1. STRESS-RELATED DISORDERS DR. JAWAHER A. AL-NOUH Consultant psychiatrist-clinical assistant professor -department of psychiatry K.S.U-K.K.U.H

2. OBJECTIVES : - What is stress?.-Reaction to stress: normal and pathological. -Grief. Adjustment disorders. -Acute stress disorder. -Post traumatic stress disorder( PTSD).

4. “…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,

5. 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

6. TYPES OF STRESSORS Career Pressures

7. 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)

8. 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.

9. 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.

10. SPECIFY IF:  Acute: if the disturbance lasts less than 6 months.  Chronic: if the disturbance lasts for 6 months or longer.

11. 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

12. 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.

13. Differential Diagnosis  MDD.  Acute stress disorder and PTSD.

14. Treatment:

15. SUMMARY OF ADJ.DIS.

16. 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.

17. *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.

18. 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 

19. 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)

20. D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:  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.

21. ONSET: P T S D B:Delayed onset Post – traumatic Stress disorder A Acute stress disorder if onset of symptoms is at least 6 months after the stressor Minimum One month and less than 6 months. With in one Month of the stressor.

22. DURATION: P T S D( Chronic) PTSD( Acute) Acute stress disorder if duration of symptoms is 3 months or more. duration of symptoms is less than 3 month and more than one month. 2days-4 weeks

23. SUMMARY OF THE DIAGNOSIS: Re-experiencing, avoidance, hyper arousal.

24. 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.

25. EPIDEMIOLOGY : the lifetime prevalence:  8 % of the general population. Risk Factors: 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

26. TREATMENT:

27. Encouragement to discuss the event: support and reassurance Pharmacotherapy: SSRI-BZD for short period. Psychotherapy.

28. COMORBIDITY: high rates two thirds (66%) having at least two other disorders. Common:  depressive disorders  substance-related disorders  other anxiety disorders  bipolar disorders

29. 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  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.

30. ASK:

31. 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

32. 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

33. 3- Resolution (months, years) Have grieved Return to work Resume old roles Acquire new roles Re-experience pleasure Seek companionship and love of others

34. 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.

35. NORMALREACTION TO IMPENDING DEATH: 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)

36. HELPING THE BEREAVED AND DYING PATIENTS - 1-facilitate normal process of grief. 2-support 3-consider practical problems 4-medications

37. BEREAVEMENTORDEPRESSION? 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

38. 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

39. Reference: BASIC PSYCHIATRY by prof.m.Alsughayer –second edition Pages189-202

40. THANK YOU