Stress can result in various acute or chronic physical and mental conditions. Increased secretion and effects of major stress mediators can cause acute reactions, including headaches, eating and sleep disorders, gastrointestinal conditions, exacerbations of existing conditions, and multiple nonspecific constitutional symptoms. Sustained excessive secretion and effects of major mediators of stress can contribute to various behavioral and neuropsychiatric manifestations, such as anxiety and depression.
Are you familiar with common stress-related medical conditions and best practices for their diagnosis and management? Don't let stress about stress-related health concerns arise; make sure your knowledge is current with this short quiz.
Pain onset in tension-type headache can have a throbbing quality and is usually more gradual than onset in migraines. Compared with migraines, tension-type headaches are more variable in duration, more constant in quality, and less severe.
Aspects of tension-type headache history include the following:
- May occur acutely under emotional distress or intense worry
- Duration of 30 minutes to 7 days
- No nausea or vomiting (anorexia may occur)
- Photophobia and/or phonophobia
- Minimum of 10 previous headache episodes; < 180 days per year, with headache to be considered "infrequent"
- Bilateral and occipitonuchal or bifrontal pain
- Pain described as "fullness, tightness/squeezing, pressure," or "band-like/vise-like"
- Insomnia
- Often present upon rising or shortly thereafter
- Muscular tightness or stiffness in neck, occipital, and frontal regions
- Duration > 5 years in 75% of patients with chronic headaches
- Difficulty concentrating
- No prodrome
New-onset headache in elderly patients should suggest etiologies other than tension-type headache.
International Headache Society diagnostic criteria for tension-type headaches state that two of the following characteristics must be present:
- Pressing or tightening (nonpulsatile quality)
- Frontal-occipital location
- Bilateral; mild/moderate intensity
- Not aggravated by physical activity
Read more about the presentation of tension-type headaches.
The specific Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for major depressive disorder are outlined below.
At least five of the following symptoms have to have been present during the same 2-week period (and at least one of the symptoms must be diminished interest/pleasure or depressed mood):
- Depressed mood: for children and adolescents, this can also be an irritable mood
- Diminished interest or loss of pleasure in almost all activities (anhedonia)
- Significant weight change or appetite disturbance: for children, this can be failure to achieve expected weight gain
- Sleep disturbance (insomnia or hypersomnia)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness
- Diminished ability to think or concentrate; indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must not be attributable to the physiologic effects of a substance (eg, a drug of abuse, a medication) or another medical condition. The disturbance must not be better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. No manic episodes or hypomanic episodes can have been reported.
Depressive disorders can be rated as mild, moderate, or severe. The disorder can also occur with psychotic symptoms, which can be mood congruent or incongruent. Depressive disorders can be determined to be in full or partial remission.
Read more about the presentation of depression.
The AASM guidelines state that psychological and behavioral interventions are effective and recommended for chronic insomnia, both primary and secondary types. Initial approaches to treatment should include at least one behavioral intervention, such as stimulus control therapy; relaxation therapy; or a combination of cognitive therapy, stimulus control therapy, and sleep restriction therapy with or without relaxation therapy. The AASM guidelines also state that over-the-counter antihistamines, antihistamine/analgesic drugs, barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended for the treatment of chronic insomnia.
According to the AASM guidelines, polysomnography and daytime MSLT are not indicated in the routine assessment of chronic insomnia, including insomnia due to neuropsychiatric or psychiatric disorders. Polysomnography is indicated when sleep apnea or movement disorders are suspected, as well as when initial diagnosis is unclear, treatment fails, or precipitous arousals occur with violent or injurious behavior.
The mainstay of emergency department therapy for acute asthma is inhaled beta2-agonists. The most effective particle sizes are 1-5 μm. Larger particles are ineffective because they are deposited in the mouth and central airways. Particles < 1 μm are too small to be effective because they move in the airways by Brownian motion and do not reach the lower airways.
Patients who respond poorly or not at all to an inhaled beta-agonist regimen may respond to parenteral beta2-agonists, such as 0.25 mg terbutaline or 0.3 mg of 1:1000 concentration of epinephrine administered subcutaneously. This treatment should be reserved for patients who are seriously ill and not responding to serial treatments with inhaled beta-agonist/anticholinergic therapy and other more established therapies.
Omalizumab is indicated for adults and children aged ≥ 6 years with moderate to severe persistent asthma who have a positive skin test result or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. Omalizumab has been shown to reduce the number of asthma exacerbations. However, immunotherapy for the treatment of asthma should be avoided if the patient is taking beta-blockers, is having an asthma exacerbation, or has moderate or worse fixed obstruction. A major risk factor for immunotherapy-related fatalities includes uncontrolled asthma; therefore, appropriate caution should be exercised.
Read more about the treatment of asthma exacerbations.
Lifestyle modifications are the first line of management in pregnant women with GERD. Lifestyle modifications include the following:
- Losing weight (if overweight)
- Avoiding alcohol, chocolate, citrus juice, and tomato-based products (2005 guidelines from the American College of Gastroenterology also suggest avoiding peppermint, coffee, and possibly the onion family)
- Avoiding large meals
- Waiting 3 hours after a meal before lying down
- Elevating the head of the bed by 8 inches
H2-receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grade I-II esophagitis. Options include ranitidine, cimetidine, famotidine, and nizatidine.
PPIs are the most powerful medications available for treating GERD. These agents should be used only when this condition has been objectively documented. They have few adverse effects. However, data have shown that PPIs can interfere with calcium homeostasis and aggravate cardiac conduction defects. Long-term use of these agents has also been associated with bone fractures in postmenopausal women, chronic renal disease, acute renal disease, community-acquired pneumonia, and Clostridium difficile intestinal infection.
Prokinetic agents are somewhat effective, but only in patients with mild symptoms; other patients usually require additional acid-suppressing medications, such as PPIs. Long-term use of prokinetic agents may have serious, even potentially fatal, complications and should be discouraged.
The most commonly performed operation today in both children and adults with GERD is the Nissen fundoplication, which is a 360° transabdominal fundoplication. Indications for fundoplication include the following:
- Patients with symptoms that are not completely controlled by PPI therapy can be considered for surgery; surgery can also be considered in patients with well-controlled GERD who desire definitive, one-time treatment
- The presence of Barrett esophagus is an indication for surgery (whether acid suppression improves the outcome or prevents the progression of Barrett esophagus remains unknown, but most authorities recommend complete acid suppression in patients with histologically proven Barrett esophagus)
- The presence of extraesophageal manifestations of GERD may indicate the need for surgery; these include (1) respiratory manifestations (eg, cough, wheezing, aspiration); (2) ear, nose, and throat manifestations (eg, hoarseness, sore throat, otitis media); and (3) dental manifestations (eg, enamel erosion)
- Young patients
- Poor patient compliance with regard to medications
- Postmenopausal women with osteoporosis
- Patients with cardiac conduction defects
- Cost of medical therapy
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