Reactions to Stress Flashcards
What is an acute stress disorder?
The ICD-10 definition of acute stress reaction requires that the response should start within 1 hour of exposure to the stressor, and that it begins to diminish after not more than 48 hours, disappearing after a few days.
Acute stress reaction is defined as persistently heightened awareness, difficulty sleeping, flashbacks and interferance if thoughts with ADLs, that does not last longer than 1 month after a life-threatening or extremely traumatic event. (basically like PTSD but lasts less than 1 month)
What is the epidemiology of acute stress reaction?
- 15% of motor accident survivors
- 50% of women victims of sexual assault
What is the aetiology of acute stress reaction?
Many kinds of event can provoke an acute response to stress—for example, involvement in a significant but brief event (e.g. a motor accidentor afire), an event that involves actual or threatened injury (e.g. a physical assaultorrape), or the sudden discovery of serious illness.
Describe the clinical picture of acute stress reaction
The core symptoms of an acute stress reaction is anxiety and depression. Anxiety occurs to threatening reactions, while depression occurs as a response to loss. They often come together, because stressful events often combine danger and loss - an example is a road accident in which a companion is killed.
Other symptoms include the feelings of being numb or dazed, difficulty remembering the whole sequence of the traumatic event, insomnia, restlessness, poor concentration, and physical symptoms of autonomic arousal especially sweating, palpitations and tremor.
Anger or histrionic behaviour may be part of the response. Occasionally there is a flight reaction - for example, when the driver runs away from the scene.
Coping strategies and defence mechanisms are also part of the acute response to stressful events. Often the coping strategy of choice is avoidance, where the person avoids talking about the stressful events, and avoids reminders of them. The most frequent defence mechanism is denial. See The Response to Stressful Events for more info on coping strategies and defence mechanisms.
Describe the management of acute stress reaction
- One-off psychological debriefing (discussing the psychological trauma and your emotional response) straight after the event has been shown to actually be harmful. But you should encourage adaptive coping strategies such as problem-solving strategies, or emotion-reducing strategies such as venting to friends and family.
- If anxiety is severe, prescribe an anxiolytic drug such as SSRIs, TCAs etc.
- Arrange a follow-up for 2 weeks time to identify those who are still struggling with those symptoms and therefore those who are more at risk of developing PTSD.
If patients show persistent and troublesome symptoms of acute stress disorder at this point, consideration should be given to treatments that may help prevent the onset of PTSD such as prolonged exposure therapy (which aims to minimise continuing avoidance) and trauma-focused cognitive behaviour therapy - which are superior than less specific psychological approaches such as supportive counselling.
What are the key groups of symptoms of PTSD?
PTSD denotes an intense, prolonged, and sometimes delayed reaction to an intensely stressful event. There are three essential features of a post-traumatic stress reaction:
- Re-experiencing of aspects of the stressful event.
- Hyperarousal.
- Avoidance of reminders.
What is the epidemiology of PTSD?
PTSD is very common - it has a lifetime prevalence of 8% and around 15% of GP patients.
Describe the clinical picture of PTSD
PTSD usually begin within 6 months after a latency period following the trauma. Symptoms fall within the following groups:
-
Re-experiencing
- Flashbacks - vividly reliving the trauma, feeling as though it is ‘happening all over again’
- Nightmares
- Intrusive memories - being unable to keep the mind clear of memories of what happened.
-
Hyperarousal
- Persistent inability to relax
- Hypervigilance: the patient feels as though they are always on ‘red alert’
- Enhanced startle reflex
- Insomnia
- Poor concentration
- Irritability
-
Avoidance
- Difficulty in recalling stressful events at will
- Avoidance of reminders of the events
- Detachment
- Numbness - inability to feel emotion
- Diminished interest in activities.
There is overlap with depression and other anxiety disorders, and many may develop maladaptive coping strategies such as the excessive use of alcohol and drugs.
Describe the management of PTSD
In all patients:
- Assess risk of suicide in these patients. May require urgent admission.
- Assess for secondary psychological disorders such as depression, anxiety, and alcohol and drug misuse. These should also be treated - alcohol and drug misuse should be treated as a priority, but should not delay for the treatment of PTSD.
- Assess safeguarding issues with children or vulnerable adults in their care. Also screen for other family members who have been affected by the trauma.
- Offer people and their families self-help advice and the availability of local support groups. Self-help books are available from the Books on Prescription Scheme.
For people with PTSD for less than 4 weeks:
- If symptoms are severe, offer referral without delay to a specialist mental health service with experience in managing post-traumatic stress disorder.
- If symptoms are mild consider a period of watchful waiting. Explain that for most people, symptoms improve over time, and only 1/3 of patients require specialist help to get better. Arrange follow-up within 1 month.
For people with PTSD for more than 4 weeks, offer referral to specialist mental health service. You can find specialists locally using the UK Psychological Trauma Society. Veterans can be seen more rapidly under the veterans’ priority scheme.
Consider treatment with antidepressants if they show preference towards drugs, or if they do not want psychological therapy. Also offer if referral is significantly delayed.
For people with sleeping problems, advice on sleep hygiene and consider prescribing a hypnotic for short-term use. If sleep problems persist, consider prescribing a sedative antidepressant (such as mirtazapine given at night) for longer-term use.
What is adjustment disorder?
Adjustment disorder refers to the psychological reactions that arise in relation to adapting to new circumstances. Such circumstances include divorce and separation, a major change of work and abode (e.g. transition from school to university, or migration), and the birth of a handicapped child. Bereavement, the onset of a terminal illness, and sexual abuse are associated with special kinds of adjustment.
An essential point is that the reaction is understandably related to, and in proportion to, the stressful experience when account is taken of the patient’s previous experiences and personality.
Persons reaction to change/life event is greater than usually expected for the situation but not severe enough to diagnose anxiety or depressive disorder
Symptoms start within 3 months of the stressor (usually within 1 month), resolve within 6 months once stressor or its consequences are removed.
Clinical features include anxiety, poor concentration, aggressive behavior, deliberate self harm etc.
What are the clinical features of adjustment disorder?
The symptoms of an adjustment disorder include anxiety, worry, poor concentration, depression, and irritability, together with physical symptoms caused by autonomic arousal, such as palpitations and tremor.
There may be outbursts of dramatic or aggressive behaviour, single or repeated episodes of deliberate self-harm, or the misuse of alcohol or drugs.
The onset is more gradual than that of an acute reaction to stress, and the course is more prolonged.
Social or occupational function is impaired. The impairment in social or occupational function, as well as the intensity of distress, is what distinguishes adjustment disorder from normal adaptive reactions.
The diagnosis is usually made by excluding an anxiety or depressive disorder, as stressful events can cause those and other psychological conditions. A further requirement for diagnosis is that the disorder starts soon after the change of circumstances. Both ICD-10 and DSM-5 require that the disorder starts within 3 months, and ICD-10 indicates that it usually starts within 1 month. An essential point is that the reaction is understandably related to, and in proportion to, the stressful experience when account is taken of the patient’s previous experiences and personality.
Once the stressor or its consequences are removed, the symptoms resolve within 6 months.
What is the treatment for and prognosis for adjustment disorder?
Treatment
Problem-solving counselling encourages the patient to seek solutions to stressful problems, and to consider the advantages and disadvantages of various kinds of actions.
Prognosis
Clinical experience suggests that most adjustment disorders last for several months, and a few persist for years if the stressor or its consequences cannot be removed.
What psychological therapies are used in PTSD?
Trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used
What is grief reaction?
Grief reaction is a type of adjustment disorder. It is normalfor people to feel sadness and grief following the death of a loved one and this does not necessarily need to be medicalised. However, having some understanding of the potential stages a person may go through whilst grieving can help determine whether a patient is having a ‘normal’ grief reaction or is developing a more significant problem.
What are the stages of grief?
One of the most popular models of grief divides it into 5 stages.
- Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
- Anger: this is commonly directed against other family members and medical professionals
- Bargaining
- Depression
- Acceptance
It should be noted that many patients will not go through all 5 stages.
