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ways Common subjective responses are fear (of repetition of the stress-inducing event), rage (at frustration), guilt (over aggressive impulses), and shame (over helplessness) Acute and reactivated stress may be manifested by restlessness, irritability, fatigue, increased startle reaction, and a feeling of tension Inability to concentrate, sleep disturbances (insomnia, bad dreams), and somatic preoccupations often lead to self-medication, most commonly with alcohol or other central nervous system depressants Maladaptive behavior in response to stress is called adjustment disorder, with the major symptom specified (eg, adjustment disorder with depressed mood ) Posttraumatic stress disorder (PTSD) included among the anxiety disorders in DSM-IV is a syndrome characterized by reexperiencing a traumatic event (eg, rape, severe burns, military combat) and decreased responsiveness and avoidance of current events associated with the trauma Patients with PTSD experience physiologic hyperarousal, including startle reactions, intrusive thoughts, illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating event, impulsivity, difficulties in concentration, and hyperalertness The symptoms may be precipitated or exacerbated by events that are a reminder of the original stress Symptoms frequently arise after a long latency period (eg, child abuse can result in later-onset posttraumatic stress syndrome) The sooner therapy is initiated after the trauma, the better the prognosis Therapy at that time should be brief and simple (once in a safe environment), expecting quick recovery and promoting a sense of mastery over the traumatic event Treatment initiated later, when symptoms have crystallized, includes programs for cessation of alcohol and other drug abuse, group and individual psychotherapy, and improved social support systems The therapeutic approach is to facilitate the normal recovery that was blocked at the time of the trauma

Adjustment disorders must be distinguished from anxiety disorders, affective disorders, and personality disorders exacerbated by stress and from somatic disorders with psychic overlay

FIGURE 7-22

medications such as carbamazepine (400 800 mg daily) will often mitigate impulsivity and difficulty with anger management Benzodiazepines such as clonazepam (1 4 mg daily) will reduce anxiety and panic attacks when used in adequate dosage, but dependency problems are a concern, particularly when the patient has had such problems in the past

Stress reduction techniques include immediate symptom reduction (eg, rebreathing in a bag for hyperventilation) or early recognition and removal from a stress source before fullblown symptoms appear It is often helpful for the patient to keep a daily log of stress precipitators, responses, and alleviators Relaxation and exercise techniques are also helpful in reducing the reaction to stressful events

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Return to satisfactory function after a short period is part of the clinical picture of this syndrome Resolution may be delayed if others responses to the patient s difficulties are thoughtlessly harmful or if the secondary gains outweigh the advantages of recovery The longer the symptoms persist, the worse the prognosis

Ehlers A et al Early psychological interventions for survivors of trauma: a review Biol Psychiatry 2003 May 1;53(9):817 26 [PMID: 12725974] Katon WJ et al Dissemination of evidence-based mental health interventions: importance to the trauma field J Trauma Stress 2006 Oct;19(5):611 23 [PMID: 17075915] Stevens LM et al JAMA patient page Posttraumatic stress disorder JAMA 2006 Aug 2;296(5):614 [PMID: 16882969] Vaiva G et al Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma Biol Psychiatry 2003 Nov 1;54(9):947 9 [PMID: 14573324]

The stress reactions of life crisis problems are a function of psychosocial upheaval, and patients frequently present with somatic symptoms While it is not easy for the patient to make necessary changes (or they would have been made long ago), it is important for the therapist to establish the framework of the problem, since the patient s denial system may obscure the issues Clarifying the problem allows the patient to begin viewing it within the proper context and facilitates the sometimes difficult decisions the patient eventually must make (eg, change of job or relocation of adult-dependent offspring)

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