Stress (Anxiety)

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What is Stress?Statistics on StressRisk Factors for StressProgression of StressSymptoms of StressClinical Examination of StressHow is Stress Diagnosed?Prognosis of StressHow is Stress Treated?Stress ReferencesDrugs/Products Associated with Stress What is Stress?

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Stress is defined as an organism's total response to environmental demands or pressures. When stress was first studied in the 1950s, the term was used to denote both the causes and the experienced effects of these pressures. More recently, however, the word stressor has been used for the stimulus that provokes a stress response. One recurrent disagreement among researchers concerns the definition of stress in humans. Is it primarily an external response that can be measured by changes in glandular secretions, skin reactions, and other physical functions, or is it an internal interpretation of, or reaction to, a stressor; or is it both?

Statistics on Stress

Stress impacts, in some form or another, everyone at some stage in their life, just in varying severity. A 1996 study found that 75% of adults felt abnormaly stressed during their working week. This is a real problem and a real health issue. Stress may be implicated in up to 70% of patient visits to the family doctor.

Stress can affect anyone, including children. Stress occurs in virtually all children at some stage as a response to something threatening or dangerous. Not all stress is bad, as stress can be an important means of getting people motivated and active but too much stress can be detrimental to one's health. Separation anxiety is the most common cause of stress in young children but academic and social pressures (especially the quest to fit in) also lead to stress in older children.

Risk Factors for Stress

The causes of stress are multiple and varied but they can be broadly classified into external stressors (such as the loss of a relative, where outside forces act on us) and internal stressors (majority of stress is self-generated thus we have some control over it).

Risk factors for uncontrollable stress:

Social and financial problems Medical illness Lack of social support Family history

Prolonged stress can cause physiological changes that can result in a physical disorder. The following life stressors have been ranked as the top ten life changes that can lead to psychosomatic disorders:

Death of a spouse Divorce Death of a close family member Marital separation Serious personal injury or illness Fired from work Jail term Death of a close friend Pregnancy Business readjustment.

It is important to recognise that particular stresses do not affect people equally. Some patients see stress as a challenge to be overcome, whilst others feel overwhelmed. Thus the response of an individual to stress may be mediated by many factors, including the number of different stressors involved, personality style, cultural background, social circumstances, the symbolic meaning of the stress, past life experiences and the availability of supports.

Children

There are numerous possible causes for stress in children that are divided into internal (arising within) and external (outside factors acting on the child) sources. Examples of external sources include:

Parents or others pressuring children or setting high expectations. Sudden unexpected loss or change- Such as loss of a friend or family member, change of school. Social situation where the child feels uncomfortable. Arguments or conflicts with friends or family. Big changes in the family, eg moving house, getting a divorce, losing a job.

Some internal causes of stress problems include:

Perfectionist personality. Too high self-expectations. Difficulties coping with change. Shyness or feeling uncomfortable in groups. Pessimistic attitude. Working too hard/trying too hard. Poor time management- particularly important in older children who become stressed about homework and exams. Unreasonable beliefs.

Progression of Stress

Stress usually first affects our inner emotions. Initial symptoms may include these feelings:

Anxiousness Nervousness Distraction Excessive worry Internal pressure

These emotional states then can begin to affect your outward appearance:

Unusually anxious or nervous Distracted Self-absorbed Irritable

As the stress level increases, or if it is prolonged over a long period of time, the severe emotional or physical effects that follow may become a factor:

Excessive fatigue Depression Sometimes even think of hurting yourself or others Headache Nausea and vomiting Diarrhoea Chest pain or pressure Heart racing Dizziness or flushing Tremulousness or restlessness Hyperventilation or choking sensation

In the vast majority of cases, these symptoms remain relatively minor and don't last very long. If they become more severe or increase in frequency and severity, seek medical help.

Symptoms of Stress

Your doctor will take a thorough history to identify possible causes and effects of stress. This will include letting you explain your worries, asking questions about your life and particular stressors, and questions regarding symptoms.

The most common symptoms of stress are:

Physical: fatigue,headache, insomnia, muscle aches/stiffness (especially neck, shoulders and low back), palpitations (awareness of the heart beating), chest pains, abdominal cramps, nausea, trembling, cold extremities, flushing or sweating and frequent colds. Mental: decrease in concentration and memory, indecisiveness, mind racing or going blank, confusion, loss of sense of humor. Emotional: anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, impatience, short temper. Behavioural: pacing, fidgeting, nervous habits (nail-biting, foot-tapping), increased eating, smoking, drinking, crying, yelling, swearing, blaming and even throwing things or hitting.

Children

Identifying stress in children can be difficult as they may be less likely to verbalise their feelings and concerns and more likely to display behavoural changes. The following are some common symptoms of stress in children that should be looked out for:

Your child becoming easily upset or angry. Tiredness and having problems sleeping. In teenagers- Smoking or drinking more than usual. Complaints of tense muscles, headaches and backache. Evidence of worry, feeling overwhelmed and helpless. Poor concentration- May be reflected by a drop in school grades. Being "jumpy" and "fidgety." Lots of blaming and complaining. Diarrhoea. Loss of enthusiasm. Anhedonia- meaning loss of interest or pleasure in normally enjoyable activities for your child. e.g. sport, hobbies, friends. Less resistance to viruses and infections. If possible try to determine what is causing your child to worry- Is it a big test coming up at school, due to family conflict or a fight with a friend? Determining the source of stress can help doctors and patients find ways to overcome it.

Clinical Examination of Stress

Your doctor will conduct a general physical examination, particularly looking for signs of stress such as:

Twitching or trembling Muscle tension Headaches Sweating Dry mouth Difficulty swallowing Abdominal pain (may be the only symptom of stress especially in a child)

How is Stress Diagnosed?

When the doctor suspects that a patient's illness is connected to stress, he or she will take a careful history that includes stressors in the patient's life (family or employment problems, other illnesses, etc.).

Many physicians will evaluate the patient's personality as well, in order to assess his or her coping resources and emotional response patterns. There are a number of personality inventories and psychological tests that doctors can use to help diagnose the amount of stress that the patient experiences and the coping strategies that he or she uses to deal with them.

There are no specific investigations to identify whether you are stressed and the doctor will normally rely on information gained from the history to make the diagnosis.

Prognosis of Stress

The prognosis for recovery from a stress-related illness is related to a wide variety of factors in a person's life, many of which are genetically determined (race, sex, illnesses that run in families) or beyond the individual's control (economic trends, cultural stereotypes and prejudices). It is possible, however, for humans to learn new responses to stress and, thus, changing their experiences of it.

A person's ability to remain healthy in stressful situations is sometimes referred to as stress hardiness. Stress-hardy people have a cluster of personality traits that strengthen their ability to cope. These traits include believing in the importance of what they are doing; believing that they have some power to influence their situation; and viewing life's changes as positive opportunities rather than as threats.

Ongoing stress can have serious complications such as heart attack, stroke and depression.

How is Stress Treated?

The most effective solution is to find and address the source of your stress or anxiety. Unfortunately, this is not always possible.

A first step is to take an inventory of what you think might be making you "stress out":

What do you worry about most? Is something constantly on your mind? Is anything in particular making you sad or depressed?

If you can identify the source of your stress, remove yourself from it or address the situation. That may be all that is needed to resolve the situation and your anxiety. Even if you are only able to get away for a few seconds or minutes, the break is important and can help you on the way to a more permanent solution.

Lifestyle is also essential:

Eat a well-balanced, healthy diet. Don't overeat. Get adequate amounts of sleep. Exercise regularly. Limit caffeine and alcohol. Don't use nicotine, cocaine, or other recreational drugs. Learn and practice relaxation techniques like guided imagery, progressive muscle relaxation, yoga, tai chi, or meditation. Take breaks from work. Make sure to balance fun activities with your responsibilities. Spend time with people doing activities you enjoy. Think positively!

Stress can have serious consequences and chronic stress can cause depression and anxiety. if you have symptoms of stress discussed or have difficulty coping, seek professional medical advice. Your doctor can teach you coping mechanisms, provide counselling and offer medications (such as anti-depressants or blood pressure tablets) to reduce the symptoms of stress.

Children

It is important to ensure children and adolescents do not adopt negative methods of coping with stress such as taking drugs and alcohol, smoking, increasing intake of caffeine drinks and cola, continuing to pressure themselves and setting unrealistically high goals.

Parents can help their children's stress by teaching them how to manage their time, helping them to relax and encouraging a healthy diet and lifestyle. In particular for school and exams, parents should encourage their children to do their best but try not to make them feel pressured or feel you will be disappointed if they don't do well. Parents can help children studying by being interested in their work, helping them set up a quiet place to study, working out an appropriate study timetable with suitable breaks and providing a healthy diet.

Stress References

Children, Youth and Women's Health Service, Parenting and Child Health, Stress, 2005. Available [online] from URL: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=141&id=1951. Herbert J, Fortnightly review: Stress, the brain, and mental illness BMJ 1997;315:530-535. Posen D, Stress Management for Patient and Physician, The Canadian Journal of Continuing Medical Education, 1995. Sadock BJ, Sadock VA. Kaplan and Sadock's Pocket Handbook of Clinical Psychiatry 3rd Edition. Lippincott Williams and Wilkins, Philadelphia USA. Turner J, Raphael B, Stress management and counselling in primary care, MJA 1998. Wein H, Stress and Disease: New Perspectives, NIH Word on Health, 2000.

Symptoms of This Disease:HyperactivityInattentionMemory LossBreathlessnessADHD: Recognising the SymptomsTreatments Used in This Disease:Individual TherapyParent Training / Parent TherapyDrugs/Products Used in the Treatment of This Disease:Aropax (Paroxetine hydrochloride)Deptran (Doxepin hydrochloride)Dothep (Dothiepin hydrochloride)Prozac (Fluoxetine hydrochloride)
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Polycystic Ovarian Syndrome (PCOS)

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What is Polycystic Ovarian Syndrome?Statistics on Polycystic Ovarian SyndromeRisk Factors for Polycystic Ovarian SyndromeProgression of Polycystic Ovarian SyndromeSymptoms of Polycystic Ovarian SyndromeClinical Examination of Polycystic Ovarian SyndromeHow is Polycystic Ovarian Syndrome Diagnosed?Prognosis of Polycystic Ovarian SyndromeHow is Polycystic Ovarian Syndrome Treated?Polycystic Ovarian Syndrome ReferencesDrugs/Products Associated with Polycystic Ovarian Syndrome What is Polycystic Ovarian Syndrome?

Polycystic ovarian syndrome (PCOS), also known as Stein-Leventhal syndrome, is a common condition characterised by menstrual irregularities and symptoms or laboratory evidence of hyperandrogenism (excess levels of androgen). In many women with PCOS, polycystic ovaries will be detected on ultrasound. 

PCOS was first described in 1935 as a collection of commonly occurring signs and symptoms. Since then, the criteria for diagnosing PCOS have changed several times. Most recently, the Rotterdam Consensus Conference agreed that PCOS may be diagnosed where any two of the following conditions are present:

Menstrual dysfunction: infrequent menstrual periods where no egg is released; Clinical or laboratory evidence of hyperandrogenism (e.g. increased body hair, acne, high levels of testosterone on testing); Polycystic ovaries on ultrasound.

Other characteristic features of PCOS include infertility, obesity and insulin resistance. PCOS is associated with an increased risk of developing endometrial or ovarian cancer, diabetes, high blood pressure, and cardiovascular disease. PCOS is a condition that can occur at any age, and is found in childhood, during puberty, in adolescence, adulthood and in the elderly.

Statistics on Polycystic Ovarian Syndrome

Polycystic ovarian syndrome is believed to be one of the most common hormonal abnormalities found in women. Depending on the criteria used to define the syndrome, PCOS may affect between 5 and 10% of women of reproductive age.

The presence of polycystic ovaries alone is not enough to achieve a diagnosis of PCOS. This is because multiple ovarian cysts are detected in as many as 20-25% of normal women on ultrasound examination.

Risk Factors for Polycystic Ovarian Syndrome

The cause of PCOS is poorly understood. A genetic (inherited) link is likely, but has not yet been identified.

One key factor in the development of PCOS is thought to be insulin resistance. The cells of the body become resistant to insulin, failing to respond normally. The body compensates for this by increasing insulin production, leading to hyperinsulinaemia (excess insulin in the blood). This in turn is thought to lead to the other problems of PCOS: excess androgen production, and abnormal production of the sex hormones responsible for regulating the menstrual cycle.

Progression of Polycystic Ovarian Syndrome

PCOS is a condition that can occur at any time during a woman's life. Depending on when the condition occurs, it can have varying effects. If PCOS occurs in an unborn baby, it can cause a small baby syndrome. If PCOS develops around puberty, it can cause problems with the start of a girl's period. PCOS during adolescence and adulthood will cause reduced periods, excess sex hormone levels, polycystic ovaries and, in 50%, obesity. In ageing individuals, the features of PCOS are diabetes, high blood pressure and abnormal blood lipid (cholesterol) levels; the combination of these findings is called the metabolic syndrome.

Period Problems:

These problems usually occur around puberty. There can be a delay in the onset of the first period (menarche), or normal menarche followed by a period of irregular bleeding and weight gain. Some women experience excessive menstrual bleeding (menorrhagia). Weight loss has been shown to be effective in allowing a return to normal cycles.

Excessive sex hormone levels:

This is seen in the following symptoms:

Hirsutism: excess thick pigmented body hair following a male distribution (e.g. on the upper lips, chin, around the nipples and on the abdomen). Acne Male-pattern balding

It is thought that approximately 50% of women with PCOS have elevated androgen levels. However, this figure depends on the androgen in question and the method of measurement.

Infertility:

Women with PCOS have irregular menstrual cycles. They also may not release an egg (ovulate) with each menstrual cycle. Combined, these factors can lead to a woman with PCOS having difficulty falling pregnant.

Obesity and insulin resistance:

Approximately 50% of women with PCOS suffer from obesity. Obesity can also be a cause of insulin resistance, but in women with PCOS the insulin resistance is not directly due to obesity.

Type 2 diabetes mellitus:

Women with PCOS have an increased risk of developing type 2 diabetes mellitus. This risk is particularly high in women who have a first degree relative with diabetes. There is a genetic link between PCOS and diabetes.

Other possible clinical manifestations of PCOS:

Blood lipid (cholesterol) abnormalities Increased risk of endometrial cancer Metabolic syndrome Coronary heart disease Miscarriage

Symptoms of Polycystic Ovarian Syndrome

If your health professional is considering a diagnosis of PCOS, he or she may ask questions about the following:

Your menstrual history, including when you started menstruating, how regular your periods are, and how heavy they are.Symptoms of excess male sex hormone production (e.g. acne, hirsutism or male-pattern hair loss).Infertility or recurrent miscarriages.Any family history of polycystic ovarian syndrome or type 2 diabetes.

Clinical Examination of Polycystic Ovarian Syndrome

A general physical examination is important to check height, weight, blood pressure and pulse. Your medical practitioner may also want to examine you for any signs suggestive of the metabolic syndrome. A gynaecological (pelvic) examination may be necessary to rule out other causes of irregular menstrual bleeding.

How is Polycystic Ovarian Syndrome Diagnosed?

Investigations for polycystic ovarian syndrome may include:

Glucose testing with a glucose tolerance test: This test looks at how the body handles glucose. It reflects the presence of insulin resistance and is important to exclude diabetes mellitus or impaired glucose tolerance. Blood lipid (cholesterol) levels: Some women with PCOS have elevated blood cholesterol levels, which may require treatment. Hormone tests: these are an array of blood tests which may include thyroid hormone, prolactin, testosterone and sex hormone binding globulin. They are useful to rule out other causes of symptoms in suspected PCOS. Transvaginal ultrasound examination looking at the uterus and ovaries is important to exclude thickening of the lining of the womb, and to look for the classic 'polycystic' appearance of the ovaries.

Prognosis of Polycystic Ovarian Syndrome

PCOS is a life-long condition which can be managed but not 'cured'. Without treatment, women with PCOS are at increased risk of a number of complications. Some of these include:

Type 2 diabetes mellitus Hyperlipidaemia Cardiovascular disease High blood pressure Thickening of the uterine wall or endometrial cancer

However, with control of insulin levels, many symptoms of PCOS, as well as the risk of complications, may be significantly reduced.

How is Polycystic Ovarian Syndrome Treated?

The management of PCOS is complex and life-long. It involves addressing both acute issues (irregular menstruation, infertility and hirsutism), and the chronic issue of insulin resistance.  

Irregular menstruation:

If fertility is not required, menstrual dysfunction can be successfully managed by progestogens (e.g. norethisterone, medroxyprogesterone acetate) or the combined oral contraceptive pill. These methods suppress ovulation (egg release) and regulate hormone levels.

Some patients are able to achieve regular ovulation, and therefore regular menstruation, with the assistance of weight loss alone, or with metformin therapy (see below).

Endometrial hyperplasia (thickening of the lining of the womb) should be assessed in all women with PCOS and managed where necessary with hormone therapy.

Hirsutism:

Treatment of this may involve:

The combined oral contraceptive pill Cosmetic measures: hair removal (shaving, waxing, laser removal), bleaching Spironolactone Other drugs (e.g. antiandrogens such as flutamide and ketoconazole)

Infertility:

In most patients with PCOS, infertility is due to ovulatory failure (failure of the ovary to release an egg each month). Treatment is therefore directed at inducing regular ovulation. Strategies may include:

Lifestyle changes:

A 5% reduction in body mass may be enough to restore ovulation and fertility in some women with PCOS. A 3-6 month trial of lifestyle modification can be reasonably recommended in most women before trialling drug therapy.

Clomiphene citrate:

This is an oestrogen antagonist which helps to induce ovulation. Treatment must be monitored with regular oestrogen levels. There is a risk of multiple pregnancy.

Metformin:

A number of studies have demonstrated successful ovulation induction with metformin, either alone or in combination with clomiphene citrate. It may also be effective in reducing the rate of first trimester miscarriages amongst women with PCOS. However, concerns remain about the safety of metformin during pregnancy, and most women cease metformin upon confirmation of pregnancy.

Ovarian surgery, gonadotrophin treatment and IVF:

Occasionally these have been used in the management of infertility associated with PCOS. However, they carry significant risks and other methods are generally preferred.

Obesity & glucose intolerance:

Lifestyle:

Lifestyle modifications, including diet and exercise, are the first things to consider in the management of obesity in PCOS. Weight loss has been shown not only to improve symptoms such as menstrual dysfunction in the short-term, but also to reduce the risk of long-term complications such as the development of diabetes. Women with PCOS often find weight loss extremely difficult. Some simple strategies to consider include:

Regular exercise of moderate intensity, at least 30 minutes per day Dietary changes: reduce fat, increase fibre, consume foods with a low glycaemic indexAvoid 'crash' or starvation dietsModerate alcohol and caffeine consumptionStop smokingConsider joining a support group to help keep on track

Medication

Glucose intolerance can be managed by oral antidiabetic agents such as metformin. Metformin is particularly appropriate for use in obese patients, as it may assist in weight loss. As mentioned above, metformin can be used to help regulate menstrual cycles and increase fertility. Other oral antidiabetic agents, such as the insulin sensitising thiazolidinediones, have been used with some success in patients with PCOS.

Polycystic Ovarian Syndrome References

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 16th Edition. McGraw-Hill. 2005. Impey L. Obstetrics and Gynaecology. 2nd edition. Blackwell. 2004. Lobo R. Priorities in polycystic ovary syndrome. MJA. 2001; 174: 554-5. Norman JR et al. Polycystic ovary syndrome. MJA. 2004; 180: 132-7. Sartor BM et al. Polycystic ovarian syndrome and the metabolic syndrome. American Journal of Medical Sciences. 2004; 330(6): 336-42. Sheehan M. Polycystic ovarian syndrome: diagnosis and management. Clinical medicine & research. 2004; 2(1): 13 -27. Hard R, Hickey M, Franks S. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Practice & Research Clinical Obstetrics & Gynaecology. 2004; 18(5): 671-83. Norman RJ, Davies MJ, Lord J, et al. The role of lifestyle modification in polycystic ovary syndrome. Trends in Endocrinology and metabolism. 2002; 13: 251-7.

Drugs/Products Used in the Treatment of This Disease:Clomhexal (Clomiphene citrate)Metformin (Terry White Chemists) (Metformin hydrochloride)
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Article Dates: Modified: 1/10/2010 Reviewed: 18/12/2006 Created: 26/4/2006 List Diseases by Medical Area All Diseases Men's Health Diseases Women's Health Diseases Children's Health Diseases Allergy Diseases Blood Diseases Bone Diseases Brain Diseases Cancer Diseases Dental Diseases Eye Diseases Fitness Diseases Gastro Diseases Heart Diseases Hormone Diseases Infection Diseases Joints Diseases Kidney Diseases Lungs Diseases Mental Health Diseases Pain Diseases Pregnancy Diseases Skin Diseases Weight Loss Diseases
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