Stress, Coping, and the Anxiety Response The state of stress has two components: Stressor – event that creates demands Stress response – person's reactions to the demands Influenced by how we judge both the event and 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 and respond well

Stress, Coping, and the Anxiety Response When we view a stressor as threatening, the natural reaction is arousal and fear Stress reactions, and the fear they produce, are often at play in psychological disorders Fear is a “package” of responses that are physical, emotional, and cognitive People who experience a large number of stressful events are particularly vulnerable to the onset of anxiety and other psychological disorders

Stress, Coping, and the Anxiety Response Stress and psychological disorders Acute stress disorder Posttraumatic stress disorder (PTSD) The DSM-5 lists these as “trauma and stressor-related disorders” Stress and physical (psychophysiological) disorders These disorders are listed in the DSM-5 under “psychological factors affecting medical condition”

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 all other organs of the body Endocrine system A network of glands throughout the body that release hormones

Stress and Arousal: The Fight-or-Flight Response There are two pathways, or routes, by which the ANS and the endocrine system produce arousal and fear reactions: Sympathetic nervous system pathway Hypothalamic-pituitary-adrenal pathway Hypothalamus signals the pituitary gland, which stimulates the adrenal cortex to release corticosteroids – stress hormones – into the bloodstream When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, which stimulates key organs either directly or indirectly When the perceived danger passes, the parasympathetic nervous system helps return body processes to normal The reactions on display in these two pathways are collectively referred to as the fight-or-flight response Each person has a particular pattern of autonomic and endocrine functioning and so a particular way of experiencing arousal and fear…

The Autonomic Nervous System

The Endocrine System

Pathways of Arousal and Fear Trait anxiety – a person's general level of arousal and anxiety Some people are usually somewhat tense; others are usually relaxed Differences appear soon after birth State anxiety – a person's sense of which situations are threatening Situation-based (example: fear of flying)

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 may begin either shortly after the event, or months or years afterward As many as 80% of all cases of acute stress disorder develop into PTSD During and immediately after trauma, we may temporarily experience levels of arousal, anxiety, and depression For some, symptoms persist well after the trauma These people may be suffering from: Acute stress disorder Posttraumatic stress disorder (PTSD) The precipitating event usually involves actual or threatened serious injury to self or others The situations that cause these disorders would be traumatic to anyone (unlike other anxiety disorders)

The Psychological Stress Disorders Aside from the differences in onset and duration, the symptoms of acute stress disorders and PTSD are almost identical: Reexperiencing the traumatic event Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt

What Triggers a Psychological Stress Disorder? Can occur at any age and affect all aspects of life At least 3.5% of people in the U.S. are affected each year Around two-thirds seek treatment at some point Ratio of women to men is 2:1 In addition, people with low incomes are twice as likely as people with higher incomes to experience one of the stress disorders Some events – including combat, disasters, abuse, and victimization – are more likely to cause disorders than others 7–9% of people in the U.S. are affected sometime during their lifetime After trauma, around 20% of women and 8% of men develop disorders

What Triggers a Psychological Stress Disorder? Combat and stress disorders Called “shell shock” or “combat fatigue” Post-Vietnam War clinicians discovered that soldiers also experienced psychological distress after combat As many as 29% of Vietnam combat veterans suffered acute or posttraumatic stress disorders An additional 22% had some stress symptoms 10% still experiencing problems A similar pattern is currently unfolding among veterans of wars in Afghanistan and Iraq

What Triggers a Psychological Stress Disorder? Disasters and stress disorders Acute or posttraumatic stress disorders may also follow natural and accidental disasters Types of disasters include earthquakes, floods, tornadoes, fires, airplane crashes, and serious car accidents Because they occur more often, civilian traumas have been implicated in stress disorders at least 10 times as often as combat traumas

What Triggers a Psychological Stress Disorder? Victimization and stress disorders People who have been abused or victimized often experience lingering stress symptoms Research suggests that more than one-third of all victims of physical or sexual assault develop PTSD Terrorism and torture The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms, as does the experience of torture

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 the development of these disorders, researchers have looked to the survivor’s: Biological processes Personalities Childhood experiences Social support systems Cultural backgrounds Severity of the traumas

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 and, in some cases, to stress disorders Some research suggests abnormal neurotransmitter and hormone activity (especially norepinephrine and cortisol) Evidence suggests that once a stress disorder sets in, further biochemical arousal and damage may also occur (especially in the hippocampus and amygdala) There may be a biological/genetic predisposition to such reactions

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

Why Do People Develop a Psychological Stress Disorder? Childhood experiences Researchers have 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

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 traumatic event

Why Do People Develop a Psychological Stress Disorder? Multicultural factors There is a growing suspicion among clinical researchers that the rates of PTSD may differ among ethnic groups in the US It seems that Hispanic Americans might be more vulnerable to PTSD than other cultural groups Possible explanations include cultural beliefs systems about trauma and the cultural emphasis on social relationships and social support

Why Do People Develop a Psychological Stress Disorder? Severity of the trauma Generally, 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

How Do Clinicians Treat the Psychological Stress Disorders? About half of all cases of PTSD improve within 6 months; the remainder may persist for years Treatment procedures vary depending on type of trauma General goals: End lingering stress reactions Gain perspective on painful experiences Return to constructive living

How Do Clinicians Treat the Psychological Stress Disorders? Treatment for combat veterans Drug therapy Antianxiety and antidepressant medications are most common Behavioral exposure techniques 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 couple, family, or group therapy formats; rap groups

How Do Clinicians Treat the Psychological Stress Disorders? Psychological debriefing A form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident Four-stage approach: Normalize responses to the disaster Encourage expressions of anxiety, anger, and frustration Teach self-help skills Provide referrals The approach has come under careful scrutiny While many health professionals continue to believe in the approach despite unsupportive research findings, the current climate is moving away from outright acceptance It's possible that certain high-risk individuals may profit from debriefing programs but that others shouldn't receive such interventions

The Physical Stress Disorders: Psychophysiological Disorders In addition to affecting psychological functioning, stress can also have great impact on physical functioning The idea that stress and related psychosocial factors may contribute to physical illnesses has ancient roots, yet it had few supporters before the 20th century

The Physical Stress Disorders: Psychophysiological Disorders Psychophysiological (psychosomatic) disorders: disorders in which biological, psychological, and sociocultural factors interact to cause or worsen a physical illness. Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders DSM-5 also labels them as psychological factors affecting medical condition

Psychological Factors Affecting Medical Condition 1. The presence of a general medical condition. 2. Psychological factors adversely affecting the general medical condition in one of the following ways: (a) Influencing the course of the general medical condition. (b) Interfering with the treatment of the general medical condition. (c) Posing additional health risks. (d) Stress-related physiological responses precipitating or exacerbating the general medical condition. It is important to recognize 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 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

Psychological Factors Affecting Medical Condition

Traditional Psychophysiological Disorders Ulcers Lesions in the wall of the stomach that result in burning sensations or pain, vomiting, and stomach bleeding Experienced by over 25 million people at some point in their lives Causal psychosocial factors: Environmental pressures, intense feelings of anger or anxiety Bacterial infection Asthma A narrowing of the body's airways that makes breathing difficult Affects up to 25 million people in the U.S. each year Environmental pressures or anxiety Allergies, a slow-acting sympathetic nervous system, weakened respiratory system

Traditional Psychophysiological Disorders Insomnia Difficulty falling asleep or maintaining sleep Affects 10% of people in the U.S. each year Causal psychosocial factors: High levels of anxiety or depression Overactive arousal system, certain medical ailments Chronic headaches Frequent intense aches of the head or neck that are not caused by another physical disorder Tension headaches affect 45 million Americans each year Migraine headaches affect 23 million Americans each year Environmental pressures; general feelings of helplessness, anger, anxiety, depression Abnormal serotonin activity, vascular problems, muscle weakness

Traditional Psychophysiological Disorders Hypertension Chronic high blood pressure, usually producing few outward symptoms Affects 75 million Americans each year Causal psychosocial factors: Constant stress, environmental danger, general feelings of anger or depression 10% caused by physiological factors alone Obesity, smoking, poor kidney function, high proportion of collagen (rather than elastic) tissue in an individual's blood vessels Coronary heart disease Caused by blockage in the coronary arteries The term refers to several problems, including myocardial infarction (heart attack) Nearly 18 million people in the US suffer from some form of coronary heart disease It is the leading cause of death in men older than 35 years and women older than 40 Job stress, high levels of anger or depression High level of cholesterol, obesity, hypertension, the effects of smoking, lack of exercise

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

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 Psychological factors Needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors – increasing their chances of developing psychophysiological disorders Sociocultural factors Adverse social conditions may set the stage for psychophysiological disorders Research also reveals that belonging to an ethnic or cultural minority group increases the risk of developing these disorders and other health problems

New Psychophysiological Disorders Since the 1960s, researchers have found many links between psychosocial stress and a wide range of physical illnesses In recent years, more and more illnesses have been added to the list of psychophysiological disorders Clearly, biological, psychological, and sociocultural variables combine to produce psychophysiological disorders In fact, the interaction of psychosocial and physical factors is now considered the rule of bodily function, not the exception

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 Using the Social Adjustment Rating Scale, studies have linked stressors of various kinds to a wide range of physical conditions Overall, the greater the amount of life stress, the greater the likelihood of illness Social Adjustment Rating Scale does not take into consideration the particular stress reactions within specific populations Researchers have even found a relationship between traumatic stress and death

Psychoneuroimmunology Psychoneuroimmunology - the relationship between stress and infection

Psychoneuroimmunology The immune system identifies and destroys antigens (foreign invaders, such as bacteria) and cancer cells Lymphocytes - white blood cells that circulate through the lymph system and the bloodstream, attacking invaders Helper T-cells, natural killer T- cells, and B-cells 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

Psychoneuroimmunology Biochemical activity Stress leads to increased activity by the sympathetic nervous system, including a release of norepinephrine Endocrine glands reduce immune system functioning during periods of prolonged stress through the release of corticosteroids Behavioral changes Stress may set in motion a series of behavioral changes – poor sleep patterns, poor eating, lack of exercise, increase in smoking and/or drinking – that indirectly affect the immune system In addition, corticosteroids also trigger increased cytokines, which lead to chronic inflammation

Psychoneuroimmunology Personality style An individual's personality style (including their level of optimism, constructive coping strategies, and resilience) experience better immune system functioning and are better prepared to fight off illness Social support People who have less social support and feel lonely seem to display poorer immune functioning when stressed than people who do not feel lonely Studies have found that social support and affiliation with others may actually protect people from stress, poor immune system functioning, and subsequent illness, and can help speed up recovery from illness or surgery

Psychological Treatments for Physical Disorders Behavioral medicine - the field of treatment that combines psychological and physical interventions to treat or prevent medical problems As clinicians have discovered that stress and related 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, support groups, and therapies designed to increase awareness and expression of emotion

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 help prevent or treat 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, asthma, pain after surgery, certain vascular diseases, and the undesirable effects of cancer treatments

Psychological Treatments for Physical Disorders Biofeedback Patients given biofeedback training are connected to machinery that gives them continuous readings about their involuntary bodily activities Somewhat helpful in the treatment of anxiety disorders, this procedure has been used successfully to treat headaches and muscular disabilities caused by stroke or accident Some biofeedback training has been effective in the treatment of heartbeat irregularities, asthma, migraine headaches, high blood pressure, stuttering, and pain

Psychological Treatments for Physical Disorders Meditation Although meditation has been practiced since ancient times, Western health care professionals have only recently become aware of its effectiveness in relieving physical distress Meditation is a technique of turning one's concentration inward and achieving a slightly changed state of consciousness Meditation has been used to manage pain, treat high blood pressure, heart problems, insomnia, and asthma

Psychological Treatments for Physical Disorders Hypnosis Individuals who undergo 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) Hypnosis seems to be particularly helpful in the control of pain; is now used to treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection

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 stress inoculation training, in which patients are taught to rid themselves of negative self-statements and to replace these with coping self-statements

Psychological Treatments for Physical Disorders Emotion expression and support groups If negative psychological symptoms (e.g., depression, anxiety) contribute to a person's physical ills, intervention to reduce these emotions should help reduce the ills These techniques have been used to treat a variety of illnesses including HIV, asthma, cancer, headache, and arthritis

Psychological Treatments for Physical Disorders Combination approaches Studies have found that the various psychological interventions for physical problems tend to be equal in effectiveness Psychological treatments are often of greatest help when they are combined and used with medical treatment This technique seems to be particularly helpful in the control of pain; is now used to treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection