in their lives,

a) Clarify and acknowledge the factors contributing to the stress,

b) Explore their resources and possible solutions for improving the situation.

Rates of ASD, diagnosed principally using DSM-IV criteria, following specific types of trauma include:

  • Motor vehicle accident: 13 percent
  • Mild traumatic brain injury: 14 percent
  • Assault: 16 percent
  • Burn: 10 percent
  • Industrial accident: 6 percent
  • Witnessing a mass shooting: 33 percent

Risk factors — It is probable that most risk factors for posttraumatic stress disorder (PTSD) also apply to ASD

  • History of a pre-trauma psychiatric disorder
  • History of traumatic exposures prior to recent exposure
  • Female gender
  • Trauma severity
  • Neuroticism
  • Avoidant coping

Stress Reduction Therapies:

  1. Exercise!!!
  2. Control manageable issues
  3. Counseling/ CBT
  4. Encourage peer social support
  5. Massage
  6. Breathing exercises + Progressive muscle relaxation
  7. Mediation (mindfulness, transcendental, guided imagery)
  8. Acupuncture

Acute stress disorder (ASD)

characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event. The disorder includes symptoms of intrusion, negative mood, dissociation, avoidance, and arousal.

 typically presents with severe levels of reexperiencing and anxiety in response to reminders of the recent trauma. These reactions tend to be readily activated by many occurrences and situations. This will often lead to generalized fear, vigilance for further threats, and active avoidance of situations that stimulate recollections of the trauma

 diagnosed in persons experiencing or witnessing a traumatic event and experiencing associated symptoms of intrusion, negative mood, dissociation, avoidance, and arousal, and significant distress or impairment. Symptoms should be present at a severe level to warrant diagnosis.

ASD can be diagnosed three days after the traumatic event; however, delaying the diagnosis until a week after the event may better identify patients who can be effectively treated and are at higher risk of developing posttraumatic stress disorder (PTSD).


5 In patients experiencing stress, look for inappropriate coping mechanisms (e.g., drugs, alcohol, eating, violence).

Screen for:

  1. Substance use
  2. ETOH
  3. Overworking
  4. Eating disorders
  5. Anger/aggressive behavior
  6. Smoking

 Reference: UpToDate 2014

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Posted in 87 Stress, 99 Priority Topics, FM 99 priority topics, Psych

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