Reaction to Stressful Event or Bereavement Flashcards
Normal stress response
Somatic
- fight or flight
- SNS and HPA axis
Emotional
- fear, anxiety, depression
Psychological
- repression (numbing, amnesia)
- adaptive and maladaptive coping
Abnormal stress –> prolonged, too intense, atypical
What constitutes a stressful event?
Psychosocial stressor
- places strain on person’s coping skills
- subjective depending on coping strategies
Traumatic stressor
- exceptionally threatening or catastrophic
- magnitude which would be traumatic for most people
- e.g. natural disaster, assaults, serious RTAs, torture, terrorist attacks, combat
Differential diagnosis for reaction to stressful event or trauma
Psycho effects:
Acute stress disorder
PTSD
Affective disorders (temporal, core symptoms)
Anxiety disorders (not traumatic usually, no dissociation in phobias; OCD have rituals and resistance)
[Psychotic disorders]
Substance use disorders
Dissociative disorders (symptoms in absence of stressor)
Malingering
Normal bereavement
Brain issue from psycho trauma:
- post concussion syndrome
Brain damage:
- organic disorders of head injury
Affect body and brain:
- adjustment disorder (less severe, more generalised)
Acute stress disorder - duration, typical symptoms, treatment, prognosis
Abnormal reaction to sudden stressful events
- prolonged (>48 hrs), more severe
- 2 days - 4 WEEKS (max) –> >4 wks = PTSD
- general symptoms/aetiology/comorbidities/RFs same as PTSD
Symptoms onset within few min of traumatic stressor
- sweating, palpitations, tremor
- intense anxiety, restlessness, insomnia, panic attacks
- may have depersonalisation, derealisation
Typically “dazed” initially, with disorientation and reduced awareness of surroundings (dissociation)
- may be followed by period of diminished responsiveness to extreme stupor or psychomotor agitation/overactivity
Amnesia for episode - can’t recall important aspects, may have flashbacks
Tx:
- general emotional and practical support (secondary repercussion of trauma e.g. RTA), aid adjustment to changes
- coping strategies, encourage recall when anxiety decreases
- brief CBT (5 sessions)
+/- SSRI
Prognosis:
- remits or becomes PTSD
Post traumatic stress disorder 創傷後遺症/壓力症 diagnostic criteria
Usually develops AFTER 1 MONTH but WITHIN 6 MONTHS of stressor
- Exposure to actual or threatened death, serious injury or sexual violence as:
- directly experiencing
- witness in person
- learning that event occurred to close family member or friend
- repeated or extreme exposure to aversive details of the traumatic event e.g. police, first responders to collect remains - > 1 of the following symptoms of INTRUSION associated with the event:
- recurrent, involuntary and intrusive distressing memories
- recurrent distressing dreams
- dissociative reactions e.g. flashbacks –> feel or act as if events were recurring
- intense or prolonged distress at exposure to internal or external cues
- marked physiological reaction to internal or external cues e.g. panic attack - PERSISTENT AVOIDANCE of stimuli a/w event:
- avoid distressing memories, thoughts or feelings
- avoid external reminders that arouse distressing memories, thoughts or feelings - NEGATIVE ALTERATIONS in COGNITION/MOOD with >2 of the following:
- dissociative amnesia – difficulty in recalling important aspects of the event
- persistent and exaggerated negative beliefs about oneself/others/world
- persistent distorted cognition about the cause or consequences of event which leads to self-blame or blaming others
- persistent negative emotional state
- markedly diminished interest or participation in activities
- feelings of detachment
- inability to experience positive emotions - ALTERATIONS IN AROUSAL and reactivity with >2 of the following:
- irritable behaviour, angry outbursts (will no provocation)
- reckless or self-destructive behaviour
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbances - Duration of all symptoms >1 MONTH
- Clinically significant distress and impairment
- Not due to substance or other medical condition
Key symptoms of PTSD and definitions
- increased arousal
- avoidance
- dissociation (amnesia, numbness, withdrawal/detachment, depersonalisation/derealisation)
- repetitive re-experiencing of traumatic event
- flashbacks: intrusive unwanted vivid mental images of the event –> may dissociate and experience event as thought it was happening again (complete loss of awareness of current surroundings)
- may have hallucinations, illusions - depressive symptoms common
- maladaptive coping – persistent anger, SA/alcohol
PTSD epidemiology
Prevalence varies based on geographical area
50-60% people will experience at least one traumatic event in their life
–> men have 8% risk of PTSD
–> women have 20% risk
F>M
PTSD aetiology
Predisposing factors:
- genetics –> 1/3 variance, higher risk if have FHx in 1st degree relatives but not significant genetic association (as in other disorders)
- enhanced physiological response to stress –> increase HPA axis, NE, CRH but lower cortisol
- neuroanatomical abnormalities –> smaller hippocampus, overactive amygdala/medial prefrontal cortex to traumatic stimuli
- personal Hx of mood/anxiety, Hx of trauma or child abuse
- female, lower IQ, lack of social support, low self-esteem
- children and older adults more vulnerable
Precipitating:
- traumatic event
- -> nature of event
- -> degree of exposure
- -> personal vulnerabilities
Perpetuating:
- fear conditioning (classical conditioning) –> fear reaction to any reminders of trauma = increase sensitisation and reinforce
- negative appraisal of early symptoms
- avoidance behaviour (and dissociation) preventing reconditioning and cognitive reappraisal –> can’t process the experience and integrate facts into memory
- stimuli triggering memories
- negative cognition/understanding of the event e.g. overgeneralising cause, blaming
PTSD management - 1st line, additional options
1st line:
PSYCHOLOGICAL
- general - emotional support, advice on adjustment to changes, coping strategies, encourage talking about the event
- TRAUMA FOCUSED CBT: graded exposure (help remember and confront situations), cognitive therapy (identify disbeliefs or distorted thoughts), psychoeducation (explain symptoms, course, prognosis)
- relaxation training, breathing techniques, grounding techniques for flashbacks
- positive thinking, self-talk
Pharmacological - if comorbid depression or CBT fails - SSRI - BZD for short term relief (max 3 wks) - occasionally may give olanzapine to augment SSRI Continuation for 12 months
Most frequent long term consequence of stressful event (3)
PTSD
MDD
Phobia
Normal adjustment
Psychological reactions involved in adapting to new circumstances (not extreme or traumatic events)
- mild short-lived anxiety, depression, irritability, poor concentration
Adjustment disorder diagnostic criteria
- Development of emotional or behavioural symptoms in response to an identifiable stressor occurring WITHIN 3 MONTHS of stressor
- Clinically significant symptoms as evidenced by one or both:
- marked distress OUT OF PROPORTION to the severity or intensity of the stressor
- significant impairment in functioning - does not meet criteria for another mental disorder and is not exacerbation of existing disorder
- not normal bereavement
- symptoms do not persist for more than an additional 6 months after stressor is terminated
Adjustment disorder severity, comorbidities and risk factors
More generalised and less severe than acute stress or PTSD
Not pervasive mood symptoms and not severe enough for other psychiatric diagnosis
Occasionally may have suicidal ideation if severe
Comorbid alcohol and SA common
Risk factors:
- poor coping skills e.g. young age
- female
- past psychiatric hx, hx of stressful events
- low self- esteem
Adjustment disorder epidemiology and prognosis
F>M
Extremes of ages
Common in psychiatric patients
Prognosis:
- majority resolve spontaneously within 6 months
- 20% adults and 40% adolescents may develop more serious psychiatric disorder
Adjustment disorder management
No specific treatment needed usually - can recover with help of family and friends
General support
- practical support, coping strategies, problem solving, psychoeducation, counselling
- self-help books
- crisis intervention if have maladaptive coping
