STRESS-RELATED DISORDERS
DR. JAWAHER A. AL-NOUH
Consultant psychiatrist-clinical assistant professor
-department of psychiatry
K.S.U-K.K.U.H
•
OBJECTIVES:
-What
is stress?
.-Reaction to stress: normal and pathological.
-Grief.
Adjustment disorders.
-Acute stress disorder.
-Post traumatic stress disorder( PTSD).
“…a sociopsychophysiological phenomenon. It is a
composite of intellectual, behavioral, metabolic, immune, and
other physiological responses to a stressor (or stressors) of
endogenous or exogenous origins. The stressors may involve
thoughts and feelings or may be a perceived threat or some
other condition such as cold. The response generally serves
a protective, adaptive function.
Lindsay, Carrieri-Kohlman,
STRESS
“….stress is the nonspecific response of
the body to any demand, whether it is
caused by, or results in pleasant or
unpleasant conditions.”
Hans Selye, MD
TYPES OF STRESSORS
Career Pressures
Adjustment Disorders




The adjustment disorders: emotional response
to a stressful event.
the stressor involves financial issues, a
medical illness, or a relationship problem.
the symptoms must begin within 3 months of the
stressor.
It can be :acute(6monthes)or chronic(more
than 6monthes)
Epidemiology




can occur at any age, but are most frequently diagnosed in
adolescents.
common precipitating stresses: school problems, parental
rejection and divorce, and substance abuse, marital problems,
divorce, moving to a new environment, and financial
problems.
one of the most common psychiatric diagnoses for disorders
of patients hospitalized for medical and surgical problems.
from 2 to 8 percent of the general population.
DSM-IV-TR DIAGNOSTIC CRITERIA FOR
ADJUSTMENT DISORDERS


A The development of emotional or behavioral symptoms in
response to an identifiable stressor(s) occurring within 3 months
of the onset of the stressor(s).
B These symptoms or behaviors are clinically significant as
evidenced by either of the following:
 marked distress that is in excess of what would be expected
from exposure to the stressor
 significant impairment in social or occupational (academic)
functioning



C The stress-related disturbance does not meet the criteria for
another specific Axis I disorder and is not merely an exacerbation
of a preexisting Axis I or Axis II disorder.
D The symptoms do not represent bereavement.
E Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6 months.
SPECIFY IF:


Acute: if the disturbance lasts less than 6 months.
Chronic: if the disturbance lasts for 6 months or longer.
ADJUSTMENT DISORDERS ARE CODED BASED
ON THE SUBTYPE
- selected according to the predominant symptoms.
- 1-With depressed mood(low mood, tearfulness)
2-With anxiety ( agitation. fearfulness)
3-With mixed anxiety and depressed mood
- (mainly in adults)
4-With disturbance of conduct( in adolescents)
5-With mixed disturbance of emotions and conduct
6-Unspecified:
- -in children and the elderly: physical symptoms
Course and Prognosis:



With appropriate treatment, the overall prognosis of an
adjustment disorder is generally favorable.
Most patients return to their previous level of
functioning within 3 months.
Some persons (particularly adolescents) who receive a
diagnosis of an adjustment disorder later have mood
disorders or substance-related disorders. Adolescents
usually require a longer time to recover than adults.
Differential Diagnosis


MDD.
Acute stress disorder and PTSD .
Treatment:
SUMMARY OF ADJ.DIS.
The stressors are sufficiently overwhelming to affect
almost anyone.
arise from experiences in war, torture, natural
catastrophes, assault, rape, and serious accidents, for
example, in cars and in burning buildings.
*A:
The person has been exposed to a traumatic event in which both of the following were
present:
 the person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others
 the person's response involved intense fear, helplessness, or horror.
Note: In children, this may be expressed instead by disorganized or agitated
behavior.
B:
The traumatic event is persistently re-experienced in one (or more) of the following ways:
 recurrent and intrusive distressing recollections of the event, including images, thoughts,
or perceptions. Note: In young children, repetitive play may occur in which themes or
aspects of the trauma are expressed.
 recurrent distressing dreams of the event. Note: In children, there may be frightening
dreams without recognizable content.
 acting or feeling as if the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or when intoxicated). Note: In
young children, trauma-specific reenactment may occur.
 intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
 physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event

C:Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by three (or more) of the following:
 efforts to avoid thoughts, feelings, or conversations associated with the
trauma
 efforts to avoid activities, places, or people that arouse recollections of the
trauma
 inability to recall an important aspect of the trauma
 markedly diminished interest or participation in significant activities
 feeling of detachment or estrangement from others
 restricted range of affect (e.g., unable to have loving feelings)
 sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
D Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:

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difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hyper vigilance
exaggerated startle response
F The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
ONSET:
Acute stress
Post –
traumatic
PTSD
disorder
Stress
disorder
A
With in one
Month of the
stressor.
Minimum
One month
and less than
6 months.
B:Delayed
onset
if onset of
symptoms is
at least 6
months after
the stressor
DURATION:
Acute stress disorder
2days-4 weeks
PTSD(Acute)
duration of
symptoms is
less than 3
month and
more than
one month.
P T S D(Chronic)
if duration of
symptoms is 3
months or more.
SUMMARY OF THE DIAGNOSIS:
Re-experiencing,
avoidance,
hyper arousal.
DIFFERENTIAL DIAGNOSIS:
R/O organic disorders




head injury during the trauma.
Epilepsy
alcohol-use disorders
other substance-related disorders (Acute intoxication or withdrawal)
panic disorder and generalized anxiety disorder
Major depression is also a frequent concomitant of PTSD.
borderline personality disorder, dissociative disorders, and factitious
disorders.
EPIDEMIOLOGY :
the lifetime prevalence:
 8 % of the general population.
Risk Factors: single, divorced, widowed, socially withdrawn, or of low socioeconomic
level.
The most important risk factors
are the severity, duration, and proximity of a person's
exposure to the actual trauma
TREATMENT:
Encouragement to discuss the event: support and
reassurance
Pharmacotherapy: SSRI-BZD for short period.
Psychotherapy.
COMORBIDITY:
high rates
two thirds (66%) having at least two other disorders.
Common:
 depressive disorders
 substance-related disorders
 other anxiety disorders
 bipolar disorders
PROGNOSIS
Symptoms can fluctuate over time and may be most intense during periods of
stress.
Untreated,




about 30 percent of patients recover completely,
40 percent continue to have mild symptoms,
20 percent continue to have moderate symptoms,
10 percent remain unchanged or become worse.
After 1 year, about 50 percent of patients will recover.
A good prognosis

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rapid onset of the symptoms,
short duration of the symptoms (less than 6 months),
good pre-morbid functioning,
strong social supports
absence of other psych.disorder. medical, or substance-related disorders or other risk factors.
ASK:
BEREAVEMENT, GRIEF, AND MOURNING:
• psychological reactions of those who survive a
significant loss.
• mourning is the process by which grief is resolved.
• Bereavement literally means the state of being
deprived of someone by death and refers to being
in the state of mourning
STAGES OF GRIEF:
1-Shock and denial (minutes, days, weeks)
Disbelief and numbness
and protest
2-Acute distress (weeks, months)
Waves of somatic distress
Withdrawal
Preoccupation
Anger
Guilt
Lost patterns of conduct
Restless and agitated
Aimless and amotivational
Identification with the bereaved
3- Resolution (months, years)
Have grieved
Return to work
Resume old roles
Acquire new roles
Re-experience pleasure
Seek companionship and love of others
PATHOLOGICAL GRIEF:
-Abnormally intense grief: MDD
-prolonged grief.>6 months
-Delayed grief : appear>2weeks after the death.
-Distorted grief. Unusual picture,e.g hostility. Over activity.
NORMAL REACTION TO IMPENDING DEATH:
• Stage 1: Shock and Denial(I feel fine)
• Stage 2: Anger(why me?)
• Stage 3: Bargaining (I will give any thing for more time)
• Stage 4: Depression(nothing worked)
• Stage 5: Acceptance (I cant fight it)
HELPING THE BEREAVED AND DYING PATIENTS
1-facilitate normal process of grief.
2-support
3-consider practical problems
4-medications
-
BEREAVEMENT OR DEPRESSION ?
In bereavement :
 NO morbid feelings of guilt and worthlessness, suicidal ideation, or
psychomotor retardation.
 Dysphoria often triggered by thoughts or reminders of the deceased.
 Onset is within the first 2 months of bereavement.
 Duration of depressive symptoms is less than 2 months.
 Functional impairment is transient and mild.
 No family or personal
Laughter and tears are both
responses to frustration and
exhaustion . . .I myself prefer to
laugh, since there is less
cleaning up to do afterward.”
-Kurt Vonnegut
Reference:
BASIC PSYCHIATRY by prof.m.Alsughayer
–second edition
Pages189-202
THANK YOU