The psychiatric disorders classified in ICD-10 and DSM-IV as resulting from stress include acute stress reactions, posttraumatic stress disorder (PTSD), and adjustment disorder. Acute stress reactions and PTSD develop in response to exceptionally threatening experiences, but acute stress subsides within days (and is not considered further), whereas PTSD is more prolonged. This disorder consists of persistent, intrusive recall or reenactment of the traumatic event in memories, dreams, and flashbacks. Restriction of the emotions, avoidance of situations that might provoke memories of the trauma, and increased arousal to particular perceptual stimuli, e.g. sudden loud sounds, are associated symptoms.
There is clear evidence that the experience and management of pain can be aggravated by PTSD. One of the main reasons for this is because PTSD is associated with high anxiety and we have seen that anxiety is associated comorbidly with chronic pain.26 Furthermore, the presence of PTSD is a poor prognostic sign.44'45 Hyper-arousal, excessive attention to changes in the environment, and an inclination to focus on bodily symptoms are frequent accompaniments of both PTSD and chronic pain, which may explain these findings.46
If PTSD is identified, treatment should be carried out by a specialized team who are familiar with treatment procedures in this condition. Debriefing and superficial treatments of this type are not valuable and have been found to worsen the prognosis in those who have more intense symptoms.47[II] Trauma-focused CBT and eye movement desensitization and reprocessing (EMDR), a technique that involves movement of the patient's eyes in a systematic way whilst recalling disturbing memories, have been found to be effective in treating PTSD in a recent meta-analysis.48 Either of these treatments is recommended as first-line in the treatment of PTSD according to a recent national guideline.49 If facilities for such treatment are not available or if these therapies are not successful, treatment with the antidepressant drugs, amitriptyline, mirtazapine, or phenelzine has been shown to be effective.49
Adjustment disorders consist of states of emotional distress that arise following a major life change or stressful life event. The symptoms accompanying this disorder include excessive worrying, mild depressed mood, poor sleep, inability to cope, and some difficulties in carrying out daily routines. However, the symptoms are not usually persistent and do not reach the threshold to enable an alternative psychiatric illness to be diagnosed. These disorders are considered to develop in response to a variety of stressful events, the symptoms representing an adaptation to these stressors or to their continuing effects. The difficulty is in deciding what is abnormal or delayed adaptation. By definition, these disorders would not have developed but for the stressful event. Symptoms last for less than six months, except in the case of prolonged depressive reaction, otherwise an alternative diagnosis should be sought. In an early study of patients with chronic pain, male patients had adjustment disorder significantly more frequently than females, but this may have been more related to change in work status.50 In most cases, it is not thought that specific intervention is necessary.
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