We will primarily discuss acute stress disorder and post-traumatic stress disorder and then we will discuss some of the effects of chronic stress on the body as well as the stress response.
Acute stress disorder is a an acute stress reaction that occurs within the first 4 weeks after a traumatic stress event. Some examples may be vehicular accident, sexual assault, robbery etc.
The difference between ASD and PTSD is that PTSD is diagnosed after 4 weeks.
Adjustment disorder is a state of stress that interferes with social functioning after a period of adaptation to a significant life change/stressful event such as bereavement or separation. However, the stressor is not severe or outside of the normal human experience. For example, losing your job or having a family member pass away.
ASD is after an exceptional physical/mental stressor that is considered “abnormal” to the typical human experience.
😷 Presentation
DSM-V breaks it down into 5 categories:
- Intrusive thoughts - nightmares and flashbacks.
- Dissociation - feeling out of it, and slowing of time.
- Negative mood
- Avoidance - efforts to avoid distressing memories, thoughts or feelings associated with the event.
- Arousal - hypervigilance, insomnia, irritability, lack of concentration, easily startled.
🧰 Management
🥇 Trauma-focused CBT - first-line
- Benzodiazepines - sometimes used for the acute anxiety symptoms such as agitation and sleep-disturbance. Should not be used long term due to addictive potential. NICE also does not recommended to prevent PTSD.
PTSD occurs after a traumatic event as well, and is the continuation of ASD. One of the diagnostic criteria for PTSD is that the symptoms are present for more than 4 weeks.
😷 Presentation
The same as ASD symptoms. Other people may report the individual to seem depressed and/or to be abusing alcohol or drugs.
🧰 Management
🥇 Trauma-focused CBT - first-line.
Eye-movement desensitisation and reprocessing - rhythmic bilateral stimulation using eye movements, and other forms of stimulation such as tones or taps, accelerates a learning process while the patient focuses on trauma memory. This reduces the vividness and emotions of the memory.
- Venlafaxine
- SSRIs - such as sertraline.
Pathophysiology of stress
The stress response is initiated by the CNS and endocrine systems.
Perceived stressors initiate an anticipatory response by the limbic system that activates the locus coeruleus to release noradrenaline.
Real stressors can begin in the limbic system again and relay to the paraventricular nucleus of the brain which then stimulates the locus coeruleus as well as the peripheral neuroendocrine response.
The neuroendocrine response begins with the hypothalamus releasing CRH → anterior pituitary releases ACTH → adrenal cortex (zona fasciculata) releases cortisol, cortisone and corticosterone.
The adrenal medulla is also activated to release noradrenaline and adrenaline.
The effects of these hormones include:
- Elevated BP and increased HR
- Bronchodilation and increased RR
- Increased glycaemic levels due to glycogenolysis and gluconeogenesis and lipolysis.
- CNS arousal - hypervigilance, irritability.
- Decreased inflammatory and immune responses
These can be positive in the short-term to deal with the stressor. However, in the long-term the stress response can be pathological.
Long-term stress may lead to:
- Headaches
- Ulcers in the mouth - due to prolonged vasoconstriction and necrosis
- Renal failure - due to reduced blood supply to the kidney also.
- Increase gastric secretions - leading to gastric ulcers.
- Dysrhythmias in the heart.
- It may aggravate chronic infections and disorders such as HSV, asthma, MS, RA, SLE, UC, eczema, acne.
- Infections are more likely due to depressed immune system by cortisol.
- Impaired healing