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News Gram™ February 2005

February 2005 ~ Volume 11, No. 7

The concept of stress is an evolving one, which means that the clinical application of this idea changes with time. In the context of employment-based injury, understanding the role of stress is crucial. NaÔve, vague and unscientific accounts of stress and its related syndromes will have increasing difficulty passing muster in a medical-legal context.

If we are to have a serviceable notion of stress, then we need to understand somewhat the neurological, endocrine and psychiatric aspects of the various conditions in which stress plays a significant role. First, a few points:

• Stress is a fact of life. We can't avoid it and, in many cases, shouldn't.
• Clinical stress always involves a fight-flight reaction.
• Most people who say they're suffering from stress are probably
bothered by something else.
• What is ordinary to one person can be enormously stressful to another.

Central to the idea of a stress disorder is that of a personal experience involving actual or threatening death or serious injury, namely a threat to one's physical integrity.

Witnessing such an event befall someone else also qualifies as such a stressor. Extending this idea a bit, such experiences may include being mugged, beaten, raped, or shot at, as in a military situation. Sexual exploitation of children with the associated experience of powerlessness may have serious, lasting consequences.

Most importantly, there is no absolute when it comes to stress. That is, someone who experiences a serious stressor, as in the case of a person being beaten and robbed, may not develop a post-traumatic stress disorder, while someone who does not get a promotion may develop signs and symptoms of a stress condition. The reason is that the impact of a stressor is a function of the previous experiences a person has had as well as his or her innate ability to contend with difficult circumstance.

The central point about the nature of the stressor is that it is usually sudden and overwhelming. That is, it is more than the person can contend with short of fleeing the scene or engaging in a battle of one sort or another. This inability makes it impossible for the person to integrate the experience into the stream of experiences that constitute his memory and sense of identity.

Perhaps because of the failure to integrate the traumatic experience into the stream of consciousness, the affected person re-experiences it over and over again. In this way, he or she internalizes it and gradually puts it in its proper perspective. What started out as alien and threatening, is tempered, if not neutralized with respect to its ability to stimulate the physiological alterations in normal functioning that make up a stress reaction. Often, the person may experience recurrent dreams for much the same reason. In some instances, a person may actually hallucinate, i.e., dissociate from the experience and treat it as if it is apart from her. So-called flashbacks often occur in which something as simple as a sound or a stranger's face may evoke a powerful affective response replete with trembling, marked muscular tension and dilated pupils.

Accompanying the repetitive re-experiencing of the traumatic event are physiological changes such as rapid pulse, sweating, shakiness and increasing respiratory excursions. Subjectively, these alterations can produce a feeling of impending doom, a foreshortened lifespan and a sense of terror. Accompanying each of these heightened states is a marked sense of urgency, a need to do something, to eliminate the source of the profound discomfort. This is the heart of the fight and flight response.

If these episodes persist, the person begins to avoid any stimuli that will evoke memories and emotions connected to the original traumatic experience. Thinking is truncated as the person tries not to think of any reminders of what happened. Places, and people are avoided as well for the same reason. There is a resultant sense that one is estranged from others, unattached to the main flow of events in the environment.

With the increased arousal that accompanies this wide spectrum of behavioral and experiential changes, there are problems falling and staying asleep, irritability, increased vigilance, an exaggerated startle response and difficulty concentrating. The end result is a marked change in the way the person presents himself in public and in the way he experiences his thoughts, feelings and behaviors.

From a clinical and legal standpoint, this global transformation, the result of the numerous behavioral, psychological and physiological changes that have ensued in the wake of the trauma, is what a psychiatrist is most interested in seeing. They point to a change in functioning, in adaptation and in interpersonal relations. This overall change in functioning and appearance gives the impression that there has been a fundamental alteration in the way the person confronts the world, understands his or her problems and then seeks to solve them.

All of the above provides the psychiatric picture of what someone contending with a stress-related problem is like. However, what grounds these various features of such reactive patterns in the stone-hardness of reality is the underlying physiological and neurological changes that occur beyond the visible presentation of the person. These are the biochemical and endocrinological signals that produce the behavioral features of a stress disorder.

Next month: Part II: The neuro-endocrinology of stress.

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