Stress related disorder

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STRESS RELATED DISORDERS-Acute Stress
Disorder-Adjustment Disorder

• NAME DR. SALINI BALAKRISHNAN

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TRAUMA-STRESSOR RELATED DISORDERS

• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Post Traumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorder
• Other Specified Trauma- and Stressor-Related
  Disorder
• Unspecified Trauma- and Stressor Related
  Disorder

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INTRODUCTION

• Adjustment normal psychological reactions
  involved in adapting to new
  circumstances
• Typical events where an adjustment period would
  be expected includes divorce and separation, a
  change in a job or home situation, transition
  between school and university and the birth of a
  child.
• Symptoms of normal adjustment would be mild short
  lived anxiety, depression, irritability and poor
  concentration.

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DEFINITION

• Adjustment disorders are the development of
  emotional or behavioural symptoms in response to
  an identifiable stressors occurring within 3
  months of the onset of the stressors.

Stressors
Anxiety Depression Mixed Anxiety Depression
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STRESSORS

• Ending of a relationship
• Losing or changing job
• Death of loved one
• Developing a serious illness (yourself or a loved
  one)
• Being a victim of a crime
• Having an accident
• Undergoing a major life change(such as getting
  married, having a baby, or retiring from a job)
• Living through a disaster, such as a fire, flood,
  or hurricane

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• The severity of the stressor or stressors does
  not always predict the severity of the disorder.
• The stressors may be a single event or they may
  be multiple stressors/ recurrent or continuous.
• Stressors may affect a single individual, an
  entire family, or a larger group or community.
• Symptoms may not immediately resolves after the
  termination of the stressors.

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RISK FACTORS

• age (young people have fewer established coping
  mechanisms)
• female gender
• past experiences of stressful events
• past psychiatry history
• low self-esteem
• a lack of support system
• a lack of social skills

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CLINICAL FEATURES

• Emotional

• Behavioral

• Sadness
• Hopelessness
• Lack of enjoyment
• Crying spells
• Nervousness
• Anxiety
• Worry
• Desperation
• Trouble sleeping
• Poor concentration
• Feeling overwhelming and suicidal thoughts

• Fighting
• Reckless driving
• Ignoring important task such as bills or homework
• Seeking approval from others by anyway possible
  (cheating/lying/ escaping reality)
• Avoiding family or friends
• Drug abuse
• Performing poorly in school
• Skipping school
• Vandalizing property

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DSM-V CRITERIA

• A. The development of emotional and behavioral
  symptoms in response to an identifiable
  stressor(s) occurring within 3 month of onset of
  stressor(s)
• B. These symptoms or behavioral are clinically
  significant, as evidenced by 1 or both of the
  following
• Marked distress that is out of proportion to the
  severity or intensity of the stressors, taking
  into account the external context and cultural
  factors that might influence symptoms severity
  and presentation
• Significant impairment in social, occupational or
  other areas of functioning.
• C. The stress related disturbance does not meet
  the criteria for another mental disorder
  and is not merely an exacerbation of pre-existing
  mental disorder
• D. The symptoms does not present in normal
  bereavement.
• E. Once the stressors (or its consequences) has
  terminated, the symptoms do not persist for more
  than 6 month.

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DSM-V CRITERIA

• Specifier
• With depressed mood low mood, tearfulness,
  feelings of hopelessness are predominant
• With anxiety nervousness, worry, jitteriness or
  separation are predominant
• With mixed anxiety and depressed mood
  combination of both depression and anxiety are
  predominant
• With mixed disturbance of emotion and conduct
  both emotional symptoms(ex depression) and
  disturbance of conduct are predominant
• Unspecified for maladaptive reactions that are
  not classifiable as one of the specific subtypes
  of adjustment disorder.

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DIFFERENTIAL DIAGNOSIS

• Major depressive disorder
• If an individual has symptoms that meet criteria
  for a major depressive disorder in response to a
  stressor, the diagnosis of an adjustment disorder
  is not applicable.
• Posttraumatic stress disorder and acute stress
  disorder
• Adjustment disorders can be diagnosed immediately
  and persist up to 6 months after exposure to the
  traumatic event.
• Acute stress disorder can only occur between 3
  days and 1 month of exposure to the stressor.
• PTSD cannot be diagnosed until at least 1 month
  has passed since the occurrence of the traumatic
  stressor.

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DIFFERENTIAL DIAGNOSIS

• Normative stress reactions
• When bad things happen, most people get upset.
  This is not an adjustment disorder. The diagnosis
  should only be made when the magnitude of the
  distress (e.g., alterations in mood, anxiety, or
  conduct) exceeds what would normally be expected
  (which may vary in different cultures) or when
  the adverse event precipitates functional
  impairment.

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MANAGEMENT

• Psychotherapy

• Pharmacotherapy

• Psychoeducation
• Crisis intervention
• Family and group therapies
• Support groups specific to the stressor
• Cognitive-behavioral therapy (CBT)
• Interpersonal psychotherapy

• Short term anxiolytic- Benzodiazepines
• Antidepressant medicines- SSRI

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PROGNOSIS

• The problem usually does not last longer than 6
  months, unless the stressor continues to be
  present.
• Most adults respond well to treatment and have a
  good long term prognosis, while adolescents may
  not respond well to treatment and may develop
  major psychiatric illness.

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ACUTE STRESS DISORDER
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ACUTE STRESS DISORDER

• Acute stress disorder is an abnormal reaction to
  sudden stressful events.
• The basic response of the body is the same as in
  the normal stress reaction, but the symptoms are
  more severe and last for a longer period.
• It is generally accepted that having symptoms
  after a stressful event is normal for up to about
  48 hours, but after this point the majority of
  people will have recovered
• Acute stress disorder lasts no more than 4 weeks.
  Cases that last longer are prescribed as post
  traumatic stress disorder.

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SYMPTOMS
1. THE EMOTIONAL RESPONSE

• Includes intense anxiety, restlessness,
  purposeless activity, insomnia, and panic
  attacks.
• Some patients experience depersonalization and
  derealization.

2. SOMATIC SYMPTOMS

• Reflect the sympathetic activation most commonly
  sweating, palpitations and tremor.

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3. DISSOCIATIVE SYMPTOMS

• This term is used to describe numbing and
  difficulty in recall, which are experienced as
  the feeling that the events have not really taken
  place, emotional numbing, being in a daze, and
  the inability to remember important aspects of
  the stressful events.
• The term flashbacks is applied to sudden and
  repeated re-experiencing of visual images of
  traumatic experiences, which usually cannot be
  recalled easily at other times.
• There may also be recurrent frightening dreams of
  these events.

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4. COPING STRATEGIES

• Include avoidance of reminders of the stressful
  events, and of talking or thinking about them.
• Social contacts may also be avoided, thus
  depriving the person of potential sources of
  support
• Maladaptive coping responses include flight
  (e.g. running away from the scene of a road
  accident), the release of emotion through
  histrionic or aggressive behaviour, excessive use
  of alcohol or deliberate self-harm.

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DSM-V CRITERIA

1. Exposure to actual or threatened death, serious
   injury, or sexual violation
2. Presence of nine (or more) of the following
   symptoms from any of the five categories of
   intrusion, negative mood, dissociation, avoidance
   and arousal, beginning or worsening after the
   traumatic event(s) occurred

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INTRUSION SYMPTOMS
DISSOCIATIVE SYMPTOMS

• Distressing memories
• Distressing dreams
• Dissociative reactions (eg flashback)
• Intense distress at exposure to cues

• Altered sense of the reality of ones
  surroundings or oneself
• Inability to remember important aspect of
  traumatic events

AVOIDANCE SYMPTOMS

• Efforts to avoid distressing memories, thoughts
  or feelings
• Efforts to avoid external reminders that arouse
  distressing memories, thoughts, or feelings

AROUSAL SYMPTOMS
NEGATIVE MOOD

• Sleep disturbance
• Irritable behaviour
• Hypervigilance
• Problems with concentration
• Exaggerated startle response

• Persistent inability to experience positive
  emotions

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DSM-V CRITERIA

• C. Duration of disturbance (symptoms in criterion
  B ) is 3 days to 1 month after trauma exposure.
• D. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• E. The disturbance is not attributable to the
  psychological effects of a substance (eg
  medication or alcohol) or another medical
  condition (eg mild traumatic brain injury) and
  is not better explained by brief psychotic
  disorder.

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MANAGEMENT
General Measures Provide emotional support Help with residual problems
Psychological treatments Encourage recall of, and coming to terms with, the events Help with more effective coping Cognitive behavioral therapy
Pharmacological treatments Short-term anxiolytics Antidepressants
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REFERENCES

• Kaplan Saddocks
• DSM-V
• Oxford, Psychiatry 4th edition.