2.1.5 Stress-Related Disorders

Stress-Related Disorders

Acute Stress Reaction

Acute stress reactions (ICD-10) refer to a temporary condition (persisting for hours or days) that can arise in a person as a direct (within 1 hour) consequence of extreme stress (such as a natural disaster, significant accident, violent attack, combat, sexual assault, multiple losses, or fire). Typically, the stressor presents a significant risk to the individual’s safety or physical well-being, or that of someone they care about deeply.

Prevalence/Incidence:

Variable between research, but roughly 15% to 20% of people report experiencing symptoms of acute stress reactions following extreme stress.

Aetiology:

Since it’s a temporary illness, there are no precise theories.

Presentation:

Acute stress reactions often present a combination of varying symptoms, starting with a dazed state and progressing to depression, anxiety, anger, or despair. Severity is categorized as mild, moderate, or severe based on the number of specific symptoms present, which include social withdrawal, narrowed attention, disorientation, aggression, hopelessness, over-activity, or excessive grief.

Severity	Number of Symptoms	Symptoms Present
Mild	None	None
Moderate	Two	Social withdrawal, narrowed attention, disorientation, aggression, hopelessness, over-activity, or excessive grief
Severe	Four, or dissociative stupor	Social withdrawal, narrowed attention, disorientation, aggression, hopelessness, over-activity, or excessive grief

Treatment:

By definition of it being a transient diagnosis, no special management of treatment is required. Make sure that additional requirements, such as those for safety, security, practical help, and social support, are met.

Outcome:

After the stressor has been eliminated, symptoms normally go away within a few hours.

If the stress persists, the symptoms usually get better within 24 to 48 hours and are gone in approximately three days.

Adjustment Disorder

Adjustment disorders lie in a grey area between what is considered normal or merely “troublesome” difficulties and the more serious psychiatric conditions. These disorders must develop within one month (ICD-10) or three months (DSM-5) following a specific psychosocial stressor and should not continue for more than six months after the stressor (or its effects) has been resolved, with the exception of “prolonged depressive reaction” in ICD-10. The symptoms are deemed “clinically significant” due to the pronounced distress or interference with normal functioning they cause. These symptoms may represent less severe (or “subthreshold”) expressions of mood disorders, anxiety disorders, stress-related disorders, somatoform disorders, or conduct disorders, in terms of either symptomatology or duration.

Prevalence/Incidence:

The prevalence of this condition in inpatient and outpatient psychiatric populations is cautiously approximated to be around 5%. In general hospital environments, the rate might reach up to 20%, with physical illness acting as the main stressor in as many as 70% of these instances.

Aetiology:

As per the definition, the issues stem from a recognizable stressor. While individual predisposition has a more significant influence compared to other disorders, the symptoms would not have emerged in the absence of the stressor.

Presentation:

ICD-10 includes brief depressive reaction, prolonged depressive reaction, mixed anxiety and depressive reaction, predominant disturbance of other emotions, conduct, mixed emotion and conduct disturbances, and other specific predominant symptoms. It also encompasses bereavement and grief reactions.

DSM-5 specifies disorders with depressed mood, anxiety, mixed anxiety and depression, conduct disturbance, mixed emotional and conduct disturbances, and unspecified. Bereavement reactions are excluded. Acute disorders last less than six months, while chronic disorders persist for more than six months.

Treatment:

Psychological: Supportive psychotherapy is the primary approach, aimed at improving coping mechanisms for unchangeable stressors and providing practical assistance, such as caregivers, financial support, occupational therapy assessments, and access to support groups. Expressing feelings may prevent maladaptive behaviours, and understanding the individual’s perception of the stressor can help correct cognitive distortions.

Pharmacological: Antidepressants or anxiolytics/hypnotics may be suitable for persistent and distressing symptoms (e.g., prolonged depression) or when psychological interventions have been unsuccessful.

Outcome:

A 5-year follow-up of patients with adjustment disorder indicates approximately 70% recovery (40% in adolescents), 10% ongoing issues (15% in adolescents), and 20% development of major psychiatric problems (45% in adolescents).

In adults, subsequent psychiatric issues are often related to depression, anxiety, or alcohol. There is a significant risk of suicide and self-harm, particularly among younger populations. Additional risk factors include poor psychosocial functioning, prior psychiatric issues, personality disorders, substance abuse, and mixed mood/behavioural symptoms. This should not be overlooked.

Post-Traumatic Stress Disorder (& Complex PTSD)

Complex PTSD (C-PTSD) and Post-Traumatic Stress Disorder (PTSD) are related but distinct conditions, primarily differentiated by the nature and duration of the traumatic experiences that cause them, as well as some of the symptoms they present.

PTSD is a mental health condition that can develop after experiencing or witnessing a traumatic event, such as natural disasters, acts of violence, or life-threatening accidents. This disorder is characterised by a range of symptoms that may include intrusive thoughts, nightmares, emotional distress, avoidance behaviours, negative alterations in mood and cognition, and increased arousal or reactivity. PTSD can significantly impact an individual’s daily life and well-being, making it crucial for mental health professionals to diagnose and treat the condition accurately. Understanding the complexities of PTSD and its various manifestations is essential to providing effective support and interventions for those affected by this debilitating disorder.

C-PTSD results from chronic or prolonged exposure to traumatic events, often over months or years. This can include ongoing abuse (physical, emotional, or sexual), living in a war-torn region, being a prisoner of war, long-term domestic violence, and other forms of chronic entrapment or captivity.

Prevalence/Incidence:

The likelihood of developing PTSD following a traumatic experience is 8-13% for men and 20-30% for women. The lifetime prevalence is approximately 7.8%, with a male-to-female ratio of 1:2. PTSD prevalence varies across cultures, and certain stressors, such as rape, torture, or being a prisoner of war, are linked to increased rates of the disorder.

Aetiology:

The aetiology of PTSD involves a complex interplay of genetic, environmental, and psychological factors that contribute to the development of the disorder following exposure to a traumatic event.

Presentation:

The ICD-10 and DSM-5 criteria for PTSD include symptoms arising within 6 months (ICD-10) or lasting at least 1 month (DSM-5) after a traumatic event, causing significant distress or impairment. Both classifications encompass persistent arousal symptoms, such as sleep difficulties, irritability, concentration issues, hypervigilance, and an exaggerated startle response.

ICD-10 highlights intrusive recollections, avoidance, and partial or complete memory loss of the stressor. DSM-5 emphasises re-experiencing the event through recollections, dreams, or dissociative reactions and notes persistent avoidance, negative alterations in cognition and mood, and inability to experience positive emotions.

In addition to the core symptoms of PTSD, C-PTSD includes additional symptoms such as difficulties in emotional regulation, disturbances in self-perception (e.g., feelings of helplessness, shame, guilt), changes in relationships with others (e.g., distrust, isolation), and a loss of a coherent sense of self (e.g., feeling detached from one’s mental processes or body). C-PTSD is also characterised by persistent difficulties in establishing a sense of safety and trust.

Criterion	ICD-11	ICD-10	DSM-5
Timeframe	Symptoms typically develop within a few weeks of the event but can be delayed	Symptoms arise within 6 months of the event (10% delayed onset)	Symptoms last at least 1 month
Arousal symptoms	Heightened alertness to threat, easily startled, hyper-vigilance, difficulty concentrating, sleep disturbance	Difficulty sleeping, irritability, concentration issues, hypervigilance, exaggerated startle	Same as ICD-10
Re-experiencing	Re-experiencing the traumatic event in the present, such as vivid intrusive memories, flashbacks, or nightmares	Intrusive recollections, vivid memories, recurring dreams	Recollections, dreams, dissociative reactions, psychological distress, physiological reactions
Avoidance	Avoidance or attempts to avoid thoughts or memories about the traumatic event, or activities, situations, or people reminiscent of the event	Avoidance of circumstances resembling/associated with the stressor	Avoidance of thoughts, feelings, memories, external reminders
Memory	Not specified in ICD-11 for PTSD. Memory disturbances are more associated with complex PTSD in ICD-11	Partial or complete memory loss of the stressor	Inability to recall an important aspect of the trauma
Negative cognition/mood	Persistent negative thoughts about oneself or the world, feelings of fear, horror, anger, guilt, or shame	N/A	Negative beliefs, distorted cognitions, negative emotional state, diminished interest, detachment, inability to experience positive emotions

Treatment:

Psychological: Trauma-focused treatments like trauma-focused CBT and EMDR are recommended as first-line treatments in all recent guidelines. Other psychological treatments include psychodynamic therapy, stress management, hypnotherapy, and supportive therapy.

Description	Examples
Trauma-focused CBT	Education about PTSD, self-monitoring of symptoms, anxiety management, breathing techniques, imaginal reliving, supported exposure to anxiety-producing stimuli, cognitive restructuring (esp. for complicated trauma), and anger management.
Eye Movement Desensitisation and Reprocessing (EMDR)	Uses voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts and to help process the emotions associated with traumatic experiences.
Psychodynamic therapy	Focuses on resolving unconscious conflicts provoked by stressful events, with the goal of understanding the meaning of the event in the context of the individual.
Stress management (stress inoculation)	Teaches skills to help cope with stress such as relaxation, breathing, thought-stopping, assertiveness, and positive thinking.
Hypnotherapy	Uses focused attention to enhancing control over hyperarousal and distress, enabling recollection of traumatic events. Concern over possible induction of dissociative states.
Supportive therapy	Non-directive, non-advisory method of exploring thoughts, feelings, and behaviours to reach clearer self-understanding.

Pharmacological: SSRIs like paroxetine and sertraline are licensed for PTSD. Other antidepressants like TCAs and MAOIs may also be used. Targeting-specific symptoms include mirtazapine, levomepromazine, prazosin, specific hypnotics, BDZs, buspirone, propranolol, carbamazepine, valproate, topiramate, lithium, and antipsychotics. Medication may be considered when there is a severe ongoing threat if the patient is too distressed or unstable to engage in psychological therapy or fails to respond to an initial psychological approach.

Description	Examples
Selective serotonin reuptake inhibitors (SSRIs)	Licensed for PTSD, supported by systematic reviews. Examples: paroxetine, sertraline, fluoxetine, escitalopram, and fluvoxamine.
Other antidepressants	Unlicensed but with evidence supporting their use. Examples: Tricyclic antidepressants (TCAs) such as amitriptyline and imipramine, Monoamine oxidase inhibitors (MAOIs) such as phenelzine.
Sleep disturbance medications	Examples: mirtazapine, levomepromazine, prazosin, zopiclone, zolpidem.
Anxiolytics/hypnotics	Examples: benzodiazepines (e.g. clonazepam), buspirone, propranolol.
Antipsychotics	Used for severe agitation, aggression, or psychotic symptoms. Examples: olanzapine, risperidone, quetiapine, clozapine, aripiprazole.

For best outcomes, trauma-focused treatments such as trauma-focused CBT and EMDR are recommended as first-line treatments. Medication may be considered when there is a severe ongoing threat or when the patient is too distressed or unstable to engage in psychological therapy or fails to respond to an initial psychological approach.

Outcome:

Around 50% of individuals who experience PTSD will recover within the first year, while approximately 30% will experience chronic symptoms. The severity of initial symptoms is a crucial factor in predicting the outcome, with good social support and the absence of maladaptive coping mechanisms such as avoidance and denial contributing to recovery. Additional factors that may impede recovery include further traumatic events, physical health problems, acquired disabilities, disfigurement, disrupted relationships, financial worries, and litigation.

Summary

	Acute stress reactions	Adjustment disorder	PTSD
Prevalence	15%-20% following extreme stress	Varied	8-13% for men 20-30% for women
Onset	Shortly after trauma	Within 3 months of the stressor	May have delayed onset
Gender	No difference	No difference	Higher in women
Aetiology	Trauma or stressor	Life stressors	Trauma or stressor
Presentation	Anxiety, dissociation, re-experiencing	Anxiety, depressed mood, mixed symptoms	Intrusive thoughts, avoidance, arousal symptoms
Treatment	Supportive care, CBT, EMDR	Psychotherapy, medication	Trauma-focused psychotherapy, medication
Outcome	Usually resolves	Good with treatment, may progress to PTSD	Chronic symptoms possible

References:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R. and Walters, E.E., 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), pp.593-602.
3. Semple, D., Smyth, R., & Burns, J. (Eds.). (2017). Oxford handbook of psychiatry (4th ed.). Oxford University Press.
4. Wittchen, H.U., et al., 2011. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21, pp.655-679.