Chapter 7 Reactions to Stressful Experiences PDF

# Chapter 7 Reactions to Stressful Experiences ## Introduction - Stressful events frequently provoke psychiatric disorders and emotional reactions. - Such reactions are discussed here, including post-traumatic stress disorder (PTSD), which is an intense and prolonged reaction to a severe stressor....

# Chapter 7 Reactions to Stressful Experiences ## Introduction - Stressful events frequently provoke psychiatric disorders and emotional reactions. - Such reactions are discussed here, including post-traumatic stress disorder (PTSD), which is an intense and prolonged reaction to a severe stressor. ## The Response to Stressful Events - The response to stressful events has three components: - An emotional response, with somatic accompaniments. - A coping strategy. - A defence mechanism. ## Emotional and Somatic Responses - These responses are of two kinds: - **Anxiety Responses:** Autonomic arousal leading to apprehension, irritability, tachycardia, increased muscle tension, and dry mouth. - **Depressive Responses:** Pessimistic thinking and reduced physical activity. ## Coping Strategies - Coping strategies are generally useful for reducing the problem or lessening the emotional reaction to it. However, they are not always adaptive, for example: - Avoidance may not be adaptive in the early stages of physical illness, as it can lead to delay in seeking appropriate treatment. ### Maladaptive Coping Strategies - These strategies reduce the emotional response to stressful circumstances in the short term, but lead to greater difficulties in the long term. - Use of alcohol or unprescribed drugs to reduce the emotional response or to reduce awareness of stressful circumstances. - Deliberate self-harm, either by drug overdose or by self-injury. - Unrestrained display of feelings can reduce tension. - Aggressive behavior can damage relationships. ### Coping Styles - When particular coping mechanisms are used repeatedly by the same person in different situations, they are said to constitute a coping style. - Some people change their coping strategies according to the circumstances. - Some people habitually use maladaptive strategies, for example, they repeatedly abuse alcohol or take overdoses of drugs when under stress. ## Defence Mechanisms - Defence mechanisms are unconscious responses to external stressors as well as to anxiety arising from internal conflict. - They were originally described by Sigmund Freud and later elaborated by his daughter, Anna Freud. - Defence mechanisms are unconscious processes. - The main mechanisms of defence are: - Repression: The exclusion from consciousness of impulses, emotions, or memories that would otherwise cause distress. - Denial: A related concept, inferred when a person behaves as if they are unaware of something that they may reasonably be expected to know. - Displacement: Transfer of emotion from a person, object, or situation with which it is properly associated, to another source. - Projection: Attribution to another person of thoughts or feelings similar to one's own, thereby rendering one's own thoughts or feelings more acceptable. - Regression: Adoption of behaviour appropriate to an earlier stage of development, for example, dependence on others. - Reaction formation: Unconscious adoption of behavior that is the opposite to that which would reflect the person's true feelings and intentions. - Rationalization: Unconscious provision of a false but acceptable explanation for behavior that has a less acceptable origin. - Sublimation: Unconscious diversion of unacceptable impulses into more acceptable outlets. - Identification: Unconscious adoption of the characteristics or activities of another person, often to reduce the pain of separation or loss. ## Classification of Reactions To Stressful Events - Not all reactions to stressful events are abnormal. - Grief is a normal reaction, and only a minority of people have a very severe or abnormally prolonged reaction. - The ICD-10 and DSM-5 reactions to stressful experiences are classified into three groups: ### Acute Reactions to Stress - The ICD-10 definition of acute stress reaction requires that the response should start within 1 hour of exposure to the stressor, and that it begins to diminish after not more than 48 hours, disappearing after a few days. - The DSM-5 definition of acute stress disorder states that the onset should occur while or after experiencing the distressing event, and requires that the condition lasts for at least 2 days and for no more than 4 weeks. ### Post-Traumatic Stress Disorder - This is a prolonged and abnormal response to exceptionally intense stressful circumstances such as a natural disaster or a sexual or other physical assault. ### Adjustment Disorder - This is a more gradual and prolonged response to stressful changes in a person's life. - Adjustment disorders are subdivided, according to the predominant symptoms, into depressive, mixed anxiety, and depressive, with disturbance of conduct, and with mixed disturbance of emotions and conduct. ## Acute Stress Reaction And Acute Stress Disorder - This category is for immediate and brief responses to sudden intense stressors in a person who does not have another psychiatric disorder at the time. - The core symptoms of an acute psychological response to stress are anxiety or depression. - Anxiety is the response to threatening experiences, and depression is the response to loss. ## Debriefing - After a major incident, counselling has often taken the form known as debriefing, or critical incident stress debriefing (CISD). - In debriefing, the victim goes through the following stages, after the counsellor has first explained the procedure: - Facts: The victim relates what happened. - Thoughts: They describe their thoughts immediately after the incident. - Feelings: They recall the emotions associated with the incident. - Assessment: They take stock of their responses. - Education: The counsellor offers information about stress responses and how to manage them. ## Management - After a traumatic event, many people talk informally to a sympathetic relative or friend, or to a member of the professional staff dealing with any physical injuries that originated during the incident. - If anxiety is severe, an anxiolytic drug may be prescribed for a day or two, and if sleep is severely disrupted a hypnotic drug may be given for one or two nights. - Since in most cases stress reactions will resolve with time, a policy of watchful waiting is appropriate. ## Variations in the Clinical Picture - Not all responses to acute stress follow this orderly sequence, in which coping strategies and defences are maintained for long enough to allow the person to function until anxiety and depression subside, and are then abandoned so that working through can occur. - Not all coping strategies are adaptive. - Defence mechanisms may persist for longer than is adaptive. ## Diagnostic Conventions - The terms acute stress reaction and acute stress disorder are used only when the person was free from these symptoms immediately before the impact of the stressful event. - Otherwise response is classified as an exacerbation of pre-existing psychiatric disorder. ## Epidemiology - Rates in the general population are unclear. - The rate of acute stress disorder has ranged from around 15% in motor accident survivors to over 50% in women victims of sexual assault. After the Wenchuan earthquake in China, about 30% of the survivors met criteria for acute stress disorder. ## Aetiology - Many kinds of event can provoke an acute response to stress. ## Planning for Disaster - Planning is needed to ensure an immediate and appropriate response to the psychological effects of a major disaster. - Such a response can be achieved by enrolling and training helpers who can support victims and are willing to be called on at short notice, and by agreeing procedures for contacting these helpers promptly. - At the time of the disaster, priorities have to be decided between the needs of the victims of the disaster, those of relatives (including children), and those of members of the emergency services. - The essential elements of psychological assistance for victims of disaster have been described by Alexander (2005). ## The Principal Components of Psychological First Aid - Comfort and consolation - Protection from further threat and distress - Immediate physical care - Helping reunion with loved ones - Sharing the experience (but not forced) - Linking survivors with sources of support - Facilitating a sense of being in control - Identifying those who need further help (triage)