Published online Jul 19, 2023. doi: 10.5498/wjp.v13.i7.402
Peer-review started: April 27, 2023
First decision: May 25, 2023
Revised: June 7, 2023
Accepted: June 19, 2023
Article in press: June 19, 2023
Published online: July 19, 2023
Processing time: 82 Days and 4.6 Hours
A condition of exposure to multiple stressors resulting in a mixed clinical picture spanning conventional categories without meeting any of them in full, encom
Core Tip: Multiplicity of stressors has been considered mostly during and following catastrophes, without considering the resulting mixed clinical picture and life event concomitant stressors. We herewith suggest a new category within the conventional classification systems: The Complex Stress Reaction Syndrome, for a condition of multiplicity of stressors, which showed a mixed clinical picture for daily life in the post coronavirus disease 2019 era, in the general population. We argue that this condition may be relevant to daily, regular life, across the lifespan, and beyond conditions of catastrophes.
- Citation: Goldstein Ferber S, Shoval G, Weller A, Zalsman G. Not one thing at a time: When concomitant multiple stressors produce a transdiagnostic clinical picture. World J Psychiatry 2023; 13(7): 402-408
- URL: https://www.wjgnet.com/2220-3206/full/v13/i7/402.htm
- DOI: https://dx.doi.org/10.5498/wjp.v13.i7.402
Many people with mental health complaints present a mixed clinical picture. Often none of the com
There are at least 4 different suggestions to revise classical classifications into transdiagnostic appro
Part of the mixed clinical pictures involves the concomitant experience of multiple stressors. As it arises from our literature search using PubMed, Google Scholar and Reference Citation Analysis (RCA), the impact of multiple stressors has been discussed by cutting edge papers mostly in the context of disasters such as hurricanes, floods, wars and in drastic conditions experienced by refugees and immi
As clinicians, we encountered a condition in which many patients showed mixed symptomatology, spanning conventional categories, without fully meeting all the conventional criteria of any of these categories during the multi-stressor COVID-19 outbreak. Our literature review supported our observa
In this paper we suggest that the CSRS type A (the psychiatric part, not including type B) may explain mixed clinical pictures in conditions of multiplicity of significant stressful life events in the post-COVID era. Thus, we argue that in the general population, experiencing concomitant multiplicity of life events-related stressors may account for the development of a mixed type of mental health disorder, not only in conditions of catastrophes (see Figure 1).
For differential diagnosis, the CSRS (type A) may be compared to: (1) Diagnosis of adjustment disorder rules out PTSD and bereavement, and it displays a short stressor onset-symptoms occurrence latency; (2) PTSD diagnosis includes exposure to one frightening stressor; (3) Obsessional thoughts are ego-syntonic by definition. The behaviors related to extrinsic stressors are clearly not included in the obsessive-compulsive disorder (OCD) conventional category; (4) Diagnosis of acute stress disorder implies a simpler stressor and a specific symptom response; (5) The criteria for defining generalized anxiety disorder list excessive worrying (on diverse issues) and shifting back and forth among them, thus not implying the multiplicity of stressors and a mixed clinical picture; (6) The diagnosis of major depression disorder includes anhedonia, low affect, psychomotor agitation, unfitting guilt feelings, diminished drive and energy, trouble concentrating, and indecisiveness with no other types of symptomatology which are included in a mixed clinical picture; and (7) C-PTSD is described as the result of a series of traumatic events, which is repetitive and hard to escape but does not include a mixed clinical picture beyond the PTSD conventional criteria. It also describes a series of events and not the simul
The impact of multiple concomitant stressors depends on individual subjective perception and stress reaction tendencies[26]. The immediate question is what can prevent the emergence of pathological stress reactions, spanning several conventional categories. In a previous study we found that close relationships may protect the individual across the types of psychopathology investigated, spanning anxiety, depression, PTSD and OCD criteria, in conditions of multiple stressors[27]. The means for illness prevention and enhanced coping are therefore suggested as keeping close relationships active. Public and media educational programs for conditions of multiplicity of life stressful events with transdiagnostic potential consequences, aimed at enhancing individual resilience by utilization of social networks, are herewith suggested, evidence-based[27,28].
We suggest a combined treatment approach of interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT), two evidence-based and cost-effective methods, designed as short-term thera
We suggested previously that when exposed to multiplicity of stressors, the lack of clear goals implies the diffusion of actions[37]. This could be a risk factor for effective treatment of patients confronted with this type of condensed stressful experience. To overcome this risk and also to respect individual differen
The CSRS emerged from the robust transdiagnostic clinical pictures during and following the pandemic[38]. The World Health Organization indicates a prevalence of 22% of a mixed picture including depre
What was probably different about the COVID-19 pandemic compared to previous catastrophes was its global scale and the fact that it was covered extensively by the social, electronic, and print media. This factor may be regarded as an additional stressor in daily life beyond disasters. Whether media use is a source of social support, especially for young people[27,40,41] or a daily life stressor in the form of bom
Although there is enough evidence to suggest that the mental health of the population deteriorated following the pandemic[43], there are suggestions that the extent of deterioration was less than anticipated[44,45]. In any case, epidemiological studies have shown that anxiety, depression, functional somatic, and even obsessional symptoms can coexist at the population or the community level[38,46,47], supporting our transdiagnostic views and the CSRS.
Inclusion of long COVID symptoms in the CSRS may create the same psychological vs physical dispute that we have witnessed with chronic fatigue syndrome or myalgic encephalomyelitis, but we include in the CSRS just neuropsychiatric symptoms, while systemic components of long COVID are excluded. In support of our view, studies that have already started appearing suggest that the long COVID syndrome is more likely to be associated with psychosocial factors rather than the COVID infection itself[48].
Thus, the origins of CSRS are rooted in the multi-faceted stress of the pandemic and its impact on mental health including its residuals in the post COVID era. The relevance of concomitant stressors included in daily life, under regular, non-catastrophic conditions, and their association with a mixed clinical picture, is gradually becoming apparent.
Our opinion goes beyond conventional approaches for construction of psychiatric taxonomy. Alter
The main differences between the validity of dimensional diagnostics and that of traditional nosology are apparent in several aspects: (1) In traditional approaches, mental pathology is regarded as a strict drift from acceptable norms while the transdiagnostic views, similar to ours, suggest an axis between normal and psychopathological conditions; (2) In dimensional approaches co-existing psychopathological states appear in parallel along with personal strengths and capacities for resilience, unlike traditional nomenclature; (3) Dimensional approaches to the convergent and divergent validity of a cluster or co-existence of different pathologies without meeting a full criteria of any category in the conventional systems, such as the CSRS, do justice to the patient and the entire individual clinical picture he or she describes to the clinician, while traditional approaches prefer multiple comorbidities; and (4) The dimensional approaches such as the CSRS, unlike conventional systems, emphasize subjec
Specifically, the CSRS has shown high reliability, as in two different countries and with two different methodologies similar results were found[25]. Additionally, the CSRS has shown high convergent and divergent validity as a combination of several identified stress symptoms, without meeting any full conventional category. These findings suggest a complex and unique type of reactivity to multiplicity of stressors. Other combinations suggested earlier, as complex anxiety and depression[50] or complex post traumatic stress disorder, showed validity for inclusion of just two conventional categories[51] while others showed a too wide range of inclusion, ruling out the potential judgement of divergent validly[10].
We acknowledge the importance of biological validation of psychiatric illness, but this still cannot be utilized for a treatment per any specified condition until the field of neuropsychiatric science advances considerably. The CSRS implies symptoms more than signs and subjectivity more than objectivity. The treatment derived from the CSRS would be patient-specific and session-specific, as human experience may go back and forth on the axis of elevated symptomology vs resilience and adaptive coping. There
It was noted earlier that the empirical validation used as the basis of conventional categories has been mostly regression statistical analyses with a weak basis for causality[49]. Contrary to any etiological arguments, we argue that the CSRS represents an association between multiplicity of stressors and a mixed clinical picture, which is worth treating to avoid further increase in the patient’s stress reactivity and future limitations of his or her resilience capacities.
We locate CSRS within the blend of the biopsychosocial model (BPS)[56] and the person-centered medicine (PCM) approach[57], as the novel CSRS is related to exogenic stressors (BPS) and occurs as a subjective complex stress reaction of the patient (PCM). Thus, as outlined here and according to our bi-national research design and findings[25], the CSRS falls within the post-modern dimensional appro
Transdiagnostic considerations towards a change in the classification of mental disorders can be accom
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