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
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
- 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
- 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
|Signs and Symptoms|
- 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
- Detachment, decrease in emotional responsiveness, restricted range of
affect and activity, sense of detachment from the body, alterations in memory or
- Sense of a foreshortened future
- Impulsive and risk-taking behaviors
- Hopelessness akin to major depressive disorders
- Increased arousal, startled response, hypervigilance,
- 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
- Mental disorders such as mood, anxiety, depression, panic,
obsessive-compulsive, and psychotic disorders
- Head trauma
- Substance-induced disorder
The patient may appear tired, pale, or disoriented.
Stress disorders are one of only a few conditions for which DSM-IV reviews
- Increased release of neurotransmitter norepinephrine at the locus
ceruleus (possibly the central nervous system arousal center, containing 50% of
- Increased noradrenergic activity at the locus ceruleus afferent
projection sites in the amygdala and hippocampus (may encode persisting memories
- 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
- Opioid system abnormalities such as a naloxone-reversible
- 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
- 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
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
- Sedating antidepressants—can relieve
insomnia; e.g., trazodone 50 to 150 mg qid
|Complementary and Alternative
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
- With insomnia: valerian (Valeriana officinalis), skullcap
- With depression: St. John's wort (Hypericum perforatum), wood
betony (Stachys betonica)
- With digestive upset: wild yam (Dioscorea villosa), chamomile
- With exhaustion: bladderwrack (Fucus vesiculosus), gotu kola
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
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
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
- Complete recovery—30%
- Partial recovery—40% mild and 20% moderate
- Recovery failure—10%
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Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
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The reader is advised to check product information (including package inserts)
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interactions, and contraindications before administering any drug, herb, or
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