Psychological Reaction to Stress
Stressful events or adverse ‘life events’ are known to contribute to the aetiology of many psychiatric disorders, including mood disturbance and anxiety disorders.
Generally, the individuals affected have some vulnerability to the mental illness as a result of genetic factors, childhood experiences, or drug or alcohol abuse. The stress may precipitate an episode of illness. Hoses with high vulnerability may become ill in the absence of stressful event, or with a relatively minor stress. In contrast the reactions to stress described here are a direct consequence of the stressful event, and would not arise without it. Three types of disorders will be described:
- Acute stress reaction
- Post -traumatic stress disorders (PTSD) which occurs in response to exceptionally severe stress
- Adjustment disorders which occur at the time of a life change or following a stressful event.
It is normal to react to stress in an emotional way. The disorders described here are considered to be abnormal reactions to stress either because the reaction is extreme or prolonged, or because it prevents the individual from functioning at home or work in their usual way. An abnormal reaction to stress may occur because of the nature of the stressor, or the resources of the individual to cope with it, and often a combination of the two Control over events
The stressor may be unusually intense, such as a combat situation or a natural disaster. Less intense events may be made more stressful by a long duration, or by a lack of control over events. Individual coping abilities are influenced by personality characteristics and previous experiences of stress and methods of coping with it. Stressful events are generally more difficult to cope with if they arise against a background of social difficulties, lack of social support or even physical illness (remember the bio-psycho-social model, for causation and management).
1. Acute Reaction to Stress:
This disorder is rarely seen by mental health professionals, but may present to primary health care (PHC). It is short-lived, with symptoms settling within hours or at most couple of days (ICD-10). The symptoms are severe, often with an initially dazed state, followed by a variety of reactions from stupor to marked agitation. Panic attacks are common. The stress that precipitates an acute stress reaction is often an overwhelmingly traumatic physical or psychological experience, such as an assault, accident or bereavement. In most cases no treatment is required as the symptoms settle spontaneously (depending on the individual). If medical help is sought, a short course of BDZ or propranolol (a ? blocker) is an appropriate treatment; with support.
2. Post- Traumatic Stress Disorders (PTSD):
PTSD occurs in response to an extremely stressful event, beyond the realms of usual experience that would be distressing to most people. This might include a serious accident or assault in which the life of the individual or their family is threatened, or man-made or natural disaster.
There is often a delay of days or weeks before the symptoms begin, although generally the disorder is established within six months of the stressor and runs a chronic, fluctuating course. The range of symptoms that are found could be arranged under three broad headings:
- v Avoidance behaviour:
- Avoids reminders of trauma
- Loss of interest in normal activities
- Detachment from family and friends
- v Re-experiencing the trauma:
- Intrusive recollections
- Distress at encountering any reminder of the trauma
- v Anxiety:
- Automatic arousal
- Poor concentration
- Exaggerated startle response
The anxiety symptoms are prominent, and this may demonstrate itself with irritability, wariness and an exaggerated startle reflex. Insomnia is common, with difficulties in both falling asleep (anxiety) and staying asleep or waking up early (depression). Nightmares are common. Recurrent thoughts about the traumatic event are characteristic of PTSD. Vivid memories come to mind repeatedly despite attempts to block them out, and these are often accompanied by the emotions that were experienced at the time. Very intense and distressing flashbacks can occur, that can feel though the trauma is happening or about to happen again. Any reminders of the trauma are avoided, and this can result in social isolation. Depressive disorder is a common co-morbidity, and substance misuse may be an effort to cope with the symptoms.
The presence of extreme stress is the key aetiological factor in PTSD (remember the vulnerability to mental illness diagram). The greater the stress, the more likely it is that PTSD will develop.
There is some evidence that it is more likely to develop:
- in the aftermath of man-made as opposed to natural disaster
- if there are long-term stressful consequences to deal with, such as bereavement, disability, court case, loss of home or job,
- If there is a history of mental illness
- If there is lack of social support, skills.
Treatment of PTSD include: (Bio-psycho-social)
- v Biological: Medications, depending on the presentation. SSRI are licensed, but in general treat depending on the symptomology ( i.e. intrusive thoughts treat as OCD, anxiety symptoms treat as GAD, depressive symptoms ,treat as Depressive disorder)
- v Psychological: CBT is effective and has strong evidence base. Debriefing is controversial and there is evidence for and against although at current time its use is diminishing. EMDR (Eye Movement Desensitization Reprocessing) is affective and is commonly a choice in specialized PTSD clinics. Supportive therapy is useful.
- v Social: social support including patient’s finance, work, accommodation and social network are extremely important.
3. Adjustment Disorders:
Are abnormal response to significant life changes, such as a bereavement, marital separation, redundancy or starting a new job or college. The abnormal response takes the form of an emotional disturbance, with symptoms of anxiety, depressed mood or feeling unable to cope. The symptoms are not severe enough to merit a diagnosis of depressive disorder or anxiety disorders, but must interfere with the patient’s ability to function normally at home, work or in social situations before a diagnosis can be made
Adjustment disorders usually begin within a month of precipitating event, and in most cases resolve within six month, simple psychological and social treatment, such as providing the patient with support, an opportunity to talk about their feelings and a practical problem-solving approach are often all that is required.
Loss of a close relative or friend is always an extremely stressful event that will inevitably provoke a marked emotional response. This is, of course, entirely normal, and the majority cope with their grief without any professional help.
The normal grieving process: (e.g. death of a husband)
- Shock. Feeling numb ‘I can’t believe he’s gone’
- Anger. ‘why did he leave me when I needed him’
- Searching. For his face in a crowd, and vivid dreams that he is alive again
- Guilt. ‘if only I had called the doctor earlier’
- Sadness. With many of the features of depression
- Acceptance. Gradual return to normal life
Needless to say, that the process above is simplified. Some individuals will ‘skip a stage’, others will not follow the above order and some will go back to a previous stage.
Bereavement can closely resemble depressive illness with persistent low mood, insomnia, loss of appetite and thoughts of hopelessness and guilt. The only treatment required, however, is support, an opportunity to talk and reassurance that it is part of a normal process of adjustment that will gradually improve.
Grief is considered to be abnormal if:
- There is a considerable delay before it begins. For example, a mother of two young children felt unable to grieve after the death of her mother because she did not want to distress the children. She put all thoughts of her mother to the back of her mind, and got on with life until 18 month later she becomes extremely depressed, tearful and felt life was no longer worth living after the death of her pet. The suppressed grief for her mother was finally expressed, but at an inappropriate time.
- Symptoms are very intense. For example, an elderly man, distressed after the sudden death of his wife, became increasingly concerned with his own death. He began to believe that his insides were rooting away and that he would die soon (Coatard’s syndrome- a severe form of depression). Theses nihilistic delusions required inpatient psychiatric treatment.
- Symptoms are very prolonged. It is difficult to apply fixed time limit on normal grief, as it will vary depending upon the individual and the circumstances of the bereavement. Generally , however, the most intense feeling of grief will be beginning to resolve, and normal activities will be resumed by about six month. Grief may become stuck at one stage of the process, for example there may be prolonged feelings of numbness and shock, and an inability to accept the reality of the loss
An Abnormal grief reaction is more likely to arise if:
- Ø The death was sudden
- Ø The relationship with the dead person was overly dependent or difficult in some way
Bereavement therapy is a brief form of psychotherapy which focus specifically upon the bereavement, encourage the individual to talk through the events leading up to and following the death in detail, and guiding them through the normal grief process, for example by encouraging ventilation of feeling of anger and guilt
Other psychological treatments include support groups, CBT and IPT (Inter Personal Therapy).
1. Stevens L, Rodin. Psychiatry: An illustrated colour text, Churchill Livingstone 2001
2. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006