Stress Related Psychiatric
Disorders
Lorenzo Pitts MSIII
HUCM
“To understand the stress response, we must
process a fundamental knowledge not only of
psychology but of physiology as well.”
—George Everly
Physiology of Stress
The ACTH Pathway
Anxiety Disorders
• Panic Disorder
• Phobias
• Obsessive Compulsive
disorder
• Generalized Anxiety
Disorder
First Rule Out
• Medical Causes of Anxiety Disorders
– Hyperthyroidism
– Vitamin B12 deficiency
– Hypoxia
– Neurological disorders
– Cardiovascular disease
– Anemia
– Pheochromocytoma
– Hypoglycemia
First Rule Out
• Medication or Substance-Induced Anxiety Disorders
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Caffeine intake and withdrawal
Amphetamines
Alcohol and sedative withdrawal
Other illicit drug withdrawal
Mercury or arsenic toxicity
Organophosphate or benzene toxicity
Penicillin
Sulfonamides
Sympathomimetics
Antidepressants
Panic Attack
Panic Disorder
• A 24 yr old female comes to the ER complaining
of a pounding heart, SOB, and sweating that
began while she was shopping and lasted
20mins. She expresses that she thought she
was going to die. Further questioning reveals
that she has had 6 of these episodes in the last
month and fears having another one.
Diagnosis & DSM-IV Criteria
1. Spontaneous recurrent panic attacks with no
obvious precipitant
2. At least one of the attacks has been followed
by a minimum of 1 month of the following:
– Persistent concern about having additional
attacks
– Worry about the implications of the attack
– A significant change in behavior related to the
attacks
Treatment
• Pharmacological
– Acute Initial TX of Anxiety
• Benzodiazepines- If necessary, continued for a brief
period (<2 wk if prescribed on a scheduled basis).
– Maintenance
• SSRIs, especially Paroxetine (Paxil) and Sertraline
(Zoloft) DOC for long term tx.
• Tx should continue for at least 8-12 months, as relapse
is common after discontinuation of therapy
Treatment
• Non-Pharmacological Psychotherapy
– Cognitive Therapy
– Behavioral Therapy
– Relaxation training
PHOBIAS
Specific & Social Phobia
• Phobia: irrational fear that leads to avoidance
of the feared object or situation.
• Specific Phobia: strong, exaggerated fear of a
specific object or situation
• Social Phobia: fear of social situation in which
embarrassment can occur.
Specific & Social Phobias
• A 32 yr old construction worker states that he
is terrified of heights. He came in to your
office because he recently started a project on
the 50th floor and has had trouble doing his
job.
Specific & Social Phobias
• A 25 yr old HUCM student has always felt
“shy” and avoids answering questions on
rounds. Last Thursday, he stayed home
although he had a presentation to give
because he did not want to make a “fool out
of himself” in front of his classmates.
Diagnosis & DSM-IV Criteria of
Specific Phobia
• Persistent excessive fear brought on by a
specific situation or object
• Exposure to the situation brings about an
immediate anxiety response
• Patient recognizes that the fear is excessive
• The situation is avoided when possible or
tolerated with intense anxiety
• If person under age 18, duration must be at
least 6 months.
Common Phobias
• Specific Phobias
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Fear of animals
Fear of heights
Fear of blood or needles
Fear of illness or injury
Fear of death
Fear of flying
• Social Phobias
– Speaking in public
– Eating in public
– Using public restrooms
Treatment
• Specific Phobia
– Systemic desensitization (with or without
hypnosis) and supportive psychotherapy.
– If necessary, short course of Benzodiazepines or
Beta Blockers may be used during desensitization
to help control autonomic symptoms.
Treatment
• Social Phobia
– SSRIs: Paroxetine (Paxil), Sertraline (Zoloft) both
FDA approved. Standard first-line medication
– Beta blockers are frequently used to control
symptoms of performance anxiety
– Treatment of choice is Assertiveness training a
compound of CBT.
Obsessive-Compulsive Disorder
OCD
• A 28 yr old medical student comes to your
office because he is distressed by his
repetitive checking of the car door to see if its
locked. He states that after he parks the car
and gets to his house, he feels as if the car
door is not locked and goes back to check on
it. This happens several times and has led to
his being late for his clerkships and getting
yelled at by his chief.
Common Patterns of
Obsessions & Compulsions
• Obsessions about contamination followed by
excessive washing or compulsive avoidance of
the feared contaminant
• Obsessions of doubt followed by repeated
checking to avoid potential danger
• Obsessions about symmetry followed by
compulsively slow performance of a task
• Intrusive thoughts with no compulsion.
Thoughts are often sexual or violent
Treatment
• Pharmacologic
– SSRIs are 1st line (fluoxetine, fluvoxamine, sertraline,
paroxetine, citalopram, escitalopram)
– Tricyclic antidepressants (Clomipramine)
• Behavioral Tx
– Considered as effective as pharmacotherapy. Best
outcomes often achieved with both. Exposure and
response prevention, involves prolonged exposure to
the ritual-eliciting stimulus and prevention of the
relieving compulsion.
– Relaxation techniques are employed to help the
patient manage the anxiety that occurs when the
compulsion is prevented.
Post Traumatic Stress Disorder
PTSD
• A 23 yr old female who was raped 5 months
ago complains of recurrent thoughts of that
event every time a coworker touches her. She
states this has been happening for the past 2
months often accompanied by nightmares
that wake her up at night. She feels extremely
anxious when these thoughts “pop in” and
lately has had trouble working at her job.
Diagnosis & DSM-IV Criteria
• Having experienced or witnessed a traumatic
event. The event was potentially harmful or fatal,
and the initial rxn was intense fear or horror
• Persistent reexperiencing of the event
• Avoidance of stimuli associated with the trauma
• Numbing of responsiveness
• Persistent symptoms of increased arousal
• Symptoms must be present for at least 1 month
Treatment
• Pharmacological
– TCAs- imipramine and doxepin
– SSRIs, MAOIs
– Anticonvulsants- for flashbacks and nightmares
• Non-Pharmacological
– Psychotherapy
– Relaxation training
– Support groups, family therapy
Diagnosis and Treatment of Post-traumatic
Stress Disorder
FIGURE 1.
Algorithm for the diagnosis and treatment of post-traumatic stress disorder. (DSM-IV = Diagnostic and Statistical Manual of Mental Disorders,
4th ed.; PTSD = post-traumatic stress disorder; SSRI = selective serotonin reuptake inhibitor)
PTSD vs. Acute Stress Disorder
PTSD
• Event occurred at any time
in past
• Symptoms last GREATER
than 1 month
Acute Stress Disorder
• Event occurred LESS than 1
month ago
• Symptoms last LESS than 1
month
PTSD in the Military
• A case of PTSD is defined as an individual having
at least two outpatient visits or one or more
hospitalizations at which PTSD was diagnosed.
The threshold of two or more outpatient visits is
used to increase the likelihood that the individual
actually had PTSD
• The Army has 67% of the cases, the Air Force has
9%, the Navy has 11%, and the Marines have
13%.
Annual New Post-Traumatic Stress
Disorder Diagnoses in All Services
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As of September 7, 2010
Year
Not Deployed
Deployed
2000
1,614
0
2001
1,703
0
2002
1,709
138
2003
1,524
1,169
2004
1,577
3,901
2005
1,648
6,788
2006
1,714
7,762
2007
2,069
11,660
2008
2,371
14,183
2009
2,432
13,595
2010
1,423
7,739
Total
21,784
66,935
Source: Personal communication with Dr. Michael Carino, Army Office of the
Surgeon General, September 21, 2010. Data source is the Defense Medical
Surveillance System (DMSS).
PTSD in the Military
• According to the Department of Veterans
Affairs, experts believe PTSD occurs in:
– 11-20% of Veterans that served in Operation Iraqi
Freedom and Operation Enduring Freedom.
– 10% of Desert Storm Veterans.
– 30% of Vietnam Veterans.
Thank you
References
• www.emedicine.com
• http://www.aafp.org/afp/2003/1215/p2401.h
tml#afp20031215p2401-f1
• http://www.psychiatryonline.com/pracGuide/
pracGuideTopic_9.aspx
• First aid for the psychiatry clerkship