Reaction to Stressful Event/Bereavement

Question 1

ADJUSTMENT DISORDER:

Answer 1

• Feeling unable to cope with psychosocial stresses.
• Symptoms significant enough to be out of proportion to the original stressor/cause disturbance to social or occupational functioning
• Symptoms occur within 3/12(DSM-IV), 1/12(ICD-10) of original stressor
• Symptoms usually fully resolve within 6/12 of onset.
• Only diagnose if criteria not met for other specific diagnoses ie mood/psychotic/anxiety disorders/PTSD/normal bereavement reaction.

Question 2

ACUTE STRESS REACTION:

Answer 2

• Onset immediately after/within few minutes of traumatic stressor
• Initial dazed state
• Then possible disorientation and narrowing of attention, inability to process external stimuli
• Followed by period of diminished responsiveness or psychomotor agitation
• May have amnesia
• Symptoms normally begin to decline after 24-48h, minimal >3d

Question 3

POST-TRAUMATIC STRESS DISORDER:

Answer 3

1. Symptoms develop >1/12 but ≤6/12 of traumatic stressor
   - significant distress/functional impairment
2. Symptoms include:
   a) Repetitive re-experiencing of traumatic event:
   - Flashbacks: Intrusive, unwanted memories; vivid mental images/dreams of original experience.
   - Distress: Caused by internal/external cues resembling stressor
   * patients may dissociate and experience original event as though happening at that moment.
   - Hallucinations and illusions
   b) Avoidance of stimuli associated with stressor, amnesia for aspects of trauma, emotional numbness(feeling detached), social withdrawal
   c) Increased arousal
   - Insomnia
   - Anger outbursts
   - Hypervigilance
   - Poor concentration
   - Exaggerated startle response.

*Patients have high rates of co-morbid substance misuse. Important DDx: Head injury, epilepsy

Question 4

TYPES OF DISSOCIATIVE(CONVERSION) DISORDERS:

Answer 4

1. Dissociative amnesia
   - Not due to normal forgetfulness, organic brain disorders or intoxicaiton.
2. Dissociative fugue
   - Amnesia for personal identity, maintenance of self-care and social interaction
   - usually short-lived and may involve seemingly purposeful travel/assuming new identity.
3. Dissociative stupor
   - Severe psychomotor retardation not due to physical or psychiatric disorder.
4. Dissociative anaesthesia and sensory loss
   - Cutaneous/visual
   - Does not correspond to dermatomes or known neurological patterns.
5. Dissociative motor disorders
   - Partial/complete paralysis
6. Dissociative convulsions(psychogenic non-epileptic seizures)
   - Tongue-biting, urinary incontinence and serious injury are uncommon
   - Absence of epileptic activity on EEG.
7. Ganser’s syndrome
   - Complex disorder with ‘approximate answers’
8. Multiple personality disorder(dissociative identity disorder)

Question 5

DISSOCIATION

Answer 5

• Disruption in usually integrated functions of consciousness and cognition.
• Memories of past, awareness of identity, thoughts, emotions, movement, sensation and/or control of behaviour become separated from an individual’s personality such that they function independently and are not open to voluntary control.
• ICD-10 diagnosis requires evidence of psychological causation with onset of symptoms.
• Don’t diagnose if evidence of physical or psychiatric disorder that explains symptoms.

Question 6

PARKES’S STAGES OF BEREAVEMENT:

Answer 6

1. Alarm
2. Numbness
   - state of being emotionally disconnected.
3. Pining
   - Bereaved is constantly reminded of and pre-occupied with the deceased.
   - ‘pangs of grief’, intense anxiety, hypnagogic, hypnopompic, pseudohallucinations, illusions of deceased.
4. Depression and despair
   - Depressed and irritable mood
   - Features of depression
5. Recovery and reorganization

Question 7

BEREAVEMENT AND DEPRESSION

- bereaved are at higher risk of depressive illness

Answer 7

Characteristics suggesting development of major depressive episode:

1. Guilt
   - other than events surrounding death of loved one
2. Suicidal ideation
   - other than feeling ‘better of dead’ or ‘wanting to join the deceased’
3. Preoccupation with worthlessness
4. Marked psychomotor retardation
5. Prolonged and marked functional impairment
6. Hallucinatory experiences

Question 8

DDx:

• always screen for PTSD and depression after life-threatening event. Risk of depression increases x6 in 6/12 following stressful event.

Answer 8

1. Adjustment disorder
2. Acute stress reaction
3. PTSD
4. Normal bereavement
5. Dissociative/conversion disorder
6. Exacerbation/precipitation of other psychiatric illness:
   - Mood disorder
   - Anxiety disorders
   - Psychotic disorders(esp acute and transient psychotic disorders)
7. Malingering

Question 9

TRAUMATIC STRESS

Answer 9

• outwith range of normal human experience
• magnitude such that experienced as traumatic by most people.
• occurs when person feels that their own/loved one’s physical/psychological integrity is under serious threat