Stress Reactions

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Acute stress reaction

This is an acute reaction which occurs rapidly (minutes to hours) after a sudden and stressful event.

– This can include sexual assault, an injury, a near-death experience etc.

– This leads to several symptoms in response which usually arise very quickly and terminate within 3 days

 

Symptoms:

– Initial state of being dazed and confused

– Purposeless overactivity and withdrawal

– Intense brief anxiety

– Autonomic arousal –> sweating, dry mouth, vomiting

 

Management – Help patient to re-orientate with trauma-focussed CBT

Prognosis – Most cases resolve rapidly within 3 days. If symptoms persist > 1 month, leads to PTSD

 

Post-traumatic stress disorder (PTSD)

This is a chronic condition that occurs following a traumatic event e.g. sexual assault, near death experience

– These events get stored as emotionally charged memories which the patient re-experiences

 

Symptoms – These must be present >1 month

– Persistent intrusive thoughts and re-experiencing –> flashbacks, nightmares and intrusive images

– Autonomic hyperarousal –> persistent activation gives startle, hypervigilance, insomnia

– Avoidance –> patient avoids situations and stimuli associated with the event

– Emotional detachment –> feeling detached from people and lack of ability to experience feelings

– Higher risk of depression, substance misuse, unexplained physical symptoms

 

Management:

– 1st line is trauma-focused CBT (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy

– The aim is to recall these memories and emotionally resolve them

 

Adjustment disorder

This is a condition which encompasses the abnormal psychological symptoms which occur in response to life adversity (e.g. job loss, divorce etc.)

– Symptoms occur within weeks of a stressful life events and last < 6 months

– The symptoms mimic those of anxiety and depression, but they are of lower severity and the patient will typically overcome them within 6 months

 

Symptoms:

– Anxiety –> autonomic arousal, insomnia, hypervigilance

– Depression –> sadness, tearfulness, anhedonia, fatigue

 

Diagnosis

– Only made when symptoms are not enough to justify diagnosis of anxiety or depression

 

Management:

– 1st line is encouraging ventilation of feelings and making problem-solving strategies

– 2nd line is CBT 

 

Abnormal Grief Reaction

This is an adjustment disorder which specifically occurs after a bereavement

– It is characterised by a prolonged grief of greater intensity than would occur in other people

– People are left feeling numb, shocked and confused about their role in their life.

 

Normal grief occurs in 5 stages: Shock and disbelief –> Anger –> Guilt –> Sadness –> Acceptance

– This last <2 years and does not require specific management other than support.

 

In abnormal grief reaction, grief is delayed, greater intensity and lasts > 2 years. More likely where:

– Relationship with the deceased was difficult

– Sudden death

– Normal grieving was constrained (e.g. putting on a brave face for the children)

 

Management – CBT

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