Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Stress

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 Headaches Lethargy 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 Boredom Reduced feelings of empathy Chronic fatigue Anger, cynicism, pessimism Depression Nervousness Self-hate Guilt	Mistakes or judgment errors Impulsiveness Inappropriate or aggressive communication Apathy 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:

MDD

Eating disorders

GAD

Panic Disorder

Phobias

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

PTSD

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

Treatment:

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:

Exercise!!!

Control manageable issues

Counseling/ CBT

Encourage peer social support

Massage

Breathing exercises + Progressive muscle relaxation

Mediation (mindfulness, transcendental, guided imagery)

Acupuncture

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

Screen for:

Substance use

ETOH

Overworking

Eating disorders

Anger/aggressive behaviour

Smoking

Study Guide

Stress