Reaction To Severe Stress & Adjustment Disorders: Photo by Burst From Pexels

REACTION TO SEVERE
STRESS & ADJUSTMENT

DISORDERS
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TERMINOLOGY &
CLASSIFICATION
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Terminology & Classification
3
F40-F48 Neurotic, stress-related and

somatoform disorders:
 F43 Reaction to severe stress, and adjustment
disorders:
 F43.0 Acute stress reaction;
 F43.1 Post-traumatic stress disorder (PTSD);
 F43.2 Adjustment disorders;
 F43.8 Other reactions to severe stress;
 F43.9 Reaction to severe stress, unspecified.
WHO, ICD-10 Version:2016

CLINICAL PICTURE
hyms.ac.uk
POST-TRAUMATIC STRESS
DISORDER (PTSD)
www.leafly.com
Post-traumatic stress disorder (PTSD)
6
An psychiatric disorder resulting from

exposure to an experience involving direct or
indirect threat or serious harm or death.
May be experienced along (rape/assault) or in
company of overs (natural disaster, a terrorist
act, war/combat).
www.ptsd.va.gov
PTSD symptoms by DSM-5
7
Criterion A: Stressor:
Exposure to actual or threatened death, serious injury, or sexual violence in
one (or more) of the following ways:
• Directly experiencing the traumatic event.
• Witnessing, in person, the event as it occurred to others.
• Learning that the traumatic event occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the event
must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the traumatic
event (first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies,
or pictures, unless this exposure is work related.
APA. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
8 PTSD symptoms by DSM-5
Criterion B: Intrusion Symptoms:
The traumatic event is persistently re-experienced in one or more of the following ways:
• Recurrent, involuntary, and intrusive distressing memories of the traumatic event. Note: In children
older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event. Note: In children, there may be frightening dreams without recognizable content.
• Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event were
recurring. (Such reactions may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may
occur in play.
• Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
• Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of
the traumatic event.
9
Criterion C: Avoidance:
Persistent avoidance of stimuli associated with the traumatic
event, beginning after the traumatic event occurred, as
evidenced by one or both of the following:
• Avoidance of or efforts to avoid distressing memories, thoughts, or
feelings about or closely associated with the traumatic event.
• Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event.
10 PTSD symptoms by DSM-5
Criterion D: Negative Alterations in Mood:
Negative alterations in cognitions and mood associated with the traumatic event,
beginning or worsening after the traumatic event occurred, as evidenced by two (or more)
of the following:
• Inability to remember an important aspect of the traumatic event (typically due to dissociative
amnesia, and not to other factors such as head injury, alcohol, or drugs).
• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g.,
“I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous
system is permanently ruined”).
• Persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the
individual to blame himself/herself or others.
• Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
• Markedly diminished interest or participation in significant activities.
• Feelings of detachment or estrangement from others.
• Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings). APA. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
11
Criterion E: Alterations in Arousal and Reactivity:
Trauma-related alterations in arousal and reactivity that began or worsened
after the traumatic event, including two or more of the following:
• Irritable behavior and angry outbursts (with little or no provocation),
typically expressed as verbal or physical aggression toward people or objects.
• Reckless or self-destructive behavior.
• Hypervigilance.
• Exaggerated startle response.
• Problems with concentration.
• Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
12
Criterion F: Duration:
Persistence of symptoms in Criteria B, C, D, & E for more than
1 month.
Criterion G: Functional Significance:
The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Criterion H: Exclusion:
The disturbance is not due to medication, substance use, or
other illness.
13
In order to diagnose PTSD according to the DSM-5, the
following should be met:
 Criterion A
 One symptom or more from Crit.B
 One symptom or more from Crit.C
 Two symptoms or more from Crit.D
 Two symptoms or more from Crit.E
 Criterion F
 Criterion G
 Criterion H
www.verywellmind.com
Snapshot of PTSD
14
A 28-year-old male presents with a recent onset of upsetting
dreams, anxiety, and disturbing flashbacks. The patient reports
that he returned from active duty in Iraq 3 months ago and was
adjusting to life back at home until about 7 weeks ago when he
began having intense fear of loud noises and seeing sudden
flashbacks to bombing attacks he endured during his time in Iraq.
He had to take a leave from his army instructor duties as he was
not able to handle the familiar settings of practice shooting ranges
and sudden loud explosions during battalion training. After
refusing to leave his house, he was finally persuaded by his wife to
visit your clinic.
step2.medbullets.com
1) to interpret events more realistically
Treatment of PTSD with respect to their threat content;
15
Goals of treatment: 2) ▲ interpersonal work and leisure
functioning;
1) ▼ intrusive symptoms; 3) ▲ self-esteem, trust and feelings of
2) ▼ avoidance symptoms; safety;
3) ▼ numbing & withdrawal; 4) to explore and clarify meanings
attributed to the event;
4) ▼ hyperarousal;
5) ▲ access to memories that have
5) ▼ psychotic symptoms when been dissociated/ repressed to be
present; clinically appropriate;
6) ▲ impulse control when this 6) ▲ social support systems;
is a problem. 7) to move from identification as a
victim to that of a survivor.
Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.

16
Treatment of PTSD
Pharmacotherapies Psychotherapies
(trauma-focused
1st line SSRIs 2st line nonSSRIs psychotherapies)
(mirtazapine, venlafaxine)
Adjunctive medications: • Psychoeducation;

If hyperarousal: benzodiazepine or
• CBT
buspirone;
If prominent mood liability or explosiveness: • Psychodynamic therapy
anticonvulsant or lithium; • Eye movement
If prominent dissociation: valproic acid; desensitization &
If persistent insomnia: trazodone; reprocessing (EMDR)
If psychotic: atypical antipsychotic Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.
A phased approach to treating PTSD
17
PREVENTION
(psychological & pharmacological intervention)
Facilitate the patient’s taking control over the dominance of intrusive and
disruptive memories of the trauma
Provide psychoeducation with which acceptance of the impact of the trauma

goes hand in hand
Assist patient in establishing mastery over feelings including fear of

symptoms and somatic responses to them
Assist patient to be specifically mobilized to use available social supports to

facilitate stabilization
Murray R.M. , Kendler K.S., McGufﬁn P. &others, Essential Psychiatry (4-th ed.), 2008-
18
Acute stress
reaction F43.0
www.123rf.com
Acute stress reaction (disorder)
19
A transient disorder of significant severity which

develops in an individual without any other
apparent mental disorder in response to
exceptional physical or mental stress and which
usually subsides within hours or days.
The risk of this disorder developing is increased if
physical exhaustion or organic factors (e.g. in the
elderly) are also present.

IDC-10 criteria of Acute stress reaction
20
There must be an immediate and clear connection between the
impact of an exceptional stressor and the onset of symptoms
(within a few minutes or immediate) In addition, the
symptoms:
• show a mixed and usually changing picture; in addition to the initial
state of "daze", depression, anxiety, anger, despair, overactivity, and
withdrawal may all be seen, but no one type of symptom predominates
for long;
• resolve rapidly (within a few hours at the most) in those cases where
removal from the stressful environment is possible; in cases where the
stress continues or cannot by its nature be reversed, the symptoms
usually begin to diminish after 24-48 hours and are usually minimal
after about 3 days.
Acute stress disorder by DSM-5
21
Criterion A: Stressor:
Exposure to actual or threatened death, serious injury, or sexual violence in
one (or more) of the following ways:
• Directly experiencing the traumatic event.
• Witnessing, in person, the event as it occurred to others.
• Learning that the traumatic event occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the event
must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the traumatic
event (first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).
Note: Does not apply to exposure through electronic media, television, movies, or pictures,
unless this exposure is work related.
22
Criterion B:
Presence of nine or more of the following
symptoms from any of the five categories of
intrusion, negative mood, dissociation, avoidance,
and arousal, beginning or worsening after the
traumatic event occurred:
23 Acute stress disorder by DSM-5
Intrusion Symptoms:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event.
Note: In children, repetitive play may occur in which themes or aspects of the traumatic event
occurred.
2. Recurrent distressing dreams in which the content or effect of the dream are
related to the event. Note: In children, there may be frightening dreams without recognizable
content.
3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the
traumatic event were recurring. (Such reactions may occur on a continuum, with
the most extreme expression being a complete loss of awareness of present
surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in
response to internal or external cues that symbolize or resemble an aspect of the
traumatic event.
24
Negative Mood:
5. Persistent inability to experience positive
emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
25
Dissociative Symptoms:
6. An altered sense of the reality of one’s surroundings or
oneself (e.g., seeing oneself from another’s perspective, being
in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to
other factors such as head injury, alcohol, or drugs).
26
Avoidance Symptoms:
8. Efforts to avoid distressing memories, thoughts, or feelings
about or closely associated with the traumatic event.
9. Efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
27
Arousal Symptoms:
10. Sleep disturbance (e.g., difficulty falling or staying asleep,
restless sleep).
11. Irritable behavior and angry outbursts (with little or no
provocation), typically expressed as verbal or physical
aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
28
Criterion D: Functional Significance:
The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Criterion C: Duration:
Duration of the disturbance (symptoms in Criterion B) is 3 days
to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3
days and up to a month is needed to meet disorder criteria.
Criterion E: Exclusion:
The disturbance is not due to medication, substance use, or
other illness.
Snapshot of Acute stress disorder
29
A 28-year-old male assembly-line worker comes in for treatment
after developing symptoms a few days after a serious factory
accident in which he was knocked unconscious by a machine. He
was medically cleared directly following the event but later
developed nightmares about the accident. He says he has been very
anxious, fears returning to work, and is thinking about seeking
disability pay. He has refused to talk to his wife about the incident,
because it “makes it worse.” Being around large objects also
frightens him, since he is worried he will be hit in the head again
and he notes that he thinks about the accident constantly.
Photo by George Becker from Pexels & Eugene Toy, Debra Klamen Case Files Psychiatry, Third Edition LANGE Case Files 2009
Treatment of Acute stress disorder
30
Principles of treatment:
1) Brevity;
2) Immediacy;
3) Centrality;
4) Expectancy;
5) Proximity;
6) Simplicity.
favpng.com
31
Therapeutic tactics:
 recognize & accept what
1) Providing information; happened;
 unrealistic hope needs to be
balanced by realistic
explanations;
 strengthen coping
2) Psychological support; mechanisms;
 promotes adaptive defenses

32
Therapeutic tactics:
 acceptance of feelings, symptoms,
3) Crisis intervention; reality and the need for help;
 recognition of psychologically
distressing issues;
4) Emotional first aid.  identification of available resources;
 acceptance of responsibility and
absence of blame;
 cultivation of an optimistic attitude;
 cultivation efforts to resume activities
of daily life as much as possible.

PTSD vs Acute stress disorder
33
PTSD Acute Stress Disorder

TRAUMA
Traumatic event;
Re-experience the event;
Avoidance of stimuli associated • May be a precursor to PTSD
with the trauma; Unable to VS • Similar symptoms to PTSD
function; • Symptoms persist 3 days after a
More than a Month; trauma until 1 month after the
Arousal increased; exposure
+ negative alterations in cognition
and mood
Toronto Notes. Comprehensive medical reference and review for the (MCCQE) Part I & (USMLE) Step 2, 34th Edition. By T.B. Marvasti & S. McQueen
F43.2
www.floridamentalhealthhelpline.com
Adjustment disorders
35
Adjustment disorders are maladaptive reactions to an

identifiable psychosocial stressor. They are caused by
environmental stressors having an effect on functioning.
The risk that a stressor will cause an adjustment disorder
depends on one’s emotional strength and coping skills.
The onset is usually within 1 month of the occurrence of the
stressful event or life change, and the duration of symptoms
does not usually exceed 6 months.
Kaplan Medical, USMEL STEP 2 CK Lecture Notes 2017 Psychiatry, Epidemiology, Ethics, Patient Safety
Adjustment disorders
36
Causes:
 Adaptation to a significant life change or to the
consequences of a stressful life event (including the
presence or possibility of serious physical illness)
 Disruption in the integrity of an individual's social
network (through bereavement or separation
experiences)
 Disruption in the integrity of wider system of social
supports and values (migration or refugee status).

Clinical form of Adjustment disorders
37
Brief depressive reaction F43.20

 A transient, mild depressive state of duration not
exceeding 1 month.
Prolonged depressive reaction F43.21
 A mild depressive state occurring in response to a
prolonged exposure to a stressful situation but of duration
not exceeding 2 years.
Mixed anxiety & depressive reaction F43.22
 Both anxiety and depressive symptoms are prominent

Snapshot of Adjustment disorders
38
A 35-year-old married woman, mother of three children, was
desperate when she learned she had cancer and would need
mastectomy followed by chemotherapy and radiation. She was
convinced that she would not recover, that her body would be
forever distorted and ugly, that her husband would no longer
find her attractive, and that her children would be ashamed of
her baldness and the fact that she had cancer. She wondered
whether anyone would ever want to touch her again. Because
her mother and sister had also experienced breast cancer, the
patient felt she was fated to an empty future.

39
With predominant disturbance of other emotions

F43.23
 The symptoms are usually of several types of
emotion, such as anxiety, depression, worry,
tensions, and anger.
 This category should also be used for reactions in
children in which regressive behaviour such as
bed-wetting or thumb-sucking are also present.

40
With predominant disturbance of conduct F43.24

 The main disturbance is one involving conduct,
e.g. an adolescent grief reaction resulting in
aggressive or dissocial behaviour.
With mixed disturbance of emotions and conduct
(Hysterical) F43.25
 Both emotional symptoms and disturbance of
conduct are prominent features.

Treatment of Adjustment disorders
41
 Remove or ameliorate the stressor

 Brief psychotherapy to improve
coping skills
 Pharmacotherapy: Anxiolytic or
antidepressant medications are used to
ameliorate symptoms if therapy is not
effective.
Kaplan Medical, USMEL STEP 2 CK Lecture Notes 2017 Psychiatry, Epidemiology, Ethics, Patient Safety
pngtree.com
Psychogenic
(situational)
psychoses historical
footnote
www.medicinenet.com
Psychogenic psychoses
43 historical footnote
Reactive (psychogenic) psychosis, refers to an acute

psychosis with excellent prognosis emerging in response to a
stressful life situation.
In addition to psychosocial conflicts of everyday life such as
sudden loss of one's livelihood and broken relationships,
natural disasters and major social changes profoundly
affecting the individual's existence such as earthquakes,
imprisonment or emigration provide a fertile ground for the
development of reactive psychosis.
onlinelibrary.wiley.com
Psychogenic psychoses
44 historical footnote
The classical psychopathological concept of

reactive psychosis “Jaspers' triad”:
 Psychosis occurs after a psychic trauma;
 The trauma content reflecting in patient’s
condition;
 Patient’s recovery follows the resolution of
the psychotraumatic situation.
Gavenko V.L., Korostiy V.I., Kozhina A.M &others, Psychiatry : manual for English medium students of higher medical schools and interns,
2014-389p
45 Psychogenic psychoses in DSM-5 & IDC-10
DSM-5 IDC-10
Brief Psychotic Disorder Acute & transient psychotic disorders
A. Presence of one (or more) of the following symptoms. At
least one of these must be (1), (2), or (3):
1. delusions
2. hallucinations
a) an acute onset (within 2 weeks) as the defining feature
3. disorganized speech (e.g., frequent derailment or of the whole group;
incoherence) b) the presence of typical syndromes;
4. grossly disorganized or catatonic behavior c) the presence of associated acute stress.
Note: Do not include a symptom if it is a culturally sanctioned
response pattern. F23.0 Acute polymorphic psychotic disorder without
B. Duration of an episode of the disturbance is at least 1 day symptoms of schizophrenia
but less than 1 month, with eventual full return to F23.1 Acute polymorphic psychotic disorder with
premorbid level of functioning.
C. The disturbance is not better explained by major
symptoms of schizophrenia
depressive or bipolar disorder with psychotic features or F23.2 Acute schizophrenia-like psychotic disorder
another psychotic disorder such as schizophrenia or F23.3 Other acute predominantly delusional psychotic
catatonia, and is not attributable to the physiological disorders
effects of a substance (e.g., a drug of abuse, a medication) F23.8 Other acute and transient psychotic disorders
or another medical condition. F23.9 Acute and transient psychotic disorder, unspecified
F24 Induced delusional disorder
APA. (2013). Diagnostic and statistical manual of mental disorders (5th ed.); WHO, ICD-10 Version:2016
Clinical form of Psychogenic psychoses
historical footnote
46
Affective-shock reactions develop acutely, the patients being

unable to rationalize stressful event and manifesting “biological”
forms of defense which are not adequate to the situation.
 Hyperkinetic form (psychogenic agitation) - patient would lose
their orientation in their surroundings, cry, impulsively run
somewhere, rather often to the most dangerous place (fugue-
like reactions).
 Hypokinetic form (the “imaginary death” reaction) manifests
itself by inhibition up to absolute stupor that developing after
the psychic trauma.
Amnesia often follows in both form
Gavenko V.L., Korostiy V.I., Kozhina A.M &others, Psychiatry : manual for English medium students of higher medical schools and interns, 2014-389p
47
historical footnote
Hysterical psychoses are a group of disordes with various clinical
manifestations, bearing features describe in dissociative disorders.
 hysterical twilight state of consciousness;
 Pseudodementia;
 Ganser’s syndrome;
 Puerilism,
 Syndrome of delirium-like fantasies;
 Syndrome of personality regression (“running wild”);
 Hysterical stupor.
historical footnote
48
Psychotic epidemics are a so-called collective

psychosis which develops in a group of people and
induced by mentally ill member of the group. Such
psychotic epidemics were quite common in the
Middle Ages, and manifested themselves through
different symptoms: fits, paralyses, hallucinations,
hysterical dances involving hundreds and
thousands of people.
historical footnote
49
Reactive delusional psychoses develop under the effect of psychic

traumas and are a rather rare ones.
Clinical picture of acute reactive delusional psychoses inherent
simplicity, elementary, imagery, and emotional richness of
delirium pronounced affect of fear and anxiety. Most often, there
is delusions of persecution and relationships. The content of
delusions reflects the forward or reverse (delusions of innocence
and pardon convicts) as a traumatic situation.
Snapshot of Reactive psychosis
50
Mr B, a 40‐year‐old Hong Kong‐born Chinese man, returned to his
hometown to attend his father's funeral. He had lived in a Western
country for more than a decade, running a successful business there. He
was the eldest son of a large, traditional Chinese family, psychologically
balanced, resilient and hard working. He emigrated against his parents'
wishes and had only tenuous contact with his family thereafter; the
funeral was the first reunion since his departure. Plagued with intense
guilt and shame for breaking the pivotal ethical code of ‘filial piety’ and
hurt by hints of accusations of betrayal voiced by other family members,
he felt increasingly tense and confused. During the funeral he started
talking incomprehensibly and became agitated. Later he lapsed into a
stupor and 24 h later was admitted to a psychiatric unit for the first time
in his life.
51 Snapshot of Reactive psychosis
Mrs A, a 44‐year‐old Chinese woman, was admitted with a 3‐week history of increasing mental disorganization
characterized by auditory and visual hallucinations and periods of apathetic withdrawal interspersed with sudden
outbursts of chaotic excitement. Her physical condition was excellent and results of a wide range of laboratory
investigations, including brain imaging, were negative. She had no previous psychiatric or medical disorders of
note and no family history of mental illness. Mrs A was born and raised in a small Chinese fishing village where she
lived with her husband and their three children. She was invariably described as a good ‐natured, diligent and loyal
person. Mrs A's husband and eldest daughter had emigrated to Hong Kong where they settled successfully, but
Mrs A could not follow them for 3 years and even then, due to administrative difficulties, she had to leave her two
younger children behind in the care of relatives. Arriving in Hong Kong, she had to confront major
disappointments. Her husband had moved in with another woman and her daughter, struggling to fit in new social
circles, treated her like a stranger. Mrs A had no qualifications and no money, and she suddenly found herself in a
temporary shelter. She barely understood the dialect let alone the cosmopolitan city lifestyle. An intense longing for
the children she had left behind and a profound guilt for abandoning them further aggravated the increasingly
bewildering situation. A return to the village seemed impossible both due to the lack of money and the fear of
shame (‘loss of face’). She was trapped in an intolerable situation which she was powerless to influence. It was in
this context that she first became increasingly withdrawn and preoccupied and then she began to show active
psychotic symptoms. On admission she was perplexed and on occasions appeared confused.
Treatment of Psychogenic psychoses
52
Pharmacotherapy:
 Tranquillizers & anxiolytics;
 Neuroleptics;
 Antidepressants;
Psychotherapy:
 CBT
 Psychoeducation
Gavenko V.L., Korostiy V.I., Kozhina A.M &others, Psychiatry : manual for English medium students of higher medical
schools and interns, 2014-389p

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REACTION TO SEVERE

STRESS & ADJUSTMENT

F40-F48 Neurotic, stress-related and

WHO, ICD-10 Version:2016

An psychiatric disorder resulting from

Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.

Adjunctive medications: • Psychoeducation;

Provide psychoeducation with which acceptance of the impact of the trauma

Assist patient in establishing mastery over feelings including fear of

Assist patient to be specifically mobilized to use available social supports to

A transient disorder of significant severity which

WHO, ICD-10 Version:2016

Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.

Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.

PTSD Acute Stress Disorder

Adjustment disorders are maladaptive reactions to an

WHO, ICD-10 Version:2016

Brief depressive reaction F43.20

WHO, ICD-10 Version:2016

Kay J. & Tasman A., Essentials of Psychiatry, 2006 -1078p.

With predominant disturbance of other emotions

WHO, ICD-10 Version:2016

With predominant disturbance of conduct F43.24

WHO, ICD-10 Version:2016

 Remove or ameliorate the stressor

Reactive (psychogenic) psychosis, refers to an acute

The classical psychopathological concept of

Affective-shock reactions develop acutely, the patients being

Psychotic epidemics are a so-called collective

Reactive delusional psychoses develop under the effect of psychic

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