Stress Disorders Chapter 6

Stress Disorders Chapter 6
Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

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 events and our capacity to react to them effectively People who sense that they have the ability and resources to cope are more likely to take stressors in stride and respond well Comer, Abnormal Psychology, 8e DSM-5 Update

When we view a stressor as threatening, the natural reaction is arousal and fear Fear is a “package” of responses that are physical, emotional, and cognitive Stress reactions, and the fear they produce, are often at play in psychological disorders People who experience a large number of stressful events are particularly vulnerable to the onset of anxiety and other psychological disorders Comer, Abnormal Psychology, 8e DSM-5 Update

Stress also plays a more central role in certain psychological disorders, including: Acute stress disorder Posttraumatic stress disorder (PTSD) Technically, DSM-5 lists these patterns within a group called "trauma- and stressor-related disorders“ These disorders are triggered by traumatic stressors and include symptoms such as heightened arousal, anxiety, and mood disturbance, and memory difficulties Comer, Abnormal Psychology, 8e DSM-5 Update

The physical disorders of stress are typically called psychophysiological disorders These disorders are listed in DSM-5 under “psychological factors affecting medical condition” Here significant stressors set in motion an interaction of biological, psychological, and sociocultural factors to help produce or worsen a physical illness or ailment Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

The Autonomic Nervous System
Comer, Abnormal Psychology, 8e DSM-5 Update

Stress and Arousal: The Fight-or- Flight Response
The second pathway is the hypothalamic-pituitary-adrenal (HPA) pathway When we are faced by stressors, the hypothalamus signals the pituitary gland, which stimulates the adrenal cortex to release corticosteroids – stress hormones – into the bloodstream Comer, Abnormal Psychology, 8e DSM-5 Update

Comer, Abnormal Psychology, 8e DSM-5 Update
The Endocrine System Comer, Abnormal Psychology, 8e DSM-5 Update

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… Comer, Abnormal Psychology, 8e DSM-5 Update

Pathways of Arousal and Fear
Comer, Abnormal Psychology, 8e DSM-5 Update

People differ in: Their general level of arousal and anxiety Called “trait anxiety” Some people are usually somewhat tense; others are usually relaxed Differences appear soon after birth Their sense of which situations are threatening Called “state anxiety” Situation-based (example: fear of flying) Comer, Abnormal Psychology, 8e DSM-5 Update

The Psychological Stress Disorders
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 the anxiety disorders) Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 7–9% of people in the U.S. are affected sometime during their lifetime Around two-thirds seek treatment at some point Ratio of women to men is 2:1 After trauma, around 20% of women and 8% of men develop disorders 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 Comer, Abnormal Psychology, 8e DSM-5 Update

Combat and stress disorders For years clinicians have recognized that soldiers experience distress during combat 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 Comer, Abnormal Psychology, 8e DSM-5 Update

Disasters and stress disorders Acute and 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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 As many as half of those directly exposed to terrorism or torture may develop this disorder Comer, Abnormal Psychology, 8e DSM-5 Update

Victimization and stress disorders A common form of victimization is sexual assault/rape Around 1 in 6 women is raped at some time during her life 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 Comer, Abnormal Psychology, 8e DSM-5 Update

Victimization and stress disorders Ongoing victimization and abuse in the family may also lead to stress disorders Comer, Abnormal Psychology, 8e DSM-5 Update

Terrorism and torture The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms, as does the experience of torture Unfortunately, these sources of traumatic stress are on the rise in our society Comer, Abnormal Psychology, 8e DSM-5 Update

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: Survivors’ biological processes Personalities Childhood experiences Social support systems Cultural backgrounds Severity of the traumas Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Social support People whose social support systems are weak are more likely to develop a stress disorder after a traumatic event Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Psychological debriefing 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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

About 80 years ago, clinicians first identified a group of physical illnesses that seemed to result from an interaction of biological, psychological, and sociocultural factors Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders DSM-5 labels them as psychological factors affecting medical condition Comer, Abnormal Psychology, 8e DSM-5 Update

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 somatic symptom disorders, which will be discussed in Chapter 7 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Causal physiological factors: Bacterial infection Comer, Abnormal Psychology, 8e DSM-5 Update

Asthma A narrowing of the body’s airways that makes breathing difficult Affects up to 25 million people in the U.S. each year Most victims are children at the time of first attack Causal psychosocial factors: Environmental pressures or anxiety Causal physiological factors: Allergies, a slow-acting sympathetic nervous system, weakened respiratory system Comer, Abnormal Psychology, 8e DSM-5 Update

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 Causal physiological factors: Overactive arousal system, certain medical ailments Comer, Abnormal Psychology, 8e DSM-5 Update

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 Causal psychosocial factors: Environmental pressures; general feelings of helplessness, anger, anxiety, depression Causal physiological factors: Abnormal serotonin activity, vascular problems, muscle weakness Comer, Abnormal Psychology, 8e DSM-5 Update

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 Causal physiological factors: 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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 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 Comer, Abnormal Psychology, 8e DSM-5 Update

A number of variables contribute to the development of psychophysiological disorders, including: Biological factors Psychological factors Sociocultural factors Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Psychological factors According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors – increasing their chances of developing psychophysiological disorders Examples: a repressive coping style, a Type A personality style – particularly hostility and time urgency Comer, Abnormal Psychology, 8e DSM-5 Update

Sociocultural factors Adverse social conditions may set the stage for psychophysiological disorders One of society’s most adverse social conditions is poverty Research also reveals that belonging to an ethnic or cultural minority group increases the risk of developing these disorders and other health problems Comer, Abnormal Psychology, 8e DSM-5 Update

New 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 In recent years, more and more illnesses have been added to the list of psychophysiological disorders Comer, Abnormal Psychology, 8e DSM-5 Update

Since the 1960s, researchers have found many links between psychosocial stress and a wide range of physical illnesses Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Comer, Abnormal Psychology, 8e DSM-5 Update

Are physical illnesses related to stress? 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 Researchers have even found a relationship between traumatic stress and death Comer, Abnormal Psychology, 8e DSM-5 Update

Are physical illnesses related to stress? One shortcoming of the Social Adjustment Rating Scale is that it does not take into consideration the particular stress reactions within specific populations For example, members of minority groups may respond to stress differently and women and men have been shown to react differently to certain life changes measured by the scale Comer, Abnormal Psychology, 8e DSM-5 Update

Psychoneuroimmunology
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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 lymph system and the bloodstream, attacking invaders Lymphocytes include helper T-cells, natural killer T-cells, and B-cells Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Biochemical activity Stress leads to increased activity by 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 functioningduring periods of prolonged stress through the release of corticosteroids In addition, corticosteroids also trigger increased cytokines, which lead to chronic inflammation Comer, Abnormal Psychology, 8e DSM-5 Update

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 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 Comer, Abnormal Psychology, 8e DSM-5 Update

Social support 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 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 Comer, Abnormal Psychology, 8e DSM-5 Update

Psychological Treatments for Physical Disorders
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 Comer, Abnormal Psychology, 8e DSM-5 Update

The field of treatment that combines psychological and physical interventions to treat or prevent medical problems is known as behavioral medicine Comer, Abnormal Psychology, 8e DSM-5 Update

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 headaches, insomnia, asthma, pain after surgery, certain vascular diseases, and the undesirable effects of cancer treatments Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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) Comer, Abnormal Psychology, 8e DSM-5 Update

Hypnosis 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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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, and arthritis Comer, Abnormal Psychology, 8e DSM-5 Update

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 With these combined approaches, today’s practitioners are moving away from the mind–body dualism of centuries past Comer, Abnormal Psychology, 8e DSM-5 Update

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