1. Chapter 6 Stress Disorders Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

2. Slide 2 Stress, Coping, and the Anxiety Response  The state of stress has two components: Stressor: event creating demands Stress response: reactions to the demands Influenced by how we appraise (a) the event, and (b) our capacity to react to the event effectively People who sense that they have the ability and resources to cope are more likely to take stressors in stride

3. Slide 3 Stress, Coping, and the Anxiety Response  Fear is a “package” of physical, emotional, and cognitive responses  Stress reactions are often at play in psychological disorders People who experience a large number of stressful events are particularly vulnerable to the onset of GAD, social phobia, panic disorder, and OCD, as well as other psychological problems

4. Slide 4 Stress, Coping, and the Anxiety Response  Stress also plays a more central role in certain psychological disorders, including: Acute stress disorder Posttraumatic stress disorder  …as well as certain physical disorders called psychophysiological disorders These disorders are listed in the DSM-IV under “psychological factors affecting medical condition”

5. Slide 5 Stress and Arousal: The Fight-or-Flight Response  The features of arousal and fear are set in motion by the hypothalamus Two important systems are activated: Autonomic nervous system (ANS) An extensive network of nerve fibers that connect the central nervous system (the brain and spinal cord) to the body’s other organs Contains two systems: sympathetic and parasympathetic Endocrine system A network of glands throughout the body which release hormones

6. Slide 6 Stress and Arousal: The Fight-or-Flight Response  There are two pathways by which the ANS and the endocrine systems produce arousal and fear reactions: Sympathetic nervous system Hypothalamic-pituitary-adrenal pathway

7. Slide 7 Stress and Arousal: The Fight-or-Flight Response  When confronting a dangerous situation, the hypothalamus first activates the sympathetic nervous system, which stimulates key organs either directly or indirectly  When the perceived danger passes, the parasympathetic nervous system helps return bodily systems to normal

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9. Slide 9 Stress and Arousal: The Fight-or- Flight Response  The second pathway is the hypothalamic- pituitary-adrenal (HPA) pathway When confronted by stressors, the hypothalamus sends a message to the pituitary gland, which signals the adrenal cortex to release corticosteroids – the stress hormones – into the bloodstream

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11. Slide 11 Stress and Arousal: The Fight-or-Flight Response  The reactions displayed by these two pathways are referred to as the fight-or-flight response  People differ in their particular patterns of autonomic and endocrine functioning and therefore also in their particular ways of experiencing arousal and fear

12. Slide 12 Stress and Arousal: The Fight-or-Flight Response  The experience of fear and anxiety is different for each person People differ in the general level of anxiety Called “trait anxiety” Some people are usually somewhat tense; others are usually relaxed Differences appear soon after birth People also differ in their sense of threat Called “state anxiety” Situation-based (example: fear of flying)

13. Slide 13 The Psychological Stress Disorders  During and immediately after trauma, many people become highly anxious and depressed For some, feelings persist well after the trauma These people may be experiencing: Acute stress disorder Posttraumatic stress disorder (PTSD) The precipitating event usually involves actual or threatened serious injury to self or others Occurs following an event which would be traumatic to anyone (unlike other anxiety disorders)

14. Slide 14 The Psychological Stress Disorders  Acute stress disorder Symptoms begin within four weeks of event and last for less than one month  Posttraumatic stress disorder (PTSD) Symptoms can begin at any time following the event but must last for longer than one month May develop from acute stress disorder

15. Slide 15 The Psychological Stress Disorders  Symptoms of acute and posttraumatic stress disorders: Reexperiencing the traumatic event Flashbacks, nightmares Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt

16. Slide 16 What Triggers a Psychological Stress Disorder?  Can occur at any age and affect all aspects of life  ~4% of U.S. population affected each year  ~8% of U.S. population affected sometime during life  Ratio of women to men is 2:1 After trauma, 20% of women and 8% of men develop disorders Some events – including combat, disasters, abuse, and victimization – are more likely to cause disorders than others

17. Slide 17 What Triggers a Psychological Stress Disorder?  Combat and stress disorders It has long been recognized that soldiers experience distress during combat Called “nostalgia,” “shell shock,” “combat fatigue” Post-Vietnam war clinicians discovered that soldiers also experienced psychological distress after combat ~30% of Vietnam combat veterans suffered acute or posttraumatic stress disorders An additional 22% had some stress symptoms ~ 10% still experiencing problems

18. Slide 18 What Triggers a Psychological Stress Disorder?  Disasters and stress disorders Acute or posttraumatic stress disorders may also follow natural and accidental disasters Civilian traumas have been implicated in stress disorders at least 10 times as often as combat trauma Types of disasters include traffic accidents, weather, earthquakes, and airplane crashes

19. Slide 19 What Triggers a Psychological Stress Disorder?  Victimization and stress disorders People who have been abused or victimized often experience lingering stress symptoms Common victimization is sexual assault/rape Psychological impact is immediate and may be long- lasting One study found that 94% of rape survivors developed an acute stress disorder within 12 days after assault

20. Slide 20 What Triggers a Psychological Stress Disorder?  Victimization and stress disorders Ongoing victimization and abuse in the family may also lead to stress disorders The experience of terrorism often leads to posttraumatic stress symptoms

21. Slide 21 Why Do People Develop a Psychological Stress Disorder?  Clearly, extraordinary trauma can cause a stress disorder However, the event alone may not be the entire explanation  To understand why only some people develop stress disorders, researchers have looked to the survivors’ biological processes, personalities, childhood experiences, and social support systems, and to the severity of the trauma itself

22. Slide 22 Why Do People Develop a Psychological Stress Disorder?  Biological and genetic factors Traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions Some research suggests abnormal NT and hormone activity (especially norepinephrine and cortisol) There may be a biological/genetic predisposition to such reactions Evidence suggests that other biological changes and damage may also occur

23. Slide 23 Why Do People Develop a Psychological Stress Disorder?  Personality factors Some studies suggest that people with certain personality profiles, attitudes, and coping styles are more likely to develop stress disorders Risk factors include: Preexisting high anxiety A history of psychological problems Negative worldview A set of positive attitudes (called resiliency or hardiness) is protective against developing stress disorders

24. Slide 24 Why Do People Develop a Psychological Stress Disorder?  Negative childhood experiences A wave of studies has found that certain childhood experiences increase risk for later stress disorders Risk factors include: An impoverished childhood Psychological disorders in the family The experience of assault, abuse, or catastrophe at an early age Being younger than 10 years old when parents separated or divorced

25. Slide 25 Why Do People Develop a Psychological Stress Disorder?  Social support People whose social support systems are weak are more likely to develop a stress disorder after a negative event  Severity of the trauma The more severe the trauma and the more direct one’s exposure to it, the greater the likelihood of developing a stress disorder Especially risky: mutilation and severe injury; witnessing the injury or death of others

26. Slide 26 How Do Clinicians Treat the Psychological Stress Disorders?  Symptoms have been found to last an average of 3 years with treatment and 5½ years without treatment Treatment type varies depending on type of trauma General goals: End lingering stress reactions Gain perspective on traumatic experience Return to constructive living

27. Slide 27 How Do Clinicians Treat the Psychological Stress Disorders?  Treatment for combat veterans Drug therapy Antianxiety and antidepressant medications are most common Behavioral exposure therapy Reduce specific symptoms, increase overall adjustment Use flooding and relaxation training Use eye movement desensitization and reprocessing (EMDR) Insight therapy Bring out deep-seated feelings, create acceptance, lessen guilt Often use family or group therapy formats; rap groups Usually used in combinations

28. Slide 28 How Do Clinicians Treat the Psychological Stress Disorders?  Community therapy Critical incident stress debriefing Physical aims: help survivors meet basic needs ASAP Four-stage approach to psychological aims Normalize responses to the disaster Encourage expressions of anxiety, anger, and frustration Teach self-help skills Provide referrals Relief workers themselves may become overwhelmed

29. Slide 29 The Physical Stress Disorders: Psychophysiological Disorders  In addition to affecting psychological functioning, stress can also have an enormous impact on physical functioning  The idea that stress and related psychosocial factors may contribute to somatic illnesses has ancient roots – René Descartes called a variation on this idea mind-body dualism

30. Slide 30 The Physical Stress Disorders: Psychophysiological Disorders  About 75 years ago, clinicians first identified a group of physical illnesses that seemed to result from an interaction of psychosocial and physical factors  Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders DSM-IV calls them psychological factors affecting medical condition

31. Slide 31 The Physical Stress Disorders: Psychophysiological Disorders  It is important to note that these psychophysiological disorders bring about actual physical damage They are different from “apparent” physical illnesses like factitious disorders or somatoform disorders, which will be discussed in Chapter 7

32. Slide 32 Traditional Psychophysiological Disorders  Before the 1970s, the best known and most common of the psychophysiological disorders were ulcers, asthma, insomnia, chronic headaches, high blood pressure, and coronary heart disease  Recent research has shown that many other physical illnesses may be caused by an interaction of psychosocial and physical factors

33. Slide 33 Traditional Psychophysiological Disorders  Ulcers Lesions in the wall of the stomach that result in burning sensations or pain, vomiting, and stomach bleeding Affect up to 10% of people in the U.S. each year Causal psychosocial factors: Environmental stress, anger, anxiety, dependent personality style Causal physiological factors: Bacterial infection

34. Slide 34 Traditional Psychophysiological Disorders  Asthma A narrowing of the body’s airways that makes breathing difficult Affects up to 15 million people in the U.S. each year Most victims are children at the time of first attack Causal psychosocial factors: Environmental pressures, troubled family relationships, anxiety, high dependency Causal physiological factors: Allergies, a slow-acting sympathetic nervous system, weakened respiratory system

35. Slide 35 Traditional Psychophysiological Disorders  Insomnia Difficulty falling asleep or maintaining sleep Affects 20 to 45% of people in the U.S. each year Causal psychosocial factors: High anxiety or depression Causal physiological factors: Overactive arousal system, certain medical ailments

36. Slide 36 Traditional Psychophysiological Disorders  Chronic headaches Tension headaches affect 40 million Americans each year Migraine headaches affect 23 million Americans each year Causal psychosocial factors: Environmental pressures; a passive personality style; general feelings of helplessness, anger, anxiety, depression Causal physiological factors: Abnormal serotonin activity, vascular problems, muscle weakness

37. Slide 37 Traditional Psychophysiological Disorders  Hypertension Chronic high blood pressure, usually producing no overt symptoms Affects 40 million Americans each year Causal psychosocial factors: Constant environmental danger, general feelings of anger or depression, an unexpressed need for power Causal physiological factors: Faulty baroreceptors (sensitive nerves in the blood vessels responsible for signaling the brain that pressure is too high)

38. Slide 38 Traditional Psychophysiological Disorders  Coronary heart disease Caused by a blocking of the coronary arteries Includes angina pectoris (chest pain); coronary occlusion (complete blockage of a coronary artery); and myocardial infarction (heart attack) Leading cause of death in men older than 35 years and women older than 40 years in the U.S. Causal psychosocial factors: Job stress, high levels of anger or depression Causal physiological factors: High level of cholesterol, obesity, hypertension, the effects of smoking, lack of exercise

39. Slide 39 Traditional Psychophysiological Disorders  A number of factors contribute to the development of psychophysiological disorders, including: Sociocultural factors Psychological factors Biological variables

40. Slide 40 Traditional Psychophysiological Disorders  Sociocultural factors Stressful demands placed on people by their culture may set the stage for psychophysiological disorders Examples include poverty, violence, and nuclear threat (such as Three Mile Island)

41. Slide 41 Traditional Psychophysiological Disorders  Psychological factors According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to repeatedly overreact to stressors, thereby increasing their likelihood of developing psychophysiological disorders Examples: a repressive coping style, Type A personality style

42. Slide 42 Traditional Psychophysiological Disorders  Biological factors Defects in the autonomic nervous system (ANS) are believed to contribute to the development of psychophysiological disorders Other more specific biological problems may also contribute For example, a weak gastrointestinal system may create a predisposition to developing ulcers

43. Slide 43 Traditional Psychophysiological Disorders  Clearly, sociocultural, psychological, and biological variables combine to produce psychophysiological disorders  While once thought to be unusual, however, the interaction of psychosocial and physical factors is now considered the rule of bodily function, not the exception  In recent years, more and more illness have been placed in this category

44. Slide 44 New Psychophysiological Disorders  Since the 1960s, researchers have found many links between psychosocial stress and a range of physical illnesses

45. Slide 45 New Psychophysiological Disorders  Are physical illnesses related to stress? The development of the Social Adjustment Rating Scale in 1967 enabled researchers to examine the relationship between life stress and the onset of illness

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47. Slide 47 New Psychophysiological Disorders  Are physical illnesses related to stress? Using the Social Adjustment Rating Scale, studies have consistently linked stresses of various kinds to a wide range of physical conditions Overall, the greater the amount of life stress, the greater the likelihood of illness Researchers have even found a relationship between traumatic stress and death

48. Slide 48 New Psychophysiological Disorders  Are physical illnesses related to stress? One key weakness of the Social Adjustment Rating Scale is that it fails to take into account the particular stress reactions of specific populations For example, women and men have been shown to react differently to certain life changes measured by the scale

49. Slide 49 New Psychophysiological Disorders  Researchers have increasingly looked to the body’s immune system as the key to the relationship between stress and infection  This area of study is called psychoneuroimmunology

50. Slide 50 New Psychophysiological Disorders  Psychoneuroimmunology The immune system is the body’s network of activities and cells that identify and destroy antigens (foreign invaders, such as bacteria) and cancer cells Among the most important cells in this system are the lymphocytes Lymphocytes are white blood cells that circulate through the blood system and attack the invaders Lymphocytes include helper T-cells, natural killer T-cells, and B-cells

51. Slide 51 New Psychophysiological Disorders  Psychoneuroimmunology Researchers now believe that stress can interfere with the activity of lymphocytes, slowing them down and increasing a person’s susceptibility to viral and bacterial infections Several factors influence whether stress will result in a slowdown of the system, including biochemical activity, behavioral changes, personality style, and degree of social support

52. Slide 52 New Psychophysiological Disorders  Psychoneuroimmunology Biochemical activity Stress leads to increased activity of the sympathetic nervous system, including a release of norepinephrine In addition to supporting nervous system activity, this chemical also appears to slow down the functioning of the immune system Similarly, the body’s endocrine glands reduce immune system functioning during periods of prolonged stress through the release of corticosteroids

53. Slide 53 New Psychophysiological Disorders  Psychoneuroimmunology Behavioral changes Stress may set into motion a series of behavioral changes – sleep patterns, eating, exercise, smoking, and/or drinking – that indirectly affect the immune system Personality style An individual’s personality style, including their level of optimism, constructive coping strategies, and resilience, plays a role in determining how much the immune system is slowed down by stress

54. Slide 54 New Psychophysiological Disorders  Psychoneuroimmunology Social support Level of social support appears to play a role in immune system functioning People who have few social supports and feel lonely seem to display poorer immune functioning in the face of stress than people who do not feel lonely Studies have shown that social support and affiliation with others may actually speed up recovery from illness or surgery

55. Slide 55 Psychological Treatments for Physical Disorders  As clinicians have discovered that psychosocial factors may contribute to physical disorders, they have applied psychological treatment to more and more medical problems The most common of these interventions are relaxation training, biofeedback training, meditation, hypnosis, cognitive interventions, insight therapy, and support groups

56. Slide 56 Psychological Treatments for Physical Disorders  The field of treatment that combines psychological and physical interventions to treat or prevent medical problems is known as behavioral medicine

57. Slide 57 Psychological Treatments for Physical Disorders  Relaxation training People can be trained to relax their muscles at will, a process that sometimes reduces feelings of anxiety Relaxation training can be of help in preventing or treating medical illnesses that are related to stress Often used in conjunction with medication in the treatment of high blood pressure Often used alone to treat chronic headaches, insomnia, and asthma

58. Slide 58 Psychological Treatments for Physical Disorders  Biofeedback training Patients given biofeedback training are connected to machinery that gives them continuous readings about their involuntary bodily activities This procedure has been used successfully to treat pain from muscle tension; headaches; and muscular disabilities caused by stroke or accident Some biofeedback training has been effective in the treatment of asthma, irregular heartbeat, migraine headaches, and high blood pressure

59. Slide 59 Psychological Treatments for Physical Disorders  Meditation Although meditation has been practiced since ancient times, Western clinicians have only recently become aware of its effectiveness in relieving physical distress Meditation involves turning one’s concentration inward and changing one’s level of consciousness Meditation has been used to treat pain, high blood pressure, heart problems, and asthma

60. Slide 60 Psychological Treatments for Physical Disorders  Hypnosis Individuals undergoing hypnosis are guided into a sleeplike, suggestible state during which they can be directed to act in unusual ways, to remember unusual sensations, or to forget remembered events With training, hypnosis can be done without a hypnotist (self-hypnosis)

61. Slide 61 Psychological Treatments for Physical Disorders  Hypnosis This technique is now used as an aid to psychotherapy and to treat medical conditions, including asthma, insomnia, high blood pressure, and infection

62. Slide 62 Psychological Treatments for Physical Disorders  Cognitive interventions People with physical ailments have sometimes been taught new attitudes or cognitive responses as part of treatment One intervention is self-instruction training, in which patients are taught to rid themselves of negative self- statements and to replace these with positive self- statements This technique has been used in pain management, headaches, ulcers, and back disorders

63. Slide 63 Psychological Treatments for Physical Disorders  Insight therapy and support groups If negative psychological symptoms (e.g., depression, anxiety) contribute to a person’s physical ills, therapy to address these emotions should help reduce the ills These techniques have been used to treat a variety of illness including asthma, cancer, headache, and arthritis

64. Slide 64 Psychological Treatments for Physical Disorders  Combination approaches Studies have found that the various psychological treatments for physical problems tend to be equal in effectiveness Psychological treatments are often most effective when used in combination and with medical treatment With these combined approaches, today’s practitioners are moving away from the mind-body dualism of centuries past