Stress

Course Objectives:

1 Understanding Mind Body Health

2 Identify the Uunderlying cause of Stress

3 Identifying the Different Kinds of Stress

4 Myths about Stress

5 Learning to deal with Stress

 

Mind/Body Health: Stress

We’ve probably all felt stress. Sometimes it’s brief and highly situational, like being in heavy traffic. Other times, it’s more persistent and complex—relationship problems, an ailing family member, a spouse’s death. And sometimes, stress can motivate us to accomplish certain tasks.

Dangerous Stress

Stress becomes dangerous when it interferes with your ability to live a normal life for an extended period of time. You may feel “out of control” and have no idea of what to do, even if the cause is relatively minor. This in turn, may cause you to feel continually fatigued, unable to concentrate, or irritable in otherwise relaxed situations. Prolonged stress may also compound any emotional problems stemming from sudden events such traumatic experiences in your past, and increase thoughts of suicide.

Natural reactions

Stress can also affect your physical health because of the human body’s built-in response mechanisms. You may have found yourself sweating at the thought of an important date, or felt your heartbeat pick up while watching a scary movie. These reactions are caused by hormones that scientists believe helped our ancestors cope with the threats and uncertainties of their world.

If the cause of your stress is temporary, the physical effects are usually short-term as well. In one study, the pressure of taking exams led to increased severity of acne among college students, regardless of how they ate or slept. The condition diminished after exams were over. Abdominal pain and irregularity have also been linked to situational stress.
The longer your mind feels stressed, however, the longer your physical reaction systems remain activated. This can lead to more serious health issues.

Physical wear and tear

The old saying that stress “ages” a person faster than normal was recently verified in a study of women who had spent many years caring for severely ill and disabled children. Because their bodies were no longer able to fully regenerate blood cells, these women were found to be physically a decade older than their chronological age.

Extended reactions to stress can alter the body’s immune system in ways that are associated with other “aging” conditions such as frailty, functional decline, cardiovascular disease, osteoporosis, inflammatory arthritis, type 2 diabetes, and certain cancers.

Research also suggests that stress impairs the brain’s ability to block certain toxins and other large, potentially harmful molecules. This condition is also common to patients suffering from Alzheimer’s Disease.

Pressure points

Although sudden emotional stress has been linked to severe heart dysfunction in otherwise healthy people, scientists are uncertain whether chronic stress alone causes cardiovascular disease. What is clear is that excessive stress can worsen existing risk factors such as hypertension and high cholesterol levels. Studies also show that people who are quick to anger or who display frequent hostility—a behavior common to those under stress—have an increased risk of heart disease and crying fits.

Feelings of despair that accompany stress can easily worsen into chronic depression, a condition that can lead you to neglect good diet and activity habits. This, in turn, can put you at a greater risk for heart disease, obesity, and kidney dysfunction.

Stress can also complicate your ability to recover from a serious illness. A Swedish study found that women who have suffered heart attacks tend to have poorer chances of recovery if they are also experiencing marital stressors such as infidelity, alcohol abuse, and a spouse’s physical or psychiatric illness. On the other hand, stress management training is a proven method for helping speed recovery follow a heart attack.

What you can do

Learning to deal with stress effectively is a worthwhile effort, even if you already consider yourself capable of handling anything life sends your way.

Many of the most common long-term stressors—family illness, recovery after injury, career pressures—often arise without warning and simultaneously. Stress management is particularly valuable if your family has a history of hypertension and other forms of heart disease.

Identify the cause.You may find that your stress arises from something that’s easy to correct. A psychologist can help you define and analyze these stressors, and develop action plans for dealing with them.

Monitor your moods. If you feel stressed during the day, write down what caused it along your thoughts and moods. Again, you may find the cause to be less serious than you first thought.

Make time for yourself at least two or three times a week. Even ten minutes a day of “personal time” can help refresh your mental outlook and slow down your body’s stress response systems. Turn off the phone, spend time alone in your room, exercise, or meditate to your favorite music.

Walk away when you’re angry.Before you react, take time to mentally regroup by counting to 10. Then look at the situation again. Walking or other physical activities will also help you work off steam.

Analyze your schedule.Assess your priorities and delegate whatever tasks you can (e.g., order out dinner after a busy day, share household responsibilities). Eliminate tasks that are “shoulds” but not “musts.”

Set reasonable standards for yourself and others. Don’t expect perfection.

Stress: The Different Kinds of Stress

Stress management can be complicated and confusing because there are different types of stress--acute stress, episodic acute stress, and chronic stress -- each with its own characteristics, symptoms, duration, and treatment approaches. Let's look at each one.

Acute Stress

Acute stress is the most common form of stress. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. Acute stress is thrilling and exciting in small doses, but too much is exhausting. A fast run down a challenging ski slope, for example, is exhilarating early in the day. That same ski run late in the day is taxing and wearing. Skiing beyond your limits can lead to falls and broken bones. By the same token, overdoing on short-term stress can lead to psychological distress, tension headaches, upset stomach, and other symptoms.

Fortunately, acute stress symptoms are recognized by most people. It's a laundry list of what has gone awry in their lives: the auto accident that crumpled the car fender, the loss of an important contract, a deadline they're rushing to meet, their child's occasional problems at school, and so on.

Because it is short term, acute stress doesn't have enough time to do the extensive damage associated with long-term stress. The most common symptoms are:

- emotional distress--some combination of anger or irritability, anxiety, and depression, the three stress emotions;

- muscular problems including tension headache, back pain, jaw pain, and the muscular tensions that lead to pulled muscles and tendon and ligament problems;\

- stomach, gut and bowel problems such as heartburn, acid stomach, flatulence, diarrhea, constipation, and irritable bowel syndrome;

- transient over arousal leads to elevation in blood pressure, rapid heartbeat, sweaty palms, heart palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, and chest pain.

Acute stress can crop up in anyone's life, and it is highly treatable and manageable.

Episodic Acute Stress

There are those, however, who suffer acute stress frequently, whose lives are so disordered that they are studies in chaos and crisis. They're always in a rush, but always late. If something can go wrong, it does. They take on too much, have too many irons in the fire, and can't organize the slew of self-inflicted demands and pressures clamoring for their attention. They seem perpetually in the clutches of acute stress.

It is common for people with acute stress reactions to be over aroused, short-tempered, irritable, anxious, and tense. Often, they describe themselves as having "a lot of nervous energy." Always in a hurry, they tend to be abrupt, and sometimes their irritability comes across as hostility. Interpersonal relationships deteriorate rapidly when others respond with real hostility. The work becomes a very stressful place for them.

The cardiac prone, "Type A" personality described by cardiologists, Meter Friedman and Ray Rosenman, is similar to an extreme case of episodic acute stress. Type A's have an "excessive competitive drive, aggressiveness, impatience, and a harrying sense of time urgency." In addition there is a "free-floating, but well-rationalized form of hostility, and almost always a deep-seated insecurity." Such personality characteristics would seem to create frequent episodes of acute stress for the Type A individual. Friedman and Rosenman found Type A's to be much more likely to develop coronary heat disease than Type B's, who show an opposite pattern of behavior.

Another form of episodic acute stress comes from ceaseless worry. "Worry warts" see disaster around every corner and pessimistically forecast catastrophe in every situation. The world is a dangerous, unrewarding, punitive place where something awful is always about to happen. These "awfulizers" also tend to be over aroused and tense, but are more anxious and depressed than angry and hostile.

The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent tension headaches, migraines, hypertension, chest pain, and heart disease. Treating episodic acute stress requires intervention on a number of levels, generally requiring professional help, which may take many months.

Often, lifestyle and personality issues are so ingrained and habitual with these individuals that they see nothing wrong with the way they conduct their lives. They blame their woes on other people and external events. Frequently, they see their lifestyle, their patterns of interacting with others, and their ways of perceiving the world as part and parcel of who and what they are.
Sufferers can be fiercely resistant to change. Only the promise of relief from pain and discomfort of their symptoms can keep them in treatment and on track in their recovery program.

Chronic Stress

While acute stress can be thrilling and exciting, chronic stress is not. This is the grinding stress that wears people away day after day, year after year. Chronic stress destroys bodies, minds and lives. It wreaks havoc through long-term attrition. It's the stress of poverty, of dysfunctional families, of being trapped in an unhappy marriage or in a despised job or career. It's the stress that the never-ending "troubles" have brought to the people of Northern Ireland, the tensions of the Middle East have brought to the Arab and Jew, and the endless ethnic rivalries that have been brought to the people of Eastern Europe and the former Soviet Union.
Chronic stress comes when a person never sees a way out of a miserable situation. It's the stress of unrelenting demands and pressures for seemingly interminable periods of time. With no hope, the individual gives up searching for solutions.

Some chronic stresses stem from traumatic, early childhood experiences that become internalized and remain forever painful and present. Some experiences profoundly affect personality. A view of the world, or a belief system, is created that causes unending stress for the individual (e.g., the world is a threatening place, people will find out you are a pretender, you must be perfect at all times). When personality or deep-seated convictions and beliefs must be reformulated, recovery requires active self-examination, often with professional help.
The worst aspect of chronic stress is that people get used to it. They forget it's there. People are immediately aware of acute stress because it is new; they ignore chronic stress because it is old, familiar, and sometimes, almost comfortable.

Chronic stress kills through suicide, violence, heart attack, stroke, and, perhaps, even cancer. People wear down to a final, fatal breakdown. Because physical and mental resources are depleted through long-term attrition, the symptoms of chronic stress are difficult to treat and may require extended medical as well as behavioral treatment and stress management.

Stress: Six Myths About Stress

Six myths surround stress. Dispelling them enables us to understand our problems and then take action against them. Let's look at these myths.

Myth 1: Stress is the same for everybody.
Completely wrong. Stress is different for each of us. What is stressful for one person may or may not be stressful for another; each of us responds to stress in an entirely different way.

Myth 2: Stress is always bad for you.
According to this view, zero stress makes us happy and healthy. Wrong. Stress is to the human condition what tension is to the violin string: too little and the music is dull and raspy; too much and the music is shrill or the string snaps. Stress can be the kiss of death or the spice of life. The issue, really, is how to manage it. Managed stress makes us productive and happy; mismanaged stress hurts and even kills us.

Myth 3: Stress is everywhere, so you can't do anything about it.
Not so. You can plan your life so that stress does not overwhelm you. Effective planning involves setting priorities and working on simple problems first, solving them, and then going on to more complex difficulties. When stress is mismanaged, it's difficult to prioritize. All your problems seem to be equal and stress seems to be everywhere.

Myth 4: The most popular techniques for reducing stress are the best ones.
Again, not so. No universally effective stress reduction techniques exist. We are all different, our lives are different, our situations are different, and our reactions are different. Only a comprehensive program tailored to the individual works.

Myth 5: No symptoms, no stress.
Absence of symptoms does not mean the absence of stress. In fact, camouflaging symptoms with medication may deprive you of the signals you need for reducing the strain on your physiological and psychological systems.

Myth 6: Only major symptoms of stress require attention.
This myth assumes that the "minor" symptoms, such as headaches or stomach acid, may be safely ignored. Minor symptoms of stress are the early warnings that your life is getting out of hand and that you need to do a better job of managing stress.

Learning to Deal with Stress

What is causing people the most stress in the New Year? A recent survey by the American Psychological Association said the following issues are the top vote getters:

- 63% of those surveyed said money issues;
- 44% said national security; and
- 31% said job security.

Younger Americans were more worried about money (74%) and national security (40%) than those over 35.

Many of us include getting a handle on stress as part of our New Years resolutions, and the survey also shows the most popular things we do to deal with our worries:

- One-third of us either eat (22%) or drink alcohol (14%) to cope with stress;

- Others rely on exercise (45%) and religious and spiritual activities (44%);

- 14% turn to massage and yoga to relieve stress.

If you've resolved to get a handle on stress in the new year, psychologists offer this bit of advice: The quickest fixes are rarely the best fixes. In fact, they can sometimes cause more harm than good.

While people tend to reduce stress in familiar ways they've learned over time, those ways may not be good for their health. In fact, these healthier behaviors can have added effects and be longer lasting when trying to deal with stress and build resilience:

- Make connections - Good relationships with family and friends are important. Make an attempt to reconnect with people. Accepting help and support from those who care about you can help alleviate stress.

- Set realistic goals -Take small concrete steps to deal with tasks instead of overwhelming yourself with goals that are too far-reaching for busy times.

- Keep things in perspective - Try to consider stressful situations in a broader context and keep a long-term perspective. Avoid blowing events out of proportion.

- Take decisive actions - Instead of letting stressors get the best of you, make a decision to address the underlying cause of a stressful situation.

- Take care of yourself - Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Taking care of yourself helps keep your mind and body primed to deal with stressful situations.

Listening to the Warning Signs of Stress

Your boss dumps a last-minute presentation on you. You feel annoyed, but confident that you can handle it. An hour later the phone rings—it’s day care. Your daughter is sick and you need to pick up her up. The day continues as more bad news continues to interrupt your day, one that you thought would be problem-free. That crankiness you feel, that headache, that tension in your neck and that desire to devour a box of chocolates—that’s you feeling stressed. It’s also your body sending out a call for help.

Stress is your body’s natural reaction to any kind of demand that disrupts life as usual. In small doses, stress is good—such as when it helps your conquer a fear or gives extra endurance and motivation to get something done. But there’s also bad stress, which is often caused by worries such as our money, jobs, relationships or health, whether it be sudden and short or long-lasting. Feeling stress for too long, whether for several hours, days or months, sets off your body’s warning system of physical and emotional alarms.

Your body’s stress warning signs tell you that that something isn’t right. Much like the glowing orange, “check engine” light on your car’s dashboard, if you neglect the alerts sent out by your body, you could have a major engine malfunction. Stress that is left unchecked or poorly managed is known to contribute to high blood pressure, heart disease, obesity, diabetes and suicide.

So when things aren’t going your way, or you feel like you are losing control or are overwhelmed, pay attention to the warning signs listed below. They are just some of the ways that your body is telling you it needs maintenance and extra care.

• Headaches, muscle tension, neck or back pain
• Upset stomach
• Dry mouth
• Chest pains, rapid heartbeat
• Difficulty falling or staying asleep
• Fatigue
• Loss of appetite or overeating “comfort foods”
• Increased frequency of colds
• Lack of concentration or focus
• Memory problems or forgetfulness
• Jitters
• Irritability
• Short temper
• Anxiety

Everyone reacts to stress differently, and each body sends out its different set of red flags. Some people may not even feel the physical or emotional warning signs until hours or days of stressful activities. But when you do notice a stiff back or that you are snapping at your friends, pay attention to the signs and listen to what your body is telling you. While the adrenaline rush after acing that presentation to the board is something to enjoy, the warning signs of stress are not anything to take lightly or ignore. By noticing how you respond to stress, you can manage it better and in healthy ways, which will help your body correct itself, reducing the high cost and care of chronic, long-term health problems.

Managing Your Stress in Tough Economic Times

As talk of falling housing prices, rising consumer debt and declining retail sales bring up worries about the nation’s economic health, more Americans feel additional stress and anxiety about their financial future.

Money is often on the minds of most Americans. In fact, money and work are two of the top sources of stress for almost 75 percent of Americans, according to the American Psychological Association’s 2007 Stress in America survey. Add to the mix headlines declaring a looming economic recession, and many begin to fear how they can handle any further financial crunch.

But, like most of our everyday stress, this extra tension can be managed. Psychologists first recommend taking pause and not panicking. While there are some unknown effects in every economic downturn, our nation has experienced recessions before. There are also healthy strategies available for managing stress during tough economic times.

The American Psychological Association offers these tips to help deal with your stress about money and the economy:

Pause but don’t panic. There are many negative stories in newspapers and on television about the state of the economy. Pay attention to what’s happening around you, but refrain from getting caught up in doom-and-gloom hype, which can lead to high levels of anxiety and bad decision making. Avoid the tendency to overreact or to become passive. Remain calm and stay focused.

Identify your financial stressors and make a plan. Take stock of your particular financial situation and what causes you stress. Write down specific ways you and your family can reduce expenses or manage your finances more efficiently. Then commit to a specific plan and review it regularly. Although this can be anxiety-provoking in the short term, putting things down on paper and committing to a plan can reduce stress. If you are having trouble paying bills or staying on top of debt, reach out for help by calling your bank, utilities or credit card company.

Recognize how you deal with stress related to money. In tough economic times some people are more likely to relieve stress by turning to unhealthy activities like smoking, drinking, gambling or emotional eating. The strain can also lead to more conflict and arguments between partners. Be alert to these behaviors—if they are causing you trouble, consider seeking help from a psychologist or community mental health clinic before the problem gets worse.

Turn these challenging times into opportunities for real growth and change. Times like this, while difficult, can offer opportunities to take stock of your current situation and make needed changes. Think of ways that these economic challenges can motivate you to find healthier ways to deal with stress. Try taking a walk—it’s an inexpensive way to get good exercise. Having dinner at home with your family may not only save you money, but help bring you closer together. Consider learning a new skill. Take a course through your employer or look into low-cost resources in your community that can lead to a better job. The key is to use this time to think outside the box and try new ways of managing your life.

Ask for professional support. Credit counseling services and financial planners are available to help you take control over your money situation. If you continue to be overwhelmed by the stress, you may want to talk with a psychologist who can help you address the emotions behind your financial worries, manage stress, and change unhealthy behaviors.

The Road To Resilience
Introduction

How do people deal with difficult events that change their lives? The death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events: these are all examples of very challenging life experiences. Many people react to such circumstances with a flood of strong emotions and a sense of uncertainty.

Yet people generally adapt well over time to life-changing situations and stressful conditions. What enables them to do so? It involves resilience, an ongoing process that requires time and effort and engages people in taking a number of steps.

This brochure is intended to help readers with taking their own road to resilience. The information within describes resilience and some factors that affect how people deal with hardship. Much of the brochure focuses on developing and using a personal strategy for enhancing resilience.

What Is Resilience?

Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress -- such as family and relationship problems, serious health problems, or workplace and financial stressors. It means "bouncing back" from difficult experiences.

Research has shown that resilience is ordinary, not extraordinary. People commonly demonstrate resilience. One example is the response of many Americans to the September 11, 2001 terrorist attacks and individuals' efforts to rebuild their lives.

Being resilient does not mean that a person doesn't experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. In fact, the road to resilience is likely to involve considerable emotional distress.
Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts, and actions that can be learned and developed in anyone.

Resilience Factors & Strategies
Factors in Resilience

A combination of factors contributes to resilience. Many studies show that the primary factor in resilience is having caring and supportive relationships within and outside the family. Relationships that create love and trust, provide role models, and offer encouragement and reassurance help bolster a person's resilience.

Several additional factors are associated with resilience, including:

  • The capacity to make realistic plans and take steps to carry them out
  • A positive view of yourself and confidence in your strengths and abilities
  • Skills in communication and problem solving
  • The capacity to manage strong feelings and impulses

All of these are factors that people can develop in themselves.

Strategies For Building Resilience

Developing resilience is a personal journey. People do not all react the same to traumatic and stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies.

Some variation may reflect cultural differences. A person's culture might have an impact on how he or she communicates feelings and deals with adversity -- for example, whether and how a person connects with significant others, including extended family members and community resources. With growing cultural diversity, the public has greater access to a number of different approaches to building resilience.

Some or many of the ways to build resilience in the following pages may be appropriate to consider in developing your personal strategy.

10 Ways to Build Resilience

Make connections. Good relationships with close family members, friends, or others are important. Accepting help and support from those who care about you and will listen to you strengthens resilience. Some people find that being active in civic groups, faith-based organizations, or other local groups provides social support and can help with reclaiming hope. Assisting others in their time of need also can benefit the helper.

Avoid seeing crises as insurmountable problems. You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.

Accept that change is a part of living. Certain goals may no longer be attainable as a result of adverse situations. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter.

Move toward your goals. Develop some realistic goals. Do something regularly -- even if it seems like a small accomplishment -- that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"

Take decisive actions. Act on adverse situations as much as you can. Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away.

Look for opportunities for self-discovery. People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality, and heightened appreciation for life.

Nurture a positive view of yourself. Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.

Keep things in perspective. Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion.

Maintain a hopeful outlook. An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.

Take care of yourself. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.

Additional ways of strengthening resilience may be helpful. For example, some people write about their deepest thoughts and feelings related to trauma or other stressful events in their life. Meditation and spiritual practices help some people build connections and restore hope.

The key is to identify ways that are likely to work well for you as part of your own personal strategy for fostering resilience.

Learning From Your Past

Some Questions to Ask Yourself

Focusing on past experiences and sources of personal strength can help you learn about what strategies for building resilience might work for you. By exploring answers to the following questions about yourself and your reactions to challenging life events, you may discover how you can respond effectively to difficult situations in your life.
Consider the following:

  • What kinds of events have been most stressful for me?
  • How have those events typically affected me?
  • Have I found it helpful to think of important people in my life when I am distressed?
  • To whom have I reached out for support in working through a traumatic or stressful experience?
  • What have I learned about myself and my interactions with others during difficult times?
  • Has it been helpful for me to assist someone else going through a similar experience?
  • Have I been able to overcome obstacles, and if so, how?
  • What has helped make me feel more hopeful about the future?
Staying Flexible

Resilience involves maintaining flexibility and balance in your life as you deal with stressful circumstances and traumatic events. This happens in several ways, including:

  • Letting yourself experience strong emotions, and also realizing when you may need to avoid experiencing them at times in order to continue functioning
  • Stepping forward and taking action to deal with your problems and meet the demands of daily living, and also stepping back to rest and reenergize yourself
  • Spending time with loved ones to gain support and encouragement, and also nurturing yourself
  • Relying on others, and also relying on yourself
Whether from a charging lion, or a pending deadline, the body’s response to stress can be both helpful and harmful. The stress response gives us the strength and speed to ward off or flee from an impending threat. But when it persists, stress can put us at risk for obesity, heart disease, cancer, and a variety of other illnesses.

Perhaps the greatest understanding of stress and its effects has resulted from a theory by George Chrousos, M.D., Chief of the Pediatric and Reproductive Endocrinology Branch at the National Institute of Child Health and Human Development (NICHD), and Philip Gold, MD, of the Clinical Neuroendocrinology Branch at the National Institute of Mental Health (NIMH).

A threat to your life or safety triggers a primal physical response from the body, leaving you breathless, heart pounding, and mind racing. From deep within your brain, a chemical signal speeds stress hormones through the bloodstream, priming your body to be alert and ready to escape danger. Concentration becomes more focused, reaction time faster, and strength and agility increase. When the stressful situation ends, hormonal signals switch off the stress response and the body returns to normal.

But in our modern society, stress doesn’t always let up. Many of us now harbor anxiety and worry about daily events and relationships. Stress hormones continue to wash through the system in high levels, never leaving the blood and tissues. And so, the stress response that once gave ancient people the speed and endurance to escape life-threatening dangers runs constantly in many modern people and never shuts down.

Research now shows that such long-term activation of the stress system can have a hazardous, even lethal effect on the body, increasing risk of obesity, heart disease, depression, and a variety of other illnesses.

Much of the current understanding of stress and its effects has resulted from the theory by Drs. Chrousos and Gold. Their theory explains the complex interplay between the nervous system and stress hormones — the hormonal system known as the hypothalamic-pituitary-adrenal (HPA) axis. Over the past 20 years, Dr. Chrousos and his colleagues have employed the theory to understand a variety of stress-related conditions, including depression, Cushing’s syndrome, anorexia nervosa, and chronic fatigue syndrome.

The Stress Circuit
The HPA axis is a feedback loop by which signals from the brain trigger the release of hormones needed to respond to stress. Because of its function, the HPA axis is also sometimes called the “stress circuit.”

Briefly, in response to a stress, the brain region known as the hypothalamus releases corticotropin-releasing hormone (CRH). In turn, CRH acts on the pituitary gland, just beneath the brain, triggering the release of another hormone, adrenocorticotropin (ACTH) into the bloodstream. Next, ACTH signals the adrenal glands, which sit atop the kidneys, to release a number of hormonal compounds.

These compounds include epinephrine (formerly known as adrenaline), Norepinephrine (formerly known as noradrenaline) and cortisol. All three hormones enable the body to respond to a threat. Epinephrine increases blood pressure and heart rate, diverts blood to the muscles, and speeds reaction time. Cortisol, also known as glucocorticoid, releases sugar (in the form of glucose) from the body reserves so that this essential fuel can be used to power the muscles and the brain.

Normally, cortisol also exerts a feedback effect to shut down the stress response after the threat has passed, acting upon the hypothalamus and causing it to stop producing CRH.

This stress circuit affects systems throughout the body. The hormones of the HPA axis exert their effect on the autonomic nervous system, which controls such vital functions as heart rate, blood pressure, and digestion.

The HPA axis also communicates with several regions of the brain, including the limbic system, which controls motivation and mood, with the amygdala, which generates fear in response to danger, and with the hippocampus, which plays an important part in memory formation as well as in mood and motivation. In addition, the HPA axis is also connected with brain regions that control body temperature, suppress appetite, and control pain.

Similarly, the HPA axis also interacts with various other glandular systems, among them those producing reproductive hormones, growth hormones, and thyroid hormones. Once activated, the stress response switches off the hormonal systems regulating growth, reproduction, metabolism, and immunity. Short term, the response is helpful, allowing us to divert biochemical resources to dealing with the threat.

Stress, heredity, and the environment
According to Dr. Chrousos, this stress response varies from person to person. Presumably, it is partially influenced by heredity. For example, in most people the HPA axis probably functions appropriately enough, allowing the body to respond to a threat, and switching off when the threat has passed. Due to differences in the genes that control the HPA axis, however, other people may fail to have a strong enough response to a threat, while still others may over respond to even minor threats.

Beyond biological differences, the HPA axis also can alter its functioning in response to environmental influences. The HPA axis may permanently be altered as a result of extreme stress at any time during the life cycle — during adulthood, adolescence, early childhood, or even in the womb.

If there are major stresses in early childhood, the HPA feedback loop becomes stronger and stronger with each new stressful experience. This results in an individual who, by adulthood, has an extremely sensitive stress circuit in place. In life threatening situations — such as life in an area torn by war — this exaggerated response would help an individual to survive. In contemporary society, however, it usually causes the individual to overreact hormonally to comparatively minor situations.

Effects on the body
Stress and the Reproductive system

Stress suppresses the reproductive system at various levels, says Dr. Chrousos. First, CRH prevents the release of gonadotropin releasing hormone (GnRH), the “master” hormone that signals a cascade of hormones that direct reproduction and sexual behavior. Similarly, cortisol and related glucocorticoid hormones not only inhibit the release of GnRH, but also the release of luteinizing hormone, which prompts ovulation and sperm release. Glucocorticoids also inhibit the testes and ovaries directly, hindering production of the male and female sex hormones testosterone, estrogen, and progesterone.

The HPA overactivity that results from chronic stress has been shown to inhibit reproductive functioning in anorexia nervosa and in starvation, as well as in highly trained ballet dancers and runners. For example, in one study, Chrousos found that men who ran more than 45 miles per week produced high levels of ACTH and cortisol in response to the stress of extreme exercise. These male runners had low LH and testosterone levels. Other studies have shown that women undertaking extreme exercise regimens had ceased ovulating and menstruating.

However, the interaction between the HPA axis and the reproductive system is also a two way street. The female hormone estrogen exerts partial control of the gene that stimulates CRH production. This may explain, why, on average, women have slightly elevated cortisol levels. In turn, higher cortisol levels, in combination with other, as yet unknown, factors, may be the reason why women are more vulnerable than men to depression, anorexia nervosa, panic disorder, obsessive compulsive disorder, and autoimmune diseases like lupus and rheumatoid arthritis.

Growth and stress
The hormones of the HPA axis also influence hormones needed for growth. Prolonged HPA activation will hinder the release of growth hormone and insulin-like growth factor 1 (IGF-1), both of which are essential for normal growth. Glucocorticoids released during prolonged stress also cause tissues to be less likely to respond to IGF-1. Children with Cushing’s syndrome — which results in high glucocorticoid levels — lose about 7.5 to 8.0 centimeters from their adult height.

Similarly, premature infants are at an increased risk for growth retardation. The stress of surviving in an environment for which they are not yet suited, combined with the prolonged stress of hospitalization in the intensive care unit, presumably activates the HPA axis. Growth retarded fetuses also have higher levels of CRH, ACTH, and cortisol, probably resulting from stress in the womb or exposure to maternal stress hormones.

Old research has also shown that the stress from emotional deprivation or psychological harassment may result in the short stature and delayed physical maturity of the condition known as psychosocial short stature (PSS).

PSS was first discovered in orphanages, in infants who failed to thrive and grow. When these children were placed in caring environments in which they received sufficient attention, their growth resumed. The children’s cortisol levels were abnormally low, a seeming contradiction, which Chrousos investigated by studying a small, non-human primate, the common marmoset. These monkeys live in small family groups in which infants are cared for by both parents. As in human society, the infants are sometimes well cared for, but sometimes abused. Like humans, the abused monkeys showed evidence of PSS.

The researchers determined that the stressed and abused monkeys appeared to respond normally to stress, but seemed unable to “switch off” the stress response by secreting appropriate cortisol levels, thereby remaining in a state of prolonged stress arousal as compared to their peers.

The gastrointestinal tract and stress
As many of us know, stress can also result in digestive problems. The stress circuit influences the stomach and intestines in several ways. First, CRH directly hinders the release of stomach acid and emptying of the stomach. Moreover, CRH also directly stimulates the colon, speeding up the emptying of its contents. In addition to the effects of CRH alone on the stomach, the entire HPA axis, through the autonomic nervous system, also hinders stomach acid secretion and emptying, as well as increasing the movement of the colon.

Also, continual, high levels of cortisol — as occur in some forms of depression, or during chronic psychological stress —can increase appetite and lead to weight gain. Rats given high doses of cortisol for long periods had increased appetites and had larger stores of abdominal fat. The rats also ate heavily when they would normally have been inactive. Overeating at night is also common among people who are under stress.

The immune system and stress
The HPA axis also interacts with the immune system, making you more vulnerable to colds and flu, fatigue and infections.

In response to an infection, or an inflammatory disorder like rheumatoid arthritis, cells of the immune system produce three substances that cause inflammation: interleukin 1 (IL-1), interleukin 6 (IL-6), and tumor necrosis factor (TNF). These substances, working either singly or in combination with each other, cause the release of CRH. IL-6 also promotes the release of ACTH and cortisol. Cortisol and other compounds then suppress the release of IL-1, IL-6, and TNF, in the process switching off the inflammatory response.

Ideally, stress hormones damp down an immune response that has run its course. When the HPA axis is continually running at a high level, however, that damping down can have a down side, leading to decreased ability to release the interleukins and fight infection.

In addition, the high cortisol levels resulting from prolonged stress could serve to make the body more susceptible to disease, by switching off disease-fighting white blood cells. Although the necessary studies have not yet been conducted, Dr. Chrousos considers it possible that this same deactivation of white blood cells might also increase the risk for certain types of cancer.

Conversely, there is evidence that a depressed HPA Axis, resulting in too little corticosteroid, can lead to a hyperactive immune system and increased risk of developing autoimmune diseases — diseases in which the immune system attacks the body’s own cells. Overactivation of the antibody-producing B cells may aggravate conditions like lupus, which result from an antibody attack on the body’s own tissues.

Stress-Related Disorders
One of the major disorders characteristic of an overactive HPA axis is melancholic depression. Chrousos’ research has shown that people with depression have a blunted ability to “counterregulate,” or adapt to the negative feedback of increases in cortisol. The body turns on the “fight or flight” response, but is prevented from turning it off again. This produces constant anxiety and overreaction to stimulation, followed by the paradoxical response called “learned helplessness,” in which victims apparently lose all motivation.

Hallmarks of this form of depression are anxiety, loss of appetite, loss of sex drive, rapid heart beat, high blood pressure, and high cholesterol and triglyceride levels. People with this condition tend to produce higher-than-normal levels of CRH. The high levels of CRH are probably due to a combination of environmental and hereditary causes, depending on the person affected.

However, rather than producing higher amounts of ACTH in response to CRH, depressed people produce smaller amounts of this substance, presumably because their hippocampuses have become less sensitive to the higher amounts of CRH. In an apparent attempt to switch off excess CRH production, the systems of people with melancholic depression also produce high levels of cortisol. However, by-products of cortisol, produced in response to high levels of the substance, also depress brain cell activity. These by-products serve as sedatives, and perhaps contribute to the overall feeling of depression.

Other conditions are also associated with high levels of CRH and cortisol. These include anorexia nervosa, malnutrition, obsessive-compulsive disorder, anxiety disorder, alcoholism, alcohol and narcotic withdrawal, poorly controlled diabetes, childhood sexual abuse, and hyperthyroidism.

The excessive amount of the stress hormone cortisol produced in patients with any of these conditions is responsible for many of the observed symptoms. Most of these patients share psychological symptoms including sleep disturbances, loss of libido, and loss of appetite as well as physical problems such as an increased risk for accumulating abdominal fat and hardening of the arteries and other forms of cardiovascular disease. These patients may also experience suppression of thyroid hormones, and of the immune system. Because they are at higher risk for these health problems, such patients are likely to have their life spans shortened by 15 to 20 years if they remain untreated.

Although many disorders result from an overactive stress system, some result from an under active stress system. For example, in the case of Addison’s disease, lack of cortisol causes an increase of pigment in the skin, making the patient appear to have a tan. Other symptoms include fatigue, loss of appetite, weight loss, weakness, loss of body hair, nausea, vomiting, and an intense craving for salt. Lack of the hormone CRH also results in the feelings of extreme tiredness common to people suffering from chronic fatigue syndrome. Lack of CRH is also central to seasonal affective disorder (SAD), the feelings of fatigue and depression that plague some patients during winter months.

Chrousos and his team, showed that sudden cessation of CRH production may also result in the depressive symptoms of postpartum depression. In response to CRH produced by the placenta, the mother’s system stops manufacturing its own CRH. When the baby is born, the sudden loss of CRH may result in feelings of sadness or even severe depression for some women.

Recently, Dr. Chrousos and his coworkers uncovered evidence that frequent insomnia is more than just having difficulty falling asleep. The researchers found that, when compared to a group of people who did not have difficulty falling asleep, the insomniacs had higher ACTH and cortisol levels, both in the evening and in the first half of the night. Moreover, the insomniacs with the highest cortisol levels tended to have the greatest difficulty falling asleep.

The researchers theorized that, in many cases, persistent insomnia may be a disorder of the stress system. From their ACTH and cortisol levels, it appears that the insomniacs have nervous systems that are on overdrive, alert and ready to deal with a threat, when they should otherwise be quieting down. Rather than prescribing drugs known as hypnotics to regulate the sleep system, the researchers suggested that physicians might have more success prescribing antidepressants, to help calm an overactive stress system. Behavior therapy, to help insomniacs relax in the evening, might also be useful.

After conducting many years of research into the functioning of the HPA axis, Dr. Chrousos concluded that chronic stress should not be taken lightly or accepted as a fact of life.



Methods Used to Collect/Select the Evidence


Description of Methods Used to Collect/Select the Evidence


The Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.


In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?


Criteria for Selecting the Evidence


Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.
More information about the selection of evidence is available in "Appendix B. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see the "Availability of Companion Documents" field).


Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Ranking by Type of Evidence
Systematic Review/Meta-Analysis
Controlled Trial - Randomized (RCT) or Controlled
Cohort Study - Prospective or Retrospective
Case Control Series
Unstructured Review
Nationally Recognized Treatment Guideline
Other Treatment Guideline
Textbook
Conference Proceedings/Presentation Slides
Ranking by Quality within Type of Evidence
High Quality
Medium Quality
Low Quality
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.
Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
The guideline developers reviewed published cost analyses.
Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation
Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline. Complimentary review access is also made available to all major medical specialty groups as well as other stakeholders.


Recommendations
Major Recommendations
Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of November 18, 2013. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the WLDI Web site  for the most current version available.
Refer to the original guideline document for the outline of treatment planning and introductory discussion of claims of mental illness within workers compensation.

Major Depressive Disorder

Major Depressive Disorder (MDD), Definition

The American Psychiatric Association's diagnostic manual (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision) defines MDD as a mental illness that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes (some details that will help to provide an understanding of what this definition means are provided below). This mental illness is typically manifested in phases – the person is mentally ill for a period of time, and is then typically free from the symptoms of the mental illness for a period of time, but will probably develop additional episodes of symptoms in the future.


The "major depressive episodes" to which the above definition refers are the phases when the symptoms are present. These episodes are defined as: (1) a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities; (2) the individual also experiences at least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep disturbance, psychomotor agitation or psychomotor retardation, decreased energy, feelings of worthlessness or guilt, difficulty thinking/concentrating/making decisions, recurrent thoughts of death or suicidal ideation/plans/attempts; and (3) the symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks.


The portion of the definition which reads "without a history of manic, mixed, or hypomanic episodes" serves to separate major depressive disorder from the bipolar and cyclothymic disorders.

Major Depressive Disorder, Diagnosis


The essential core of the diagnostic evaluation is the protocol provided in the American Psychiatric Association's diagnostic manual. The diagnostician should compare the claimant's presentation to all of the information in that protocol, including diagnostic features, associated features and disorders, course, and differential diagnosis.


The following examples of issues from that protocol are not intended to serve as a substitute for the full protocol. These examples are only being provided in order to give readers some idea of what the protocol involves, and to at least partially convey the complex nature of the protocol.
MDD is characterized by a history of one or more major depressive episodes. These episodes are phases when the symptoms are present for most of the day, nearly every day, for at least 2 consecutive weeks.


Diagnostic features for such major depressive episodes include:
A period of at least 2 weeks during which there is:
A depressed mood, and/or
The loss of interest or pleasure in nearly all activities
At least four additional symptoms drawn from a list that includes:
Changes in appetite or weight
Sleep disturbance
Psychomotor agitation (e.g., observable restlessness) or psychomotor retardation (e.g., observably moving more slowly than usual)
Decreased energy
Feelings of worthlessness or guilt
Difficulty thinking/concentrating/making decisions
Recurrent thoughts of death or suicidal ideation/plans/attempts

Course: This mental illness is typically manifested in phases – the person is mentally ill for a period of time, and is then typically free from the symptoms of the mental illness for a period of time, but will probably develop additional episodes of symptoms in the future.

Differential Diagnosis: The person with this disorder has not experienced any manic, mixed, or hypomanic episodes (which would push the diagnosis toward the bipolar and cyclothymic disorders, instead of MDD). The symptoms cannot be attributed to any other mental illness, or to any general medical condition.


Psychological Tests (e.g., current editions of the Minnesota Multiphasic Personality Inventory, Battery for Health Improvement, Millon Clinical Multiaxial Inventory, Structured Interview of Reported Symptoms) can be used as an important adjunct to the diagnostic process, specifically for the purpose of introducing an objective element to a process that is otherwise completely subjective.


Thorough Review of Claimant's History can ideally involve an examination of records from the claimant's entire life, and collateral reports. This thorough type of approach is preferable to relying on the report of the claimant, because scientific findings have consistently revealed that an examinee's report of his or her history is not a credible basis for clinical decision-making.
Any such diagnostic evaluation (and associated treatment planning) should take place on an independent basis. If the evaluation does not take place on an independent basis, then the clinician must avoid any discussion regarding forensic issues such as work-relatedness, disability, etc.


Stress


Initial Evaluation


Focus on identifying possible red flags or warning signs for potentially serious psychopathology that would require immediate specialty referral. Red flags may include impairment of mental functions, overwhelming symptoms, signs of substance abuse, or debilitating depression. In the absence of red flags, the occupational or primary care physician can handle most common stress-related conditions safely.


In talking to the patient, it is important for the physician to get him or her to try and explain or pinpoint incidents or reasons for the stress, rather than to just generalize (i.e., "I hate my job," "Everything makes me stressed out," etc.). The physician may have to ask more specific questions about work or home life if the patient is initially unwilling or unable to address specific issues.


Occupational stress usually stems from one of three common models:


Person-environment fit model: Poor job fit, such as a mismatch between the skills of the individual and the demands of the job, or a disparity between the individual's career-related desires vs. actual opportunities presented, is a leading cause of workplace stress.
Demand control model: Jobs that place high demands on the worker but give him or her little control or opportunities for decision-making lead to high job strain, a source of stress that is consistently linked as a contributor to physical conditions such as cardiovascular mortality, heart disease, and hypertension. Consideration should be given to the influence of the individual's occupational and personal history, which may have an effect on how this model applies to his or her situation.


Effort-reward model: Shows that stress is often the result of high effort without social reward. Like the demand control model, this model points out that a low ratio of effort to reward leads to sustained autonomic arousal and can cause physical effects such as high blood pressure or myocardial infarction.


Exploration of how and if the patient's stress follows the path of one of the above models will be helpful in determining treatment. More specific sources of stress include bereavement, illness, familial changes or disorder, or other common and/or traumatic life changes. Time off work may be helpful, although the ultimate goal should be to preserve the patient's ability to function both occupationally and socially. Time off should not be so excessive that the employee loses his or her sense of function and appreciation at work and at home.


Initial Therapy


Pursuing the patient's thoughts on how his or her stress relates to the above models may help determine the source of stress and cultivate ideas on how to eliminate or cope with the stress. Patient education and understanding about stress is necessary for effective stress management to take place.


Other common treatment pathways include the use of one or more of the following:
Relaxation techniques (such as meditation)
Exercise (aerobic exercise has been shown to positively influence mood)
Behavioral training (such as time management, anger management, assertiveness, or conflict resolution training)


Stress inoculation therapy
Cognitive therapy
Modified work

Organizational interventions


Pharmaceutical therapy (limited, short-term use of anti-anxiety agents to improve function—anything else should be used in conjunction with a specialty referral)
Follow-up visits are an important part of treatment and should be conducted by a mid-level practitioner in person or via phone every three or four days, depending on the severity of the case, while a path to recognizable treatment is established and followed. Failure to improve or make significant progress after several months may indicate the need for psychiatric assessment or counseling.


Post-traumatic Stress Disorder (PTSD)


The concept of PTSD was created by the American Psychiatric Association in 1980 to serve as a diagnosis for presentations of mental illness by people who have experienced an "extreme traumatic stressor." According to the current version of the American Psychiatric Association's diagnostic manual, the diagnosis of PTSD involves at least nine elements, which are outlined below: (1) The person witnessed death, a threat of death, or physical danger; (2) The person responded to that experience with intense fear, helplessness, or horror; (3) The person has symptoms which involve "re-experiencing" item #1 (example: repeating memories of item #1, with those memories being perceived as intrusive, and with those memories causing distress); (4) The person demonstrates avoidance of things that remind them of item #1; (5) The person experiences a "numbing of general responsiveness" (example: the person is unable to have loving feelings); (6) The person experiences symptoms of "increased arousal" (example: difficulty falling or staying asleep); (7) The involved distress or impairment is "clinically significant"; (8) The symptoms typically begin within the first three months after item #1, and typically resolve within a few months of onset; (9) The symptoms last for more than a month after item #1.


Refer to the original guideline document for Summary Tables for PTSD pharmacotherapy and PTSD psychotherapy interventions.


Official Disability Guidelines (ODG) Return-To-Work Pathways

Senile and Presenile Organic Psychotic Conditions (see original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
Not severe, medical treatment: 0 days
Severe, specially designed, limited modified work: 7 days
Severe, regular work: indefinite
Senile Dementia with Delusional or Depressive Features
Severe, specially designed, limited modified work: 7 days
Severe, affecting fellow worker productivity & safety: indefinite
Severe, regular work: indefinite
Alcohol Withdrawal Delirium
Without hospitalization: 1 to 7 days
Including rehab, substance abuse professional (SAP) evaluation: 28 days
Including rehab, SAP evaluation, job safety issues: 42 days
Drug Withdrawal Syndrome
Without hospitalization: 0 to 5 days
With hospitalization, without suicidal ideation: 7 days
With hospitalization, with suicidal ideation: 21 days
Paranoid and/or Hallucinatory States Induced by Drugs
Without hospitalization: 1 to 3 days
With hospitalization, without threat of harm: 7 days
With hospitalization, with threat of harm: 21 days
Transient Organic Psychotic Conditions
14 days
Paranoid Type
Without hospitalization, no job safety issues: 0 to 7 days
With hospitalization: 42 days or by report
Unspecified Schizophrenia
Without hospitalization, no job safety issues: 0 to 7 days
With hospitalization: 16 to 42 days
Major Depressive Disorder, Single Episode
Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 21 to 42 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days
Major Depressive Disorder, Recurrent Episode
Outpatient therapy, without symptoms affecting work: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 14 to 28 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days
Bipolar Affective Disorder, Depressed
Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0 to 21 days
With hospitalization: 21 to 42 days
Bipolar Affective Disorder, Mixed
Without hospitalization: 0 to 14 days
With hospitalization: 21 to 42 days
Paranoia
Without hospitalization: 0 to 14 days
With hospitalization: 14 to 21 days
Depressive Type Psychosis
Without hospitalization: 0 to 56 days
With hospitalization: 21 to 64 days
Anxiety States
Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0 to 7 days
With hospitalization: 14 to 21 days
Panic Disorder
1 to 14 days
Generalized Anxiety Disorder
14 to 21 days
Hysteria
Without hospitalization: 0 days
With hospitalization: 7 to 14 days
Obsessive-Compulsive Disorders
Without hospitalization: 0 days
With hospitalization: 10 days
Personality Disorders
0 days
Alcohol Dependence Syndrome
Without hospitalization: 1 day
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization, including rehab: 14 to 28 days
Safety sensitive position: as determined by the SAP
Acute Alcoholic Intoxication
1 to 2 days
Also treated as rule violation absence
Opioid Type Dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization, including rehab: 14 to 38 days (10 days post-discharge)
Safety sensitive position: as determined by the SAP
Barbiturate and Similarly Acting Sedative or Hypnotic Dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 21 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
Cocaine Dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 28 days
Safety sensitive position: as determined by the SAP
Cannabis Dependence
0 to 2 days
Amphetamine and Other Psychostimulant Dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
Hallucinogen Dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger and morale: 7 to 14 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
Alcohol Abuse
1 day
Cocaine Abuse
Without hospitalization: 0 to 1 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days
Amphetamine or Related Acting Sympathomimetic Abuse
Without hospitalization: 1 day
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days
Acute Reaction to Stress
Without hospitalization (on-going counseling/drug therapy): 1 day
With hospitalization: 10 days
Unspecified Acute Reaction to Stress, Post-traumatic Stress Disorder
Without hospitalization (on-going counseling): 1 day
With hospitalization: 10 days
Chemical dependence comorbidity: 28 days
Adjustment Reaction
Without hospitalization: 1 to 6 days
Outpatient care: 1 to 6 days
With inpatient hospitalization: 14 to 28 days
Post-concussion Syndrome
Mild: 1 day
Severe: by report
Depressive Disorder, not Elsewhere Classified
Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work or other job issues: 0 to 7 days
Outpatient therapy, with symptoms interfering with work: 21 days
Outpatient therapy, with serious job satisfaction issues: 28 to 42 days
With hospitalization, non-cognitive/modified work: 28 days
With hospitalization, cognitive work: 42 to 56 days
Attention Deficit Disorder
1 day
(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary in the original guideline document)

Clinical Algorithm(s)
None provided


Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.
The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.


Benefits/Harms of Implementing the Guideline Recommendations


Potential Benefits


These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related stress, major depressive disorder, and other mental disorders.


Potential Harms
From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed.
Tricyclic antidepressants (TCAs) are among the most effective antidepressants available, although their poor tolerance at usual recommended doses and toxicity in overdose make them difficult to use.


While selective serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs, they have their own specific problems, such as the aggravation of sexual dysfunction, interaction with co-administered drugs, and for many, a discontinuation syndrome. Despite the relative low prevalence of side effects associated with SSRIs a significant minority of older people find these drugs intolerable and experience nausea, vomiting, dizziness and drowsiness.
The Beck Depression Inventory-2nd edition (BDI®-II) is limited to assessment of depression and is easily faked. The scale is unable to identify a non-depressed state, and is thus very prone to false positive findings. It should not be used as a stand-alone measure, especially when secondary gain is present.


The risk of suicidal behavior after starting antidepressant treatment is similar among users of amitriptyline (a TCA) and fluoxetine (an SSRI).
Postmarketing reports of hepatic injury (including hepatitis and cholestatic jaundice) suggest that patients with preexisting liver disease who take duloxetine (Cymbalta) may have an increased risk for further liver damage. The new labeling extends the precaution against using Cymbalta in patients with substantial alcohol use to include those patients with chronic liver disease. It is recommended that Cymbalta not be administered to patients with any hepatic insufficiency.
Antidepressant medication (fluoxetine/Prozac) has been found to compromise the success of smoking cessation efforts.


Hypomania as a potential adverse effect of light therapy needs to be considered.
Because exposure therapy (ET) may increase distress and post-traumatic stress disorder (PTSD) symptoms in the short term, it is not well accepted by all patients, some of whom may drop out of treatment.


Benzodiazepines are only recommended for short-term use due to risk of tolerance, dependence, and adverse events (daytime drowsiness, anterograde amnesia, next-day sedation, impaired cognition, impaired psychomotor function, and rebound insomnia). These drugs have been associated with sleep-related activities such as sleep driving, cooking and eating food, and making phone calls (all while asleep). Particular concern is noted for patients at risk for abuse or addiction. Withdrawal occurs with abrupt discontinuation or large decreases in dose. Decrease slowly and monitor for withdrawal symptoms. Benzodiazepines are similar in efficacy to benzodiazepine-receptor agonists; however, the less desirable side-effect profile limits their use as a first-line agent, particularly for long-term use.


Piper methysticum (Kava) has been withdrawn in European, British, and Canadian markets due to concerns over hepatotoxic reactions, and the World Health Organization (WHO) recently recommended research into "aqueous" extracts of Kava. One randomized controlled trial (RCT) concluded that the aqueous Kava preparation produced significant anxiolytic and antidepressant activity and raised no safety concerns.


Due to adverse effects, U.S. Food and Drug Administration (FDA) now requires lower doses for zolpidem. The dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate release (IR) products and from 12.5 mg to 6.25 mg for extended release (ER) products. The ER product is still more risky than IR.


Side effects of trazodone include nausea, dry mouth, constipation, drowsiness, and headache. Improvements in sleep onset may be offset by negative next-day effects such as ease of awakening. Tolerance may develop and rebound insomnia has been found after discontinuation.
Next-day sedation with diphenhydramine has been noted as well as impaired psychomotor and cognitive function. A randomized controlled study determined that diphenhydramine has been shown to build tolerance against its sedation effectiveness very quickly, with placebo-like results after a third day of use. Due to adverse effects, the U.S. National Committee for Quality Assurance (NCQA) has included diphenhydramine in the HEDIS® (Healthcare Effectiveness Data and Information) recommended list of high-risk medications to avoid in the elderly.


Contraindications


The following are current suggested exclusionary criteria for the use of an implantable pain treatment: (a) Active psychosis; (b) Active suicidal ideation; (c) Active homicidal ideation; (d) Untreated or poorly treated major depression or major mood disturbance. Depression in and of itself in reaction to chronic pain does not disqualify a patient from implantable treatment, although moderately severe to severe depression should be treated prior to trial. Anxiety/panic disorder should also be stabilized; (e) Somatization disorder or other somatoform disorder involving multiple bodily complaints that are unexplained or exceed that could be explained by the physical exam; (f) Alcohol or drug dependence (including drug-seeking behavior and/or uncontrolled escalated use); (g) Lack of appropriate social support; (h) Neurobehavioral cognitive deficits that compromise reasoning, judgment and memory. Other "red flags" include: a) unusual pain ratings (for example, the pain rating never changes from 9-10); b) unstable personality and interpersonal function; c) non-physiological signs reported on physical exam; d) unresolved compensation and litigation issues.


There are a number of contraindications for using traditional hypnotic techniques in the treatment of post-traumatic stress disorder (PTSD): (1) In the rare cases of individuals who are refractory or minimally responsive to suggestions, hypnotic techniques may not be the best choice, because there is some evidence that hypnotizability is related to treatment outcome efficacy; (2) Some PTSD patients may be reluctant to undergo hypnosis, either because of religious belief or other reasons. If the resistance is not cleared after dispelling mistaken assumptions, other suggestive techniques can be tried, including emotional self-regulation therapy (ESRT), which is done with open eyes and uses sensory recall exercises rather than a hypnotic induction; (3) For patients who have low blood pressure or are prone to fall asleep, hypnotic procedures such as "alert hand," which emphasize alertness and activity rather than relaxation, may be substituted.


Patients living in dangerous circumstances (e.g., domestic violence or a threatening environment) are not candidates for exposure therapy until their security can be assured. Other contraindications for exposure therapy have not been confirmed in empirical research, but may include health problems that preclude exposure to intense physiological arousal: current suicidal ideation, substance abuse not in stable remission, co-morbid psychosis, or lack of motivation to undergo the treatment.


Due to adverse effects, the U.S. National Committee for Quality Assurance (NCQA) has included diphenhydramine in the HEDIS® (Healthcare Effectiveness Data and Information) recommended list of high-risk medications to avoid in the elderly.
Psychosocial rehabilitation techniques are contraindicated when client and clinician conclude that the problems are resolved.


Morphine is contraindicated in serious traumatic brain injury.
Marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated.


Qualifying Statements
Qualifying Statements


The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.


It is difficult to establish work-relatedness for major depressive disorder. Individuals who are treated within workers compensation for this disorder may be at an elevated risk of being exposed to the detrimental health effects of involvement in workers' compensation. Scientific findings have indicated that involvement in workers compensation leads to worse clinical outcomes (worse than the outcomes that are obtained when the treatment is delivered outside of the workers compensation system).


The definition of major depressive disorder provided in the guideline is a highly summarized definition that is not intended to provide a full understanding of major depressive disorder. It is instead simply intended to provide readers with a simple overview.

 

References:

Managing Stress by David Fontana - Stress management - 1989

Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and ... by Bessel A. Van der Kolk, Alexander C. McFarlane, Lars Weisæth - Psychology - 1996

Stress: The Hidden Adversary by C. B. Dobson - Psychology - 1982

Stress: Making it Work for You by National League for Nursing, National League for Nursing Council of Diploma Programs, National League for Nursing - Stress (Physiology) - 1977

Principles and Practice of Stress Management by Paul M. Lehrer, Robert L. Woolfolk, David H. Barlow, Wesley E. Sime - Medical - 2007

The Stress Effect: Discover the Connection Between Stress and Illness and ... by Richard Weinstein - Health & Fitness - 2004

Stress Management for the Healthy Type A: Theory and Practice by Ethel Roskies - Self-Help - 1987 Stress online course for social workers, marriage and family therapist, LMFT and counselors. Stress CEUs, Stress Online Courses, Stress

American Psychological Association  - Adapted from The Stress Solution by Lyle H. Miller, Ph.D., and Alma Dell Smith, Ph.D.Managing Your Stress in Tough Economic TimesThis tip sheet was made possible with help from APA member Nancy Molitor, PhD.

Stress: What it Is, what it Can Do to Your Health, how to Handle it by Walter McQuade, Ann Aikman - Self-Help - 1993

Stress: Sources, Management & Prevention: Medical & Psychological Aspects of ... by Lennart Levi, Kurt Bronner - Stress (Psychology) - 1967

Stress: Myth, Research and Theory by Fiona Jones, Jim Bright, Angela Clow - Psychology - 2001

Posttraumatic Stress Disorder: Malady Or Myth? by Chris R. Brewin - Psychology - 2007

 

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