Severe stress response and adjustment disorders

Acute stress response
This disorder arises as a reaction to exceptionally strong physical or psychological stress. It develops even in patients who have never suffered from any mental disorder in the past. The course is mostly of a short-term nature, usually disappearing after a few hours or days at the most.

The triggering factor is usually a strong experience that is associated with a threat to the affected person or someone close to them (fire, car accident, rape) or a change in social relations (divorce, job loss). The primary vulnerability varies among those affected, and this results in a different response to a stressful event. A greater risk occurs in persons weakened by long-term illness or physical or mental strain.

In the first stage, the patient enters a state of stupor, which is accompanied by a narrowed consciousness, impaired attention and mild disorientation. Another stage follows, when the affected person becomes emotionally numb or, in the opposite case, the so-called "escape reaction", manifested by tachycardia , sweating and tremors. Symptoms usually disappear after a short time. As first aid to the disabled, we provide crisis intervention or calming psychotherapy. A single dose of benzodiazepines (eg 10 mg benzodiazepam) may also be effective.

Post-traumatic stress disorder
Posttraumatic stress neurosis (PTSD - Posttraumatic Stress Disorder) is a delayed reaction to an extremely stressful event. The first description of this disorder was based on war traumatic neurosis. The development occurs after a longer period of time than in the case of an acute stress reaction, and can last several months. The sufferer relives the stressful event, returning to it in thoughts or dreams, although the memories may be disturbed. Lifetime course is estimated in 1-9% of patients. Obsessive compulsive disorder, agoraphobia , panic disorder or depressive states may also develop at the same time.

Course and prognosis
Post-traumatic stress neurosis develops several weeks to months after the stressful event.

It takes place in 3 stages:


 * 1) non-specific reaction accompanied by anxiety;
 * 2) after 4 to 6 weeks feelings of helplessness come, the sufferer loses control over himself, behaves evasively, may feel angry;
 * 3) chronic PTSD associated with demoralization and invalidation of the sufferer, transformation of life values.

According to statistics, in one third of patients the symptoms disappear over time, approximately 40% continue with mild problems and 10% have severe problems. The triggering factor is usually a stressful event (up to 30% are victims of natural disasters), but genetic disposition also plays an important role. It is reported to contribute up to 13-34% to the development of the disorder. People who have previously been exposed to strong stressful situations are more likely to develop PTSD.

The noradrenaline neurotransmitter system is responsible for the increased response to stressful stimuli. It causes tachycardia, hypertension, an increased level of adrenaline and noradrenaline metabolites is found in the urine. Negative symptomatology is controlled by the endogenous opiate system, causing the patient to lose affectivity, a tendency to isolation, and abulia. Serotoninergic dysfunction causes positive symptomatology, manifested by irritability and fits of rage.

Diagnostics
Above all, it is necessary to rule out an organic mental illness, such as an organic personality disorder, delirium or anamnestic syndrome. Similar symptoms can also arise as a result of physical injury, e.g. after head injuries. A depressive episode usually develops at the same time and the symptoms may overlap to a large extent, in which case it is advisable to diagnose and treat both at the same time. Affected people may even develop a phobic relationship to a given place or situation and may react with a panic attack when confronted with these stimuli.

Treatment
As part of the treatment, the most appropriate combination of psychotherapeutic procedures and administration of the following psychotropic drugs:


 * antidepressants : TCA (imipramine, amitriptyline), MAOI, RIMA, SSRI - with longer-term use (at least 2 months) reduce the irritability of those affected, maintenance treatment should then continue for at least 1 year;
 * antimanic drugs : lithium, carbamazepine, valproate – affect the impulsivity of the sufferer;
 * beta blockers : clonidine, propranolol – suppress vegetative symptoms.

Benzodiazepines are unsuitable for long-term use and their prescription is not recommended, neuroleptics (haloperidol, pimozide) can be used instead. Very important is early crisis intervention and supportive psychotherapy, which can mitigate the course from the very beginning. Specific procedures have also been developed within brief dynamic and cognitive behavioral therapy.

Customization failure
Adjustment disorder also arises as a result of some life event to which the patient reacts with disproportionate intensity and duration. Difficulties become apparent after approximately 1 month and can lead to incapacity for work. Symptoms can vary:


 * depressive – tends to be short-term (up to 1 month) and prolonged (up to 2 years);
 * anxious – anxious and depressive reactions are mixed, disorders of other emotions also occur (lasting for several months);
 * behavioral disorders – accompanied by aggression and antisocial behavior.

The most important thing to manage this disorder is psychotherapeutic action, especially the ability to empathize and a human approach.

Related Articles

 * Depression
 * Anxiety disorders
 * Phobic anxiety states
 * Panic disorder