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.
|Physical Response||Emotional Response|
|- ↑ ACTH, epi + norepi, glucocorticoids and endorphins
- ↓ Insulin+ reproductive hormones (est, prog, test)
|- Denial (defense mechanism) |
|Physical Response||Emotional Response||Behavioural Response|
|Mistakes or judgment errors |
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: |
|B. The traumatic event is persistently re-experienced in one (or more) of the following ways: |
|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).
- Substance use
- Eating disorders
- Anger/aggressive behaviour