STRESS IN RETROSPECT
Donald Watson, M.D.
Clinical Instructor, Department of Psychiatry
University of California, Irvine Medical Center
What is stress? Stress is any force that moves a living system away
from its point of equilibrium or homeostasis. Obviously, stress is universal
and is intrinsic to life. The same definition of stress applies at all
levels, ranging from molecular to cultural planes of complexity. Stress
is just as important in growth, development and evolution of psychological
and social functions as it is in those of genetic and biologic qualities.
For example, without psychological stress, an individual would not develop
his particular set of coping mechanisms that come to be known as the elements
of his character. In that sense, stress promotes adaptability. On the other
hand, the capacity to adapt is limited in all systems and, therefore, it
is possible to have "too much" stress. Stress is neither good nor bad.
Further, the amount of stress experienced as the result of an event does
not depend on whether the event is in itself "good" or "bad". Therefore,
stress is stress, whether it arises from joyous and welcome events or from
those that are tragic and unhoped for.
"IS THERE A DIFFERENCE BETWEEN PHYSICAL AND PSYCHOLOGICAL STRESS?"
In terms of sources, some stresses are purely psychological and
others purely physical. In terms of adapting mechanisms and reactions to
stress, though, the effects are rarely pure. For example, a purely physical
stress can cause a fractured leg. The total impact of the fracture, however,
cannot be predicted from the extent of the injury of the tissues alone.
The physiological stress resulting from the original physical stress would
be quite different for a ball player in midseason than for a psychiatrist
who could hobble around quite adequately with a walking cast. In the first
case, the broken leg would lead to serious losses of both earning power
and self-esteem, whereas those losses would not be significant in the latter
case. just as a primary stress can lead to psychological stress with its
sequellae, psychological stresses can precipitate physical reactions. The
best known example of this is, of course, the peptic ulcer.
"WHAT DETERMINES THE BEHAVIORAL REACTION TO THE PSYCHOLOGICAL STRESS
SEEN IN THE CRITICALLY ILL?"
There is no universal source of psychological stress among the
critically ill because each individual, depending on his own character
structure, will experience each potential stressor differently. For example,
some patients experience a great deal of anxiety and distress over being
forced into a dependent position while ill. Others, though, find they are
not stressed by the dependent role because it is near their position of
psychological equilibrium anyway. Referring again to the definition of
stress, anything intrinsic to the illness or the hospital environment that
forces the patient away from his position of psychological homeostasis
is stressful. in addition to enforced dependency, pain, isolation from
loved ones, the threat of death and losses can contribute to a patient's
need to adapt psychologically to his illness.
Just as an individual's psychological make-up determines what
constitutes stress for him, his behavioral reaction to the various stresses
incident to his illness is determined by his character structure. The two
most common psychological reactions to the stresses caused by critical
illness are anxiety and depression. Neither of these reactions are necessarily
pathological. In fact, they both potentially have adaptive value for the
patient. Anxiety mobilizes a great deal of energy that the patient can
use in his own behalf, and depression may be part of the normal withdrawal
incident to grieving for a substantial loss.
The pathological variants of anxiety and depression, as well as
more severe reactions such as psychoses, may require clinical intervention
during the course of physical illness. just as anxiety can be facilitating
for some patients, it can be debilitating for others. In the same patients
or in different individuals, depression, too, can become a clinically significant
part of the patient's overall illness. For example, when a person's anxiety
and depression lead to a syndrome of agitation, sleeplessness, constant
ruminations about impending doom, an inability to be reassured, loss of
appetite and somatic preoccupation to the degree of delusion formation,
the patient is suffering from a psychotic depression that could seriously
interfere with medical or surgical attempts to save his life or treat his
illness. That patient may be so self-destructive that he is conspiring
with his illness to defeat any attempts to preserve him. A comprehensive
listing of all the possible determinants of stress and reactions to stress
that might be suffered by the critically ill is beyond the scope of this
paper, but the two case studies reported in the previous article illustrate
these variables for two individuals as well as the reactions of the nursing
staff to them.
"HOW CAN THE ENVIRONMENT OF THE CRITICAL CARE UNIT AFFECT THE PATIENT'S
ABILITY TO COPE WITH HIS ILLNESS?"
The environment of the critical care unit comprises both physical
and human elements. The high technology of the unit itself intimately corresponds
to the personalities of the nurses and other personnel who choose to work
in those units. Accordingly, it is impossible to separate entirely the
physical and human components of the environment. For example, nurses themselves
sometimes feel they have become machines; externally, that subjective feeling
is confirmed by observations that critical care nurses in some settings
spend miniscule amounts of time actually talking with their patients. The
critically ill patient, already frightened about his illness, is then faced
with what would appear to be a cold, unfeeling, mechanical and emotionally
unresponsive environment. Reactions are predictable: initial anxiety is
increased and subsequent depressions are enhanced. The physiological consequences
of those emotions are usually undesired. For example, a person who has
suffered a myocardial infarction will suffer an increased workload on his
heart as a result of anxiety.
The round-the-clock intensive activity of the unit also causes
adverse psychological effects. Patients who are recovering from surgery
or metabolic illnesses in which their brain function is impaired characteristically
find the lack of time orientation to be very distressing. Typically, individuals
suffer increased confusion and agitation as a result of the loss of time
structure. They don't even know when it is day or night. Patients who are
delirious, confused, and disoriented to that extent cannot be expected
to adequately cooperate with their treatment. They thrash about, pull our
needles, dislodge EKG leads, and may, if not suitably restrained, fall
and injure themselves.
"WHAT ELEMENTS OF CRITICAL CARE SHOULD BE EXAMINED WITH RESPECT TO
THEIR PSYCHOLOGICAL EFFECTS ON THE PATIENT?"
Historically, critical care treatment programs have evolved following
technological developments, and as a result, have been developed primarily
by people fascinated by the technical aspects of treatment. Attention to
psychological factors has come late in the development of programs and
has been sporadic. in my opinion, this deficiency results partly from active
resistance to the concepts of psychiatric science on the part of managers
of critical care programs. in my long time, intimate association with people
involved in highly technical careers—scientists and engineers—I have observed
a very pronounced tendency to deny the importance of emotional variables.
This is equally true for some members of the nursing and medical professions;
there are those individuals who are defensively hostile to the concepts
of exploring and working with emotional issues. So to the extent that those
factors are at work in any particular critical care treatment program,
they must be dealt with first. it has been my experience in our hospital
that once the clouds of suspicion and hostility have been lifted, everyone
involved in the critical care treatment benefits—the patients, the nurses,
the physicians, and the psychiatrists.
"WHAT SUPPORTIVE MEASURES CAN BE PROVIDED IN THE CRITICAL CARE UNIT
TO MEET THE PSYCHOSOCIAL NEEDS OF THE SERIOUSLY ILL?"
In contrast to physiological needs which can be monitored and
attended by machines, emotional needs must be met by people. For that reason,
it falls to the nursing staff to be aware of and to attend to the psychological
needs of the patient. As indicated in the previous article, the nurses
themselves require preparation—both intellectually and emotionally—to provide
the support necessary for patients and families. That is the goal, stated
in its broadest terms, that is pursued by the liaison psychiatrist in his
ongoing relationship with the nursing staff.
Specific supportive measures that nurses can provide include reassurance,
acting as a listener to patients as they express their fears and concerns,
being available to family members as they try to cope with the feelings
they have about the patient's illness and its consequences, and being alert
and responsive to the needs of co-workers to establish a stable and harmonious
working environment. These specific tasks can only be accomplished after
a relationship is established. For that reason, the nurturing of close
relationships between nurses and their patients is the most important single
vehicle for delixiering the best of total medical care.
"WHAT ANTI-ANXIETY DRUGS ARE MOST USEFUL IN THE CARE OF THE CRITICALLY
As indicated above, but worth repeating for emphasis, the anxious
critically ill patient is not being adequately treated unless the cause
for anxiety is determined and ameliorated or eliminated. Even though this
principle of treating the underlying cause rather than just the symptoms
is a universally pursued one in medicine, for psychological disorders it
is common practice to attack only the symptoms. As a result the anti-anxiety
agents have become widely misused throughout medicine to the extent that
benzodiazepines are now the nation's second most abused drugs after alcohol.
The impact of this iatrogenic drug abuse problem goes far beyond the epidemiological
implications of addiction; failure to recognize and deal with the causes
of anxiety of patients can lead to lifelong disturbances in the patients
themselves and, by reaction, problems for the medical profession. The latter
problems take the form of loss of confidence in the profession, cynicism
toward the motivation of health care professionals and an increasing tendency
to sue for malpractice.
Because anxiety is a result of psychological stress, psychological
intervention is indicated. in most cases, simply "being with" the patient,
talking with him and reassuring him is enough to allay anxiety. On the
other hand, anti-anxiety agents are indicated in those cases where psychological
treatment is not enough to alleviate the effects of acute anxiety. For
example, a patient recovering from a myocardial infarction cannot afford
to have increased workload on his heart and it is necessary to treat the
physiological symptoms directly. As in all drug treatment, the benefits
of a particular agent must be weighed against its risks. Of the most useful
drugs, the benzodiazepines have several advantages over barbiturates for
tranquilization in both the benefit and risk columns. Barbiturates have
a much higher tendency to induce enzymes that in turn can reduce the effectiveness
of other medications. Also, barbiturates are more addicting and they depress
the respiratory center more than benzodiazepines.
In terms of specific anti-anxiety effect, the benzodiazepines
are more effective. On the other hand, they are more expensive than the
barbiturates. In general then, of the two most wisely used antianxiety
drugs—barbiturates and benzodiazepines—the benzodiazepines have more advantages
and fewer disadvantages. Sometimes, when it is desirable to avoid the addicting
potential of both classes of drugs, small doses of a major tranquilizer,
such as trifluoperazine (Stelazine) or chlorpromazine (Thorazine), can
Elderly patients require special attention in anti-anxiety drug
treatment, just as they do with most other drugs. Because of increased
body retention times and occasional paradoxical reactions, elderly patients
usually require smaller doses spaced farther apart than do younger patients.
Because they are less toxic, the benzodiazepines are usually preferable
over the barbiturates for treatment of anxiety in the elderly. When the
elderly patient suffers from an organic brain syndrome, treatment with
any psychopharmacological agent must be approached with care; symptoms
of dementia can be readily enhanced by over use of virtually any of the
"HOW CAN DEPRESSION BE MANAGED IN THE CRITICALLY ILL?"
Depression as a symptom must be approached like any other symptom.
Its cause must be established before adequate treatment can proceed. As
with anxiety, it is common in general medical practice to attempt to treat
depression without attending to its underlying cause. The causes of depression
range from the loss of an important person or object to genetically determined
patterns of depression sometimes alternating with mania. The depression
accompanying a grief reaction which results from a loss is usually self-limiting,
whereas the more pathological forms of depression may require intense,
rapid intervention to save the patient's life. Whenever there is a question
about the severity of the depression or its potential outcome, psychiatric
consultation should be obtained as early as possible so that adequate treatment
can be instituted. in the critically ill, this is likely to require a high
degree of cooperative interaction between the psychiatric and medical personnel,
particularly when there may be strong interactions between medications.
Sometimes concurrent treatment of depression and the patient's physical
illness is not possible and priorities have to be established to determine
which to treat first.
There are many modes of treatment for depression which correspond
to the severity of the disorder. In the case of simple grief, support provided
by nursing personnel to both the patient and his family is usually all
that is required. Pharmacological treatment is rarely indicated. On the
other hand, for psychotic depressions, in which the vegetative signs of
loss of sleep, loss of appetite and loss of sexual interest are prominent,
combined with somatic delusions and sometimes agitation, pharmacological
treatment or electroconvulsive therapy (ECT) are generally indicated. ECT
is sometimes the treatment of choice because it can be lifesaving; it is
fast, effective and safe. ECT is exclusively administered by psychiatrists,
but antidepressive drugs are widely used throughout medicine. Unfortunately,
both the indications for, and the pharmacology of these drugs is poorly
understood by most of the practitioners who prescribe them. As a result,
antidepressive drugs are often used as placebos in a doubleblind manner,
neither the patient nor the physician realizing that the drugs are being
used in pharmacologically ineffective doses. Symptom relief is common,
though, because depression responds well to placebos. (An adequate course
of treatment with antidepressive drugs requires from ten to thirty days
of administration before pharmacological effects are expected.) Thus, the
physician who prescribes 10 mg. of a tricyclic antidepressant "p.r.n. depression"
is not using an antidepressive drug treatment regimen at all.
"WHAT ANTI-PSYCHOTIC DRUGS ARE RECOMMENDED FOR USE IN THE SERIOUSLY
ILL OR INJURED PATIENT?"
Major tranquilizers such as trifluoperazine, chlorpromazine,
haloperidol, thloridazine and others can be used both as anti-anxiety agents
or as anti-psychotic agents for schizophrenia. Lithium carbonate is an
anti-psychotic agent used specifically in the treatment of mania. Any of
those drugs can be used in the critically ill patient, depending on his
specific condition, preferably with the help of a psychiatric consultant.
The nursing staff should be particularly alert to the distressing side
effects of the phenothiazines. Distonias, akathesia, and pseudoparkinsonism
are common and can usually be managed adequately by the administration
of anticholinergic drugs such as benztropine (Cogentin) or trihexythenidyl
(Artane). The main difference between the anti-psychotic agents is their
degree of sedation. Chlorpromazine is much more sedating than either trifluoperazine
or haloperidol. The phenothiazines are cleared by the body very slowly.
For that reason, it is possible and sometimes desirable to administer the
entire daily dosage at bedtime.