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Key Features

Essentials of Diagnosis

  • Anxiety or depression in reaction to an identifiable stress, though out of proportion to the severity of the stressor

  • Symptoms are not at the severity of a major depressive episode or with the chronicity of a generalized anxiety disorder

General Considerations

  • Stress exists when the adaptive capacity of the individual is overwhelmed by events

  • The event may be an insignificant one when objectively considered

  • 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

  • The causes or sources of stress are different at different ages

    • Young adulthood

      • Marriage or parent-child relationship

      • Employment relationship

      • Struggle to achieve financial stability

    • Middle years

      • Changing spousal relationships

      • Problems with aging parents

      • Problems associated with having young adult offspring who themselves are encountering stressful situations

    • Old age

      • Retirement

      • Loss of physical and mental capacity

      • Major personal losses

      • Thoughts of death

  • Distressing emotional and behavioral symptoms in response to stress is called adjustment disorder, with the major symptom specified (eg, "adjustment disorder with depressed mood")

Clinical Findings

Symptoms and Signs

  • Common subjective responses

    • Anxiety

    • Sadness

    • Fear

    • Rage

    • Guilt

    • Shame

  • Acute and reactivated stress manifestations

    • Restlessness

    • Irritability

    • Fatigue

    • Increased startle reaction

    • 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 CNS depressants

Differential Diagnosis

  • Anxiety disorders

  • Mood disorders

  • Bereavement

  • Other stress disorders, such as posttraumatic stress disorder

  • Personality disorders exacerbated by stress

  • Somatic disorders with psychic overlay

Diagnosis

Diagnostic Procedures

  • Obtain history

  • Identify precipitating sources of stress

Treatment

Medications

  • Judicious use of sedatives (Table 25–1) (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

  • Short-term use of selective serotonin reuptake inhibitors targeting dysphoria and anxiety may be useful

Table 25–1.Commonly used antianxiety and hypnotic agents (listed in alphabetical order within classes).

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