Psychosocial stressor
Any life event, condition or circumstance that places a strain on a person’s current coping skills
Traumatic stressor
Occurs outside the range of normal human experience, with a magnitude that means it would be experienced as traumatic by most people
Includes natural disasters, physical or sexual assaults, serious RTAs, terrorist attacks, torture and military combat
Adjustment disorder
An inability to cope, adapt or adjust to a change in circumstance, out of proportion with the original stressor or causing significant disturbance to social or occupational functioning
Mood and/or anxiety symptoms must occur within 1 month of the original stressor (ICD-10; DSM-IV says 3m), and usually resolve within 6m of onset
Many people with adjustment disorder also experience suicidal ideation
Acute stress reaction
An initial ‘dazed’ state followed by disorientation and narrowing of attention with inability to process external stimuli. Sometimes followed by either a period of diminished responsiveness or psychomotor agitation and overactivity
Symptoms develop immediately after, or within a few minutes of a traumatic stressor, and begin to diminish after 24-48hours
When do the symptoms of PTSD begin?
Usually after 1 month, but within 6 months, of a traumatic stressor
Symptoms of PTSD (5)
Repetitive re-experiencing of the traumatic event in the form of:
- Flashbacks (intrusive, unwanted memories, vivid mental images or dreams of the original experience)
- Distress caused by internal or external cues that resemble the stressor
- Hallucinations and illusions
- Avoidance of stimuli associated with the stressor
- Amnesia for aspects of the trauma
- Emotional numbness and social withdrawal
- Increased arousal (insomnia, angry outbursts, hyper vigilance, poor concentration, exaggerated startle response)
Ddx for PTSD
Head injuries (may have also been caused by the initial trauma)
Epilepsy
Comorbid substance misuse
Dissociative amnesia
Partial or complete memory loss for events of a traumatic or stressful nature not due to normal forgetfulness, organic brain disorders or intoxication
Dissociative fugue
Rare disorder characterized by amnesia for personal identity, including memories and personality. Self-care and social interaction are maintained. Usually short-lived (hours to days), but can last longer. Very often involves seemingly purposeful travel beyond the
individual’s usual range, and in some cases a new identity may be assumed
Dissociative stupor
Severe psychomotor retardation characterized by extreme unresponsiveness, lack of voluntary movement and mutism, not due to a physical or psychiatric disorder (that is,
not due to depressive, manic or catatonic stupor)
Dissociative anaesthesia and sensory loss
Cutaneous or visual sensory loss that does not correspond to anatomic dermatomes or known neurological patterns
Dissociative motor disorders
Partial or complete paralysis of one or more muscle groups not due to any physical cause
Dissociative convulsions (psychogenic non-epileptic seizures)
Used to be known as ‘pseudoseizures’; however, the name has been changed because of concerns that the term ‘pseudo’ implies a degree of voluntary control (which is not the case). May present similarly to epileptic seizures but tongue-biting, serious injury and urinary incontinence are uncommon. There is also absence of epileptic activity on the electroencephalogram (EEG)
Ganser’s syndrome
Complex disorder characterized by ‘approximate answers’, e.g. when asked what colour the grass is, an approximate response will be ‘blue’
Multiple personality disorder (dissociative identity disorder)
Apparent existence of two or more personalities within the same individual. This is a rare and highly controversial diagnosis
Depersonalisation
Feeling yourself to be strange or unreal
May be caused by psychiatric illness (e.g. depression, anxiety, schizophrenia), physical illness (e.g. epilepsy), psychosocial stress and substance abuse
Derealisation
Feeling that external reality is strange or unreal
May be caused by psychiatric illness (e.g. depression, anxiety, schizophrenia), physical illness (e.g. epilepsy), psychosocial stress and substance abuse
ICD-10 diagnosis of a dissociative disorder
Evidence of a psychological causation (stressful event or disturbed relationship) in association with the onset of dissociative symptoms
Before accepting the diagnosis, a psychiatric or physical illness must be sought and excluded
Parke’s 5 stages of normal bereavement
- Alarm - highly stressed emotional state and physiological arousal (increased HR and BP)
- Numbness - a form of self-protection against the acute pain of loss
- Pining - being constantly reminded of, and preoccupied with, the deceased, with pangs of grief and intense anxiety
- Depression and despair - although most people will meet the criteria at some stage for a depressive episode, this should not be considered pathological
- Recovery and reorganisation - acceptance of loss, return to normal function, with grief only returning occasionally
Symptoms that suggest the development of a major depressive episode, rather than a normal bereavement reaction (6)
- Guilt (other than events surrounding the death)
- Suicidal ideation (other than feeling better off dead or wanting to be with the deceased)
- Preoccupation with worthlessness
- Marked psychomotor retardation
- Prolonged and marked functional impairment
- Hallucinatory experiences (other than transiently seeing or hearing the deceased)
How does experiencing a stressful event change your risk of getting depression?
The risk of developing depression increases 6x in the 6months following a stressful event
Ddx for patients presenting with a reaction to stress or trauma
Adjustment disorder Acute stress reaction Post-traumatic stress disorder Normal bereavement reaction Dissociative (‘conversion’) disorder Exacerbation or precipitation of other psychiatric illness: • Mood disorders • Anxiety disorders • Psychotic disorders (especially acute and transient psychotic disorders) Malingering
