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Acute Stress Reactions and Stress-Related Physical Presentations
Abnormal Psychology · Chapter 13: Stress-Related Disorders and Emotional ResilienceSection 13.3 · lesson 49 of 9720 min · free with a free account
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In this lesson
Where the boundaries are set by convention, and why the wording of an answer matters.
- Describe adjustment disorders and where their boundaries fall
- Explain why the term psychosomatic is avoided
- Separate no cause found from no cause exists
- Describe burnout and occupational stress accurately
Transcript
Everything said in the video, section by section (2,672 words). Read along, or search it.
Stress-Related Disorders and Emotional Resilience
Acute Stress Reactions and Stress-Related Physical Presentations
A person is told there is nothing wrong with them, and gets worse. Not because they were told a lie, but because of what that sentence actually communicated. This section is largely about the difference between two statements that sound identical. We start with the spectrum of reactions to difficult events, and where its boundaries fall. Then adjustment disorder, which is one of the most contested categories in the classification. Then the word psychosomatic, and why the field abandoned it. Then functional presentations, and the investigation cycle that traps people. And we finish with occupational stress, burnout, and caregiver strain.
The Spectrum
Normal Reactions to Abnormal Events
Reactions to difficult events run from the entirely expectable to the clearly disordered. The boundaries between them are contested rather than self-evident. Picture four regions on a chart of severity against duration, and notice how much they overlap. That overlap is the point, and it is not an imprecision in the drawing. The boundaries are set by convention and by threshold judgments, not by natural joints. Which is why the same presentation can be described differently by two competent clinicians. The category on the left is the largest, and it is the one most easily forgotten. Normal reactions to abnormal events. Distress following bereavement, serious illness, relationship breakdown, migration, or job loss. That is expectable, proportionate, and not a disorder. It may involve low mood, poor sleep, tearfulness, preoccupation, and reduced functioning for a period. And resolve as circumstances change, or as the person adapts. The risk of medicalizing it is real, and it runs in both directions. Treating expectable distress as a condition offers unnecessary treatment. It attaches a diagnosis with real consequences. And it can undermine a person's confidence in their own capacity to weather difficulty. But treating a genuine condition as expectable distress withholds treatment that would help. Neither error is obviously worse than the other. Which is why the boundary matters, and why it is contested. This material is educational, and is not a basis for diagnosis. New or unexplained physical symptoms require medical assessment.
Adjustment Disorder
Tied to a Stressor, and Expected to Resolve
Adjustment disorder is emotional or behavioral symptoms arising in response to an identifiable stressor. Beginning within a specified window after the stressor's onset. And meeting at least one of two conditions. Distress markedly out of proportion to the severity of the stressor. Taking cultural and contextual factors into account. Or significant impairment in functioning. Two further requirements complete it. The presentation must not be better explained by another condition. And it must not simply be an exacerbation of an existing one. And it is expected to resolve within a specified period after the stressor has ended. The condition is defined partly by not persisting. Now something different, which is frequently confused with all of this. Transient reactions in the hours and days after a sudden event. An accident, a serious diagnosis, an emergency admission. They can involve marked distress, disorientation, a sense of unreality, agitation, or apparent numbness. And difficulty taking in information. They typically settle within hours to days. These are not acute stress disorder or post-traumatic stress disorder. Those require a qualifying event of a specified kind, and a defined symptom picture. Two practical implications follow in a medical setting. A person in this state should not be expected to retain complex information. And their distress at the time does not by itself predict a later condition.
Subtypes
Distinguished by Feature Set, Not by Stressor
There are six subtypes, and one feature of the list is worth noticing before the detail. With depressed mood. Low mood, tearfulness, hopelessness about the situation. Typically following loss, a layoff, or relationship breakdown. With anxiety. Worry, tension, restlessness, and difficulty concentrating. Typically following a change with uncertain consequences. A diagnosis awaited, a move, a legal process. With mixed anxiety and depressed mood, which is the commonest presentation in practice. With disturbance of conduct. Behavior that violates rules, obligations, or the rights of others. More frequently seen in adolescents. With mixed disturbance of emotions and conduct, frequently where multiple stressors coincide. And unspecified, for maladaptive reactions not fitting the above. Physical complaints, or social withdrawal. Frequently in medical settings. Now the feature to notice. The subtypes are distinguished by feature set, not by stressor. The same stressor can produce any of them. And that last row exists because the category is a residual one. Which is exactly what the controversy turns on.
Contested
A Residual Category, Argued Both Ways
A residual category is one defined substantially by what it is not. Adjustment disorder is among the most contested in the classification system. Both sides deserve stating properly. The case against retaining it. Its reliability is poor. The central judgment, whether distress is out of proportion, has no operational definition. Different assessors reach different conclusions. It risks medicalizing expectable distress, since almost anyone in difficulty could be placed in it. Its boundaries are not sharply drawn. With normal reaction on one side, and depressive and anxiety conditions on the other. And it has attracted comparatively little research, partly because it is so loosely defined. Now the case for retaining it, which is stronger than students usually expect. Removing the category would not remove the presentations. People in real difficulty following an identifiable stressor exist in large numbers. Without a category they would get a diagnosis that fits worse. A depressive episode they do not actually meet. Or be recorded as having nothing, which in many systems means receiving nothing. A category that is time-limited, tied to a stressor, and expected to resolve carries less stigma. And its looseness is partly a virtue. A residual category absorbs presentations that do not fit elsewhere. Every classification system requires some. What is not in dispute is that the presentations are real. And that people in this position benefit from support. The argument is about how they should be recorded.
A Word Abandoned
Why Psychosomatic Is No Longer Used
The word psychosomatic was introduced to describe an interaction. Conditions in which psychological and physical processes were understood to influence each other. In ordinary usage it has come to mean something entirely different. Imagined. Invented. All in the mind. That drift is why the field has largely abandoned the term. So let us be exact. Psychosomatic does not mean imaginary. A person with a stress-related physical presentation has real symptoms. Produced by real physiological processes, of the kind described in thirteen point one. Muscle tension produces genuine pain. Autonomic activation produces genuine palpitations, and genuine digestive disturbance. Nothing is being invented. The modern preference is to describe the interaction rather than name a category. Physiological and psychological processes influence each other continuously. In every person, and in every condition. Which makes a special class of psychosomatic conditions misleading in the first place. Now, why this matters clinically rather than semantically. A person who hears that their symptoms are psychosomatic frequently hears that they are not believed. The documented consequences include disengagement from care. Seeking further investigation elsewhere. And delayed identification of conditions that were present and had not yet been found.
Two Statements
No Cause Found Is Not No Cause Exists
A functional somatic presentation involves real and frequently disabling symptoms. Without an identified structural cause. The difficulty is in how a system is functioning, rather than in an identifiable lesion. Now the distinction that carries the most weight in this whole section. It is between, no cause found, and, no cause exists. They are not the same statement, and they are constantly conflated. No cause found is a statement about the investigation. It means the tests conducted did not identify a structural abnormality. Tests have limits. Some conditions are not detectable by available methods. And some are identified only later. No cause exists is a statement about the person. It is not warranted by a negative investigation. And it is also, unfortunately, the statement the person frequently hears, whatever was said. There is an accurate third option, and it is the one that permits treatment. The symptom is real, and its mechanism is functional. Functional does not mean absent. It means the difficulty lies in how the system is working. Now why the wording decides the outcome. A person told there is nothing wrong has been given no explanation and no treatment. And an implicit accusation. A person given a positive functional explanation has been given something that makes sense. Something that can be worked with. The difference in outcome between those two conversations is substantial.
The Cycle
Each Circuit Adds an Investigation and a Worry
Follow the cycle around and notice one label in particular. The symptom persists. Worry increases. A further investigation is requested, and carried out. The result is negative, and reassurance follows. But the reassurance is temporary. That is what makes this a cycle rather than a sequence. Each circuit adds an investigation, and leaves the person marginally more worried than before. Which is the opposite of what each investigation was intended to achieve. The costs accumulate in four ways. Iatrogenic harm, which is harm caused by medical intervention itself. Each investigation carries some risk, and invasive procedures carry more. A cycle of unnecessary procedures produces real injury. Escalating worry. Each negative result reassures briefly, and then raises a new question. Because the symptom persists, and is now unexplained. Incidental findings, which generate further investigation of things that would never have caused difficulty. And deterioration of the clinical relationship. The person feels disbelieved, and the clinician feels the consultations are unproductive. Both are correct about the cycle, without either being at fault. Now, how it is interrupted. Not by refusing further tests. The person reasonably experiences that as dismissal. Give a positive explanation, rather than a negative result. We have not found anything, closes nothing at all. Explain what a test can and cannot establish, before ordering it. Do not require the person to accept a psychological account before receiving care. Validation comes first, and a formulation offered after it is far more likely to be accepted.
Occupational
Demand Is Not the Problem on Its Own
Two models of workplace stress have organized most of the research. Both make the same structural point. What matters is not the amount of demand alone, but its relationship to something else. The demand-control model says strain arises from high demand combined with low control. Control over how the work is done. And support moderates it. It predicts that high-demand, low-control roles show the worst outcomes. And here is the finding that makes the model useful rather than obvious. High-demand roles with high control need not be harmful at all. Demanding work is not the problem. Demanding work over which a person has no say is. The intervention it implies is to increase control and decision latitude. Rather than reducing demand, which is frequently not possible. The effort-reward imbalance model says strain arises where sustained effort is not matched by reward. Pay, security, esteem, or prospects. It predicts that imbalance produces poorer outcomes independently of demand level. And insecurity is a substantial contributor. So the intervention addresses the reward side, rather than the workload alone. The organizational factors most consistently associated with strain follow from these models. Excessive workload. Low control over how work is done. Unclear or conflicting role expectations. Insecurity. Insufficient support from managers and colleagues. Unfairness in how decisions are made. And poorly managed organizational change. Note that both models identify an organizational feature, rather than an individual one.
Burnout
Three Dimensions, and a Status Often Misstated
Burnout is characterized by three dimensions occurring together, in relation to work. Exhaustion. Cynicism or depersonalization. And reduced sense of professional efficacy. Exhaustion is depletion of emotional and physical resources. Feeling used up by the work. It differs from depressive fatigue in scope. It is typically tied to the work, and improves away from it. Depressive fatigue is pervasive across contexts. Cynicism is detachment from the work and, where the work involves people, from them. It is directed at the work specifically. Depressive presentations involve a broader loss of interest. Reduced professional efficacy is a sense of ineffectiveness and diminished accomplishment. Specific to the work role. Depressive worthlessness concerns the self more generally. So in every row the difference is one of scope. Burnout is bounded by the work, and depressive presentations are not. Now the classification status, which is frequently misstated. In the current international classification, burnout is included as an occupational phenomenon. A factor influencing health status. And explicitly not as a medical or psychiatric condition. It is defined as arising specifically from chronic workplace stress that has not been successfully managed. And the classification states it should not be applied to other areas of life. So describing burnout as a diagnosis is inaccurate. Finally, the debated boundary with depression, because that boundary is cleaner on paper than in practice. The two overlap substantially, and measures of them correlate strongly. Exhaustion in particular is difficult to distinguish from depressive fatigue. And severe burnout frequently co-occurs with, or precedes, a depressive episode. The disagreement in the field is live. What follows practically is that a person described as burnt out should be assessed for depression. Rather than having the occupational label close the question.
Caring, And Assessing
A Demand With No Off Switch
Caring for a relative with a long-term condition produces a distinctive pattern. It is worth naming separately, because it fits neither the occupational models nor an ordinary life stressor. The demand is continuous, rather than bounded by working hours. There is no separation between the role and home. So recovery, in the sense established earlier, is largely unavailable. The relationship itself changes, producing a form of loss alongside the workload. The role is frequently invisible and unrecognized. And the carer's own health needs are commonly deferred. Caregiver strain is associated with elevated rates of depressive and anxiety presentations. And with poorer physical health outcomes. The interventions with the best evidence address the demand itself. Respite and practical support. Rather than the carer's coping alone. Four elements belong in the assessment of any stress-related presentation. A stressor history. What the demands are, how long they have been present. How much control the person has, and what support exists. Asked indirectly, since direct questions about stress under-detect. The temporal relationship. Whether symptoms began after the stressor, and fluctuate with it. That is suggestive, and it is not proof. Coincidence is common, and people search for explanations retrospectively. Screening for the anxiety and depressive conditions of chapters eleven and twelve. Any of those may be the whole picture, may co-occur, or may have developed from an adjustment reaction. And coordination with medical colleagues, which is not optional where physical symptoms are present.
Management
Stepped, and Aimed at the Right Level
Management follows a stepped approach, described at the level of principle. Normalization and support come first. For expectable distress following an identifiable stressor, the first step is frequently an explanation. That the reaction is expectable. Plus practical support, and time. Not treatment. That is a real intervention rather than the absence of one. And it is the step most often skipped. Then problem-focused work on modifiable stressors. Where something about the situation can be changed, changing it is the intervention. Helping a person address a modifiable problem is frequently more useful than helping them tolerate it. Then cognitive approaches to appraisal, where the appraisal is contributing. With the qualification that where an appraisal is accurate, there is nothing to restructure. And graded activity for functional presentations, described only as a clinician-guided principle. Where a functional presentation has produced reduced activity and increasing deconditioning. A graded return to activity, planned and supervised by a clinician, is a recognized approach. No schedule and no targets appear here. Pacing such a program is exactly the part that requires professional judgment. Now the most important statement in this section, and it concerns occupational stress. Individual-level interventions alone do not resolve organizationally caused strain. Where the source is excessive workload, low control, insecurity, or unfairness. Teaching individuals to cope better produces limited and short-lived effects. Because the demand is unchanged. Interventions addressing the organizational features show better and more durable results. One last skill, and it is doing two things at once. Lead with the reality of the symptom. That is the precondition for anything else being heard. Explain the mechanism positively, which is accurate and non-accusatory. Avoid the word just, because it contains the dismissal the person is bracing for. And do not make acceptance of the formulation a condition of care.
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