An individual experiences stress when the adaptive capacity of the individual is overwhelmed by events. The event may be an insignificant one when objectively considered, and even favorable changes (eg, promotion and transfer) requiring adaptive behavior can produce stress. For each individual, stress is subjectively defined, and the response to stress is a function of each person's personality and physiologic endowment.
Opinion differs about what events are most apt to produce stress reactions. The causes of stress are different at different ages-eg, in young adulthood, the sources of stress are found in the marriage or parent-child relationship, the employment relationship, and the struggle to achieve financial stability; in the middle years, the focus shifts to changing spousal relationships, problems with aging parents, and problems associated with having young adult offspring who themselves are encountering stressful situations; in old age, the principal concerns are apt to be retirement, loss of physical and mental capacity, major personal losses, and thoughts of death.
A n individual may react to stress by becoming anxious or depressed, by developing a physical symptom, by running away, drinking alcohol, overeating, starting an affair, or in limitless other ways. Common subjective responses are anxiety, sadness, fear, rage, guilt, and shame. 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"). Even with an identifiable stress or, if the patient meets syndromal criteria for another disorder such as major depression, then the convention would be to diagnose a major depression and not
an adjustment disorder with depressed mood.
Stress reduction techniques include immediate symptom reduction (eg, rebreathing in a bag for hyperventilation) or early recognition and removal from a stress source before full-blown symptoms appear. It is often helpful for the patient to keep a daily log of stress precipitators, responses, and alleviators. Relaxation, mindfulness-based stress reduction, and exercise techniques are also helpful in reducing the reaction to stressful events.
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 clinician 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 difficult decisions the patient eventually must make (eg, change of job).
Prolonged in-depth psychotherapy is seldom necessary in cases of isolated stress response or adjustment disorder. Supportive psychotherapy (see above) with an emphasis on the here and now and strengthening of existing coping mechanisms is a helpful approach so that time and the patient's own resiliency can restore the previous level of function. In addition, cognitive behavioral therapy has long been established to treat acute stress and facilitate recovery in patients with an adjustment disorder.
Judicious use of sedatives (eg, lorazepam, 0.5-1 mg two or three times daily orally) for a limited time and as part of an overall treatment plan can provide relief from acute anxiety symptoms. Problems arise when the situation becomes chronic through inappropriate treatment or when the treatment approach supports the development of chronicity. There are occasions where the short-term use of selective serotonin reuptake inhibitors (SSRis) targeting dysphoria and anxiety may be useful.
- Birnie K et al. Psychological benefits for cancer patients and their partners participating in mindfulness-based stress reduction (MBSR) . Psychooncology. 2010 Sep; 19(9): 1004-9.[PMID: 19918956] (2017 CURRENT Medical Diagnosis & Treatment FIFTY-SIXTH EDITION)