All individuals experience the typical stresses of life from time to time. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), stress disorders occur as a result of experiences of profound trauma, including encountering or witnessing threatened death, death, or serious injury. This must be coupled with a response that exhibits intense fear, helplessness, or horror. Physicians well know that similar reactions are seen in individuals who have endured a major operation or life-threatening disease, such as cancer. Acute stress disorder occurs soon after the traumatic event, resolving in about a month's time. Post-traumatic stress disorder (PTSD) continues for more than three months and may begin within a few days or may have delayed onset of action (possibly as long as 30 to 40 years). The lifetime U.S. prevalence rate for PTSD is 5% to 10% and can be as high as 58% in at-risk populations. Prevalence rates for acute stress disorder are unknown. Individuals of all ages can experience stress disorders.

Acute and post-tramatic stress is precipitated by the combination of a traumatic event and a strong reaction to it, which involves feelings of intense fear and helplessness. However, without a stressor the condition does not exist. The trauma of war, rape or any other inappropriate sexual experience, illness, bereavement, or natural disaster can cause stress disorders.

• Neuroticism, extroversion, poor self-confidence, past history of psychiatric problems, including sexual abuse
• Women > men
• The elderly and children
• Genetic predisposition
• Risk of PTSD increases with the magnitude of and exposure to the trauma
• Feelings of guilt or shame
• Lack of social support or financial security
• Early separation from parents, childhood neglect
• Children of alcoholic parents
• Parental poverty before the trauma

• Persistent re-experiencing of the trauma—flashbacks, dreams, intrusive thoughts, intense distress when relived, accompanying physiologic responses
• Active avoidance of stimuli that prompts recollection—inability to recall aspects of the trauma
• Detachment, decrease in emotional responsiveness, restricted range of affect and activity, sense of detachment from the body, alterations in memory or cognition
• Sense of a foreshortened future
• Impulsive and risk-taking behaviors
• Hopelessness akin to major depressive disorders
• Increased arousal, startled response, hypervigilance, insomnia
• Decreased occupational and social functioning
• Stress is also implicated in and can exacerbate illness (e.g., gastrointestinal, cardiac, cancer) as well as recuperation time and outcome

• Mental disorders such as mood, anxiety, depression, panic, obsessive-compulsive, and psychotic disorders
• Head trauma
• Substance-induced disorder
• Malingering

The patient may appear tired, pale, or disoriented.

Stress disorders are one of only a few conditions for which DSM-IV reviews physiologic reactions.

• Increased release of neurotransmitter norepinephrine at the locus ceruleus (possibly the central nervous system arousal center, containing 50% of all neurons)
• Increased noradrenergic activity at the locus ceruleus afferent projection sites in the amygdala and hippocampus (may encode persisting memories of fear)
• Possible impaired alpha₂- and beta-adrenergic receptor binding and feedback from norepinephrine release
• Elevated urinary catecholamines
• Decreased platelet monoamine oxidase (MAO) activity
• Increased sympathetic nervous system activity correlates with increased blood pressure, electromyography, heart rate, and sweat activity (possibly evoking feelings of panic)
• Increased serotonin activity
• Decreased amounts of neurotransmitter gamma-aminobutyric acid in elderly may predispose them to greater anxiety with trauma
• Decreased platelet adenylate cyclase activity
• Decreased cortisol release and increased sensitivity of it to dexamethasone inhibition
• Opioid system abnormalities such as a naloxone-reversible analgesia
• Increased rapid eye movement and decreased stage II sleep
• Elevated epinephrine and growth hormone; decreased prolactin, testosterone, and estrogen

Computerized tomography and magnetic resonance imaging can rule out brain damage.

• Psychiatric exam and psychological testing (e.g., Minnesota Multiple Personality Inventory [MMPI])
• Hypnosis—with or without sodium amytal may uncover traumatic material with amnesia
• Electroencephalogram—rules out brain damage, diagnoses sleep disorder

Acute stress is usually self-limiting with symptoms decreasing with time. Chronic stress requires a longer treatment period with most patients being more responsive to a multifaceted approach.

• Crisis intervention—provides support, acceptance, education, meets health needs
• Psychotherapy—mastering fear and overcoming avoidance behaviors in a phase-oriented approach is correlated with effective outcomes (e.g., cognitive behavioral therapy)

Drug therapy for symptom relief—none approved for this use by the Food and Drug Administration

• Benzodiazepines—more rapid onset of action than antidepressants, often combined with antidepressants; side effects include addiction, sedation, psychomotor impairment, ataxia, disinhibition
• Antidepressants—wide spectrum of activity: reduce anxiety, avoidance behavior, intrusive thoughts, impulsiveness; slow onset (two to six weeks); e.g., fluoxetine 20 to 60 mg/day; side effects include nausea, gastrointestinal effects, sexual dysfunction, sleep disturbance
• Sedating antidepressants—can relieve insomnia; e.g., trazodone 50 to 150 mg qid

Chronic stress may lead to derangements of multiple organ systems and has significant implications for normal physical, mental, and emotional functioning. Psychotherapy (individual and group support) and body-mind techniques such as meditation, cranial-sacral therapy, yoga, tai chi, and breathwork are the cornerstone for treatment of post-traumatic stress disorder and chronic stress. Early intervention has the best results, although support at any time may help. Homeopathy may be used acutely for grief, trauma, and anxiety; nutrition and herbs can provide long-term support and minimize sequelae.

• Avoid refined foods such as sugar and baked goods, as well as pro-inflammatory foods such as caffeine, alcohol, dairy, and animal products, which deplete vitamins and minerals that are mobilized during stress (particularly B-complex and magnesium).
• Increase foods that nourish the nervous system, such as whole grains, fresh vegetables, and foods rich in essential fatty acids such as nuts, seeds, and cold-water fish.
• Digestive enzymes, including betaine HCl, may be necessary to support proper digestive function which may be compromised under stress.
• B-complex (50 to 100 mg/day), calcium (1,000 mg/day), and magnesium (400 mg/day) may be depleted by stress.

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

A nervine tea or tincture may be indicated for long-term use to nourish and restore normal sympathetic/parasympathetic tone (30 to 60 drops tid). In addition, the tincture may be taken in small amounts (5 to 10 drops as needed) for symptomatic relief. Combine equal parts of passionflower ( Passiflora incarnata), lemon balm (Melissa officinalis) and oatstraw (Avena sativa) with one to three of the following herbs.

• With anxiety: kava kava (Piper methysticum), motherwort (Leonurus cardiaca)
• With insomnia: valerian (Valeriana officinalis), skullcap (Scutellaria laterifolia)
• With depression: St. John's wort (Hypericum perforatum), wood betony (Stachys betonica)
• With digestive upset: wild yam (Dioscorea villosa), chamomile (Matricaria recutita)
• With exhaustion: bladderwrack (Fucus vesiculosus), gotu kola (Centella asiatica)

Siberian ginseng (Eleuthrococcus senticosus) is an important adaptogenic herb that inhibits the alarm phase of stress. It is best taken as a fluid extract (1:1) 1/2 to 1 tsp. bid to tid. This herb may be stimulating to some and should not be taken after 3 pm. Ginseng is best used long-term (four to six months) in order to achieve maximum benefit.

An experienced homeopath would consider an individual's constitutional type to prescribe a more specific remedy and potency. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Aconite for panic with heart palpitations, shortness of breath, and fear of death
• Arsenicum for anxiety, especially about health, with restlessness and fear of being alone
• Phosphorous for free-floating anxiety and foreboding; startles easily and feels better with reassurance

Patients are treated on an outpatient basis until symptoms have subsided. With concerns of self-abuse or suicide, inpatient treatment is indicated.

Crisis intervention can prevent PTSD from developing.

• Greater risk of developing another mood, anxiety, or substance-abuse (especially alcohol) disorder
• Predisposition to comorbidity—heart disease, insomnia, gastrointestinal illness
• Suicide

Many people have acute stress disorder or present with similar symptoms after a trauma. For most this is quickly resolved. Optimistic individuals, who can use family, work, humor, art, etc., for recovery, have a better prognosis. A lengthier course and delayed onset correlate with worse prognosis. PTSD appears within the first month in 70% to 90% of patients with the following resolutions.

• Complete recovery—30%
• Partial recovery—40% mild and 20% moderate symptoms
• Recovery failure—10%

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