Roy Abraham Kallivayalil
Department of Psychiatry, Medical College, Kottayam

Corresponding Author: Dr. Roy Abraham Kallivayalil, Professor & Head, Department of Psychiatry, Medical College, Kottayam- 686 008. Phone: 9447020020. E mail: roykallivayalil@dataone.in, roykalli@gmail.com

ABSTRACT

Stress disorders can affect anyone at any point in life. The incidence of stress disorders, adjustment disorders and suicide are on the rise. Adolescents and students are especially vulnerable to the ill effects of stress. Stressful life events can increase the susceptibility to infections and other diseases in all human beings. The meaning of stress is different for different people. The impact of stress on the individual is affected by stress modifiers like strengths of the individual, the support systems available to him and his prior mastery in handling stress. Stress in hospitals is an emerging theme due to enforced life style changes and the demands involved to deal with the hospital staff. Concerns about investigations and treatment are often stressful for patients.
Recognition, assessment and management of stress and stress related conditions should be an essential theme for all medical professionals
This article describes the types of stress disorders and their clinical manifestations.

There has been increasing concern about stress, stressors and stress disorders during the last two or three  decades  among  medical  professionals, educationalists, policy makers and the  public in general. The incidence of stress disorders, adjustment disorders and suicide are on the rise. Adolescents and students are especially vulnerable to the ill effects of stress. Stressful life events can increase the susceptibility to infections and other diseases in all human beings.   Recognition,  assessment  and management of stress and stress related conditions should  be an essential theme for  all  medical professionals.

What  is  stress? Stress can be defined as any circumstance that disturbs or likely to disturb the normal physiological or psychological functioning of a person.  Walter Canon (1875-1945)  studied  the relationship of stress to disease and said, stimulation of the autonomic nervous system readied an organism for “fight or flight” response characterized by hypertension, tachycardia and increased cardiac output. This response is adaptive in animals who can fight or escape. Man being civilized  can do neither. Thus stress can lead on to disease. Hans Selye (1907-1982) developed a model to describe the effects of stress – the General Adaptation Syndrome- with three phases. The first is the ‘alarm reaction’ (when the person feels overwhelmed), followed by  a ‘stage of resistance’ (when adaptation is achieved) and finally a ‘stage of exhaustion’ (when the acquired adaptation is lost). Hans Selye believed that stress is not entirely unwelcome and famously said, “life without stress is death”. He believed that emotional growth can indeed occur  when  faced  with  stress.  He described unpleasant stress as distress.

Stress can be real, symbolic or imagined. Our body reacts to stress to minimize its impact. More is known about physiological response to acute stress than chronic stress. Many stressors occur over a prolonged period of time or may have long lasting repercussions. For example loss of spouse or children in young age, unexpected death of significant persons in one’s life, torture or  sexual assault may lead to prolonged emotional disturbance in people.

Stressors activate nor-adrenergic systems in the brain and cause  release of catecholamines from the autonomic nervous system. Stressors also activate serotonergic system in the brain. Stress also leads to endocrine changes causing increased CRF secretion from the hypothalamus. CRF enhances ACT H release which in turn stimulates the synthesis and release of  glucocorticoids.    This increased glucocorticoids in response to stress can lead to inhibition of immune functioning in human beings.

Assessment and measurement of stressors also become important. Life Events have been considered important in the causation of physical and emotional dis orders.  Holmes  &  Ra he devised  a  ‘Social Readjustment Rating Scale’ which consisted of 43 life events associated with stress. Each event was assigned life change units – for eg: death of spouse was assigned 100  units,  marriage 5 0 and job adjustments 39. According to Holmes & Rahe, more than 200 such units in an year increased the risk of developing psychosomatic disorders. This study had been quite influential.

A consideration of the reaction to stressor is also necessary. In medicine, onset or aggravation of a disease, hospitalization and treatment are all potential stressors. Illness, injury and other life events   can lead to various forms of psychological reactions. The commonest  is an acute stress reaction which may manifest with anxiety or disturbed behaviour. This is often transient can be managed by general practioners and physicians with counseling and psychotherapeutic support. Providing accurate and adequate information is also very important. Adjustment disorders are longer lasting. It can lead to poor compliance with treatment, disturbed behaviour and depression. Post Traumatic Stress Disorder (PTSD) is a protracted or delayed response to a catastrophic, life threatening or exceptional stress. These can be natural calamities like floods, cyclones, tsunami or earthquakes or man made like being the victim or witness of torture, violence, molestation or rape. Serious accidents or invasive medical procedures in hospitals may also lead on to PTSD, the onset of which may be delayed by weeks or months. Patients often relive the trauma in intrusive memories or flashbacks. Chronic anxiety, insomnia,  nightmares,  emotional  numbness, detachment and avoidance of any cues which might remind the trauma are common. Recognition and management of PTSD is important, as otherwise it may lead on to suicide or chronic depression.  All doctors must be trained in the diagnosis and early management of PTSD. ‘Psychological de-briefing’ which uses the principles of counseling is sometimes used to prevent PTSD following disasters.

People cope with stress in different ways. Stress follows a threat or demand from the external world. Some people consider events as stressful only if it produces changes in the individual. On the one hand there is demand from the environment and on the other hand we have the resources of the individual. Illness can result when this equilibrium is disturbed. Acute and chronic stress are different psychologically and physiologically. Meaning of stress is different for different people. The impact of stress on the individual is affected by stress modifiers like strengths of the individual, the support systems available to him and his prior mastery in handling stress.

Stress in hospitals is an emerging theme due to enforced life style changes and the demands involved to deal with the hospital staff. Concerns about investigations and treatment is often stressful for patients. This will be compounded if they have poor communication skills. The problems are more acute in ICUs and dialysis units where patients experience sensory and emotional isolation and deprivation. There are recent studies which encourage early discharges from hospitals because home environment is more conducive to most patients. Similarly incidence of stress related disorders are on the increase in medical professionals including medical students.  We need to develop reliable psychological tools to assess stressors and its impact  on various population groups in our country.

In the present era of globalization, liberalization and increasing consumerism stress related disorders are on the rise. All medical professionals should consider the significance of life events and stress in the causation and maintenance of illness in their patients and should possess basic skills to deal with them.

End Note

Author Information

Dr. Roy Abraham Kallivayalil,
Professor  & Head, Department of Psychiatry,
Medical College, Kottayam- 686 008.

Conflict of Interest: None declared

References

  1. Holmes TH, Rahe RH. The social readjustment rating scale. Journal of Psychosomatic Research. 1967 Aug 1;11(2):213–8. [Crossref]
  2. Kaplan & Sadocks Synopsis of Psychiatry, 10th Edition (2008).
  3. Supe AN. A study of stress in medical students at Seth G.S. Medical College. J Postgrad Med. 1998 Mar;44(1):1–6. [Pubmed] | [Source]