Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Stress

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Stress - Key Features

1. In a patient presenting with a symptom that could be attributed to stress (e.g., headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.

20-25% of Canadians >15yrs rate daily life as “quite a bit” or “extremely” stressful.

Acute Stress

Physical Response Emotional Response
- ↑ ACTH, epi + norepi, glucocorticoids and endorphins

- ↓ Insulin+ reproductive hormones (est, prog, test)
- ↑ Cognition + memory
- ↓ Pain sensation
- ↑ Energy stores mobilized, heartrate, metabolic rate, bp, resp rate

- Denial (defense mechanism)

- Disbelief
- Shock
- Anger
- Anxiety
- Restlessness
- Confusion
- Self-doubt
- Forgetfulness
- Fear, anger and excitement

Chronic Stress

Physical Response Emotional Response Behavioural Response
Gl upset

Sleep disturbances
Muscle + Back pain
↓ libido
↓ Immune response
↑ risk developing mood disorder (GAD, MDD)
↑ serum cholesterol
↑ blood pressure
↑ platelet aggregation
↑ risk of cardiovascular events
↑ risk of DM related complications and metabolic syndrome

Mental blocks

Hopelessness, frustration
Reduced feelings of empathy
Chronic fatigue
Anger, cynicism, pessimism

Mistakes or judgment errors

Inappropriate or aggressive communication
Increased drug or alcohol use
Withdrawal, isolation
↑ difficulty maintaining healthy life style (diet, exercise, sleep)
Disordered eating

2. In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).

Stress: any demand on the body, mind and spirit to perform. Function is maintained and coping is adaptive.
Distress: Coping and adaptation processes fail to return an organism to physiological and/or psychological homeostasis.
Coping: Behavioral response to reduce stress in non-detrimental way. Function maintained.
Not coping: Appreciable decline in social, work, economic, family functioning and/or maladaptive coping (ETOH, substances, smoking, social withdrawl, etc)

A) Assess function (all domains): school, family, relationships, work, health behaviors (exercise, diet, sleep), substance use, sexual function, psychological health

B) Identify maladaptive/deleterious coping strategies/behaviors

3 main ways people cope with stress (can be adaptive or maladaptive)
Task-oriented: analyze situation and take action to deal directly with situation.
Emotion-oriented: address feelings and find social supports.
Distraction-oriented: use activities or work as distraction.

3. In patients not coping with stress, look for and diagnose, if present, mental illness (e.g., depression, anxiety disorder).

Stress has high comorbidity with anxiety, depression and psychoses
Screen for following:

Eating disorders
Panic Disorder
Acute Stress disorder (symptoms of PTSD with onset before 4 weeks and duration < 4 weeks)

Diagnostic Criteria for Post-traumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
1. 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.
2. The person's response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. Intrusive distressing recollections(young children, repetitive play)
2. Nightmares
3. Flashbacks/hallucinations
4. Intense psychologic/physiologic distress at exposure to cues resembling the event.
C. Avoidance of stimuli associated with the trauma + numbing of general responsiveness
D. Persistent symptoms of increased arousal (irritable, hypervigilant, ↑ startle, ↓ [ ]
E. Duration is more than one month.
F. Causes clinically significant distress or impairment in function.

Prognosis: Spontaneous improvement, lasts 36 months (treatment), 64 months (no treatment), > 1/3 never fully recover
(+) prognosis if: Rapid engagement of treatment, early/ongoing social support, avoidance of retraumatization,good premorbid function, and absence of psychiatric disorders or substance abuse.

Comorbidity Men (%) Women (%)
Alcohol abuse or dependence 51.9 27.9
Drug abuse or dependence 34.5 26.9


NO! Exposure therapy and psychotherapy to relive experiences = (BAD)
Behavioural and cognitive therapy (enroll families in therapy as well)
SSRI (sertraline, Fluvoxamine, paroxetine) ↓ numbing, avoidance, hyperarousal
Clonidine/Risperidone may ↓ intrusive recollections, nightmares, hypervigilance and outbursts of anger
Benzos: ↓ anxiety but no impact on core symptoms (↑ substance abuse = avoid benzos)

4. In patients not coping with the stress in their lives,
a) Clarify and acknowledge the factors contributing to the stress,
b) Explore their resources and possible solutions for improving the situation.

Stress Reduction Therapies:

Control manageable issues
Counseling/ CBT
Encourage peer social support
Breathing exercises + Progressive muscle relaxation
Mediation (mindfulness, transcendental, guided imagery)

5. In patients experiencing stress, look for inappropriate coping mechanisms (e.g., drugs, alcohol, eating, violence).

Screen for:

Substance use
Eating disorders
Anger/aggressive behaviour

Study Guide