Stress Disorders Chapter 7

1. Stress DisordersChapter 7

2. What Are Psychophysiological Disorders? Medical evidence suggests attitudes, worry, and fear may have biological effects. Sudden Death Syndrome: Unexpected abrupt death that seems to have no specific physical basis (but may involve blood clotting, increased blood pressure, and changes in heart rhythm). Psychophysiological Disorder: Physical disorder that has a strong psychological basis or component. -Sudden death syndrome may be the leading cause of death, people wake up feeling fine, then later in the day collapse and die.-Sudden death syndrome may be the leading cause of death, people wake up feeling fine, then later in the day collapse and die.

3. Characteristics of Psychophysiological Disorders Not to be confused with conversion disorders (which do not involve physical disorder). Tissue damage or physiological dysfunction Usually require medical treatment AND psychotherapy.

4. Characteristics of Psychophysiological Disorders DSM-IV-TR criteria (any of the following): Temporal relationship between psychological factors and medical condition (cause!). Psychological factors interfere with treatment. Psychological factors constitute additional health-risk factors.

5. Models for Understanding Stress An event in the environment is called a Stressor. Our reaction to a stressor is called a Stress Reaction. Stress is the process by which we perceive and respond to certain events, called stressors, that we appraise as threatening or challenging. When perceived as challenges, stressors act to motivate us. When perceived as threats, stressors may harm us. -Stress is a good thing, it invigorates our lives, a life without stress would be EXTREMELY boring. -When stress is acute and momentary, it is manageable. -When stress is chronic and uncontrollable, it is unhealthy.-Stress is a good thing, it invigorates our lives, a life without stress would be EXTREMELY boring. -When stress is acute and momentary, it is manageable. -When stress is chronic and uncontrollable, it is unhealthy.

6. Models for Understanding StressPhysiological Correlates of Stress -The adrenals glands (atop the kidneys) release stress hormones on orders received through a dual-track system (from the sympathetic nervous system and from the pituitary hormones in the bloodstream. -If we perceive something in the environment to be dangerous, our cerebral cortex signals the pituitary gland to release hormones which will further signal the adrenal glands to secrete stress hormones. Likewise, the sympathetic nervous system kicks in, also signaling to the adrenal glands to release stress hormones. All of this is done to create a situation called by Walter Cannon, the fight-or-flight reaction to stress.-The adrenals glands (atop the kidneys) release stress hormones on orders received through a dual-track system (from the sympathetic nervous system and from the pituitary hormones in the bloodstream. -If we perceive something in the environment to be dangerous, our cerebral cortex signals the pituitary gland to release hormones which will further signal the adrenal glands to secrete stress hormones. Likewise, the sympathetic nervous system kicks in, also signaling to the adrenal glands to release stress hormones. All of this is done to create a situation called by Walter Cannon, the fight-or-flight reaction to stress.

7. Models for Understanding StressThe Fight of Flight Response Walter Cannon found the stress response triggers an outpouring of stress hormones from the adrenal glands. The sympathetic nervous system increases heart rate and respiration, diverts energy from digestion, dulls pain, and releases sugar and fat from storage. This process, known as Fight-or-Flight is remarkably adaptive in the face of Acute Stress, but horribly maladaptive in the face of Chronic Stress. -The fight or flight response has huge evolutionary usefulness, but in modern society, our body reacts to chronic stress in the same way it used to react to acute stress. Our body is not designed to withstand continuous arousal.-The fight or flight response has huge evolutionary usefulness, but in modern society, our body reacts to chronic stress in the same way it used to react to acute stress. Our body is not designed to withstand continuous arousal.

8. Models for Understanding StressOther Responses Other responses in the face of stress, alternatives to fight-or-flight Withdraw Pull back and conserve energy Tend and Befriend Seek and give social support

9. Models for Understanding Stress Three models for understanding stress: General Adaptation Model Life Change Model Transaction Model Models examine: Development/differential effects of stress. Apparent ability of weak stressor to result in strong stress reactions. Ability of some people to cope well with stress.

10. Models for Understanding StressThe General Adaptation Model General Adaptation Model: Three-stage model to understand physical and psychological reactions to stress. Alarm Stage: Initial reaction (increased heartbeat, decreased muscle tone and blood pressure) then rebound reaction via adrenal cortex. Adaptation/resistance Stage: Body mobilizes to defend itself. Exhaustion State: Continuing stress results in exhaustion and possibly death.

11. Models for Understanding StressThe General Adaptation Model

12. Models for Understanding StressThe Life-Change Model The Life Change Model: All changes in a person�s life (large or small, desirable or undesirable) can act as stressors. Social Readjustment Rating Scale (SRRS) measures stress potential in terms of �life change units�. The accumulation of small changes can be as powerful as one major stressor. Cultural differences in ranking of stressors. -Researchers had people rank stressors. -High stressors were assigned a large number of �life change units�. -People experiencing many life change units were likely to get sick.-Researchers had people rank stressors. -High stressors were assigned a large number of �life change units�. -People experiencing many life change units were likely to get sick.

13. Models for Understanding StressThe Life-Change Model Life Events Score Death of spouse 100 Divorce 73 Marital separation from mate 65 Detention in jail, other institution 63 Death of a close family member 63 Major personal injury or illness 53 Marriage 50 Fired from work 47 Marital reconciliation 45 Retirement 45 Major change in the health or behavior of a family member 44 Pregnancy 40 Sexual difficulties 39 Gaining a new family member 39(e.g., through birth, adoption, oldster moving, etc.) Major business re-adjustment 39(e.g., merger, reorganization, bankruptcy) Major change in financial status 38 Death of close friend 37 Change to different line of work 36 Major change in the number of arguments with spouse 35 Taking out a mortgage or loan for a major purchase 31 Foreclosure on a mortgage or loan 30 Major change in responsibilities at work 29

14. Models for Understanding StressThe Life-Change ModelCriticisms Most conclusions about the model are based on retrospective studies. The studies supporting the model are correlational, therefore no cause-and-effect relationship can be inferred. Positive and negative life events do not have equal effects.

15. Models for Understanding StressThe Life-Change ModelStressors for College Students -Table 7.1: Sample Stressors Generated and Ranked by college Undergraduates.-Table 7.1: Sample Stressors Generated and Ranked by college Undergraduates.

16. Models for Understanding StressThe Transaction Model The Transaction Model: Stress resides neither in the person alone nor in the situation alone, but rather in a transaction between the two. Subjective (cognitive) interpretation of stressful events or life changes -How we appraise an event influences how much stress we experience and how effectively we respond. -When perceived as challenges, stressors can have positive effects, arousing and motivating us to conquer problems. -But stressors can also threaten our resources-our status and security on the job, our deeply held beliefs, and our self-image. Experiencing severe or prolonged stress can physically hurt us. -How we appraise an event influences how much stress we experience and how effectively we respond. -When perceived as challenges, stressors can have positive effects, arousing and motivating us to conquer problems. -But stressors can also threaten our resources-our status and security on the job, our deeply held beliefs, and our self-image. Experiencing severe or prolonged stress can physically hurt us.

17. Stress and the Immune System Most diseases are caused by an interaction of social, psychological, and biological factors. Cognitive or emotional state influences the course or severity of a disease through an interaction of biological, behavioral, cognitive, and social pathways. Contradictory findings concerning impact of psychological factors on immune function.

18. Stress and the Immune System Lymphocytes Two types of white blood cells that are part of the body�s immune system B lymphocytes form in the bone marrow and release antibodies that fight bacterial infections. T lymphocytes form in the thymus and, among other duties, attack cancer cells, viruses, and foreign substances. -Stress weakens the immune system by diverting the energy required for its functioning to dealing with the stress. -Stress does not make us sick, rather it takes away valuable energy from the immune system. Remember how much energy it takes to implement the fight-or-flight response?-Stress weakens the immune system by diverting the energy required for its functioning to dealing with the stress. -Stress does not make us sick, rather it takes away valuable energy from the immune system. Remember how much energy it takes to implement the fight-or-flight response?

19. Stress and the Immune System The immune system can hurt us by being too active, attacking the bodies own tissues causing arthritis or allergic reactions as well as transplant rejections. The immune system can also err in the other direction allowing cancer cells to multiply or allowing a dormant herpes virus to surface (cold-sore). -If rats are injected with cancer cells, then subjected to stress, they are far more likely to develop cancer than without the stress.-If rats are injected with cancer cells, then subjected to stress, they are far more likely to develop cancer than without the stress.

20. Stress and the Immune System AIDS = Acquired immune deficiency syndrome People with AIDS have difficulty fighting off mild infections. If people with AIDS also have stressful lives, they have faster disease progression.

21. Stress and the Immune System Experiment: Tumor cells planted in rats, the rats exposed to uncontrollable stress were more likely to develop cancer. It appears that depression in humans leads to increased cancer rates. People with a history of workplace stress are at a 5.5 times greater risk of developing colon cancer.

22. Stress and the Immune System -After sweetened water (CS) was associated with a drug (US) that causes immune suppression in rats (UR), the inert substance alone triggered the conditioned immune suppression. -Could we possibly condition the enhancement of the immune system!?-After sweetened water (CS) was associated with a drug (US) that causes immune suppression in rats (UR), the inert substance alone triggered the conditioned immune suppression. -Could we possibly condition the enhancement of the immune system!?

23. Stress and the Immune System -Negative emotions and health-related consequences -Persistent stressors lead to both the release of stress hormones and unhealthy behaviors. -Both of these things will combine to lead to lead to poorer health -Stress is a good thing, it invigorates our lives, a life without stress would be EXTREMELY boring. -When stress is acute and momentary, it is manageable. -When stress is chronic and uncontrollable, it is unhealthy.-Negative emotions and health-related consequences -Persistent stressors lead to both the release of stress hormones and unhealthy behaviors. -Both of these things will combine to lead to lead to poorer health -Stress is a good thing, it invigorates our lives, a life without stress would be EXTREMELY boring. -When stress is acute and momentary, it is manageable. -When stress is chronic and uncontrollable, it is unhealthy.

24. Mediating the Effects of Stressors If people feel as though they have no control of the world they may experience Learned Helplessness. Perceiving a loss of control leads to ill health. Patients in nursing homes that have little control over their activities tend to decline faster. -Learned helplessness seems to occur in overcrowded conditions --i.e., dogs, harnessed, electrocuted, unharnessed -Won�t learn even when they can, perhaps they learned that their actions do not control the environment. --i.e., humans and loud noise --very low attributions/self-esteem; tend to blame themselves. -Feelings of helplessness seem to trigger stress hormones, which if experienced for an extended period, makes immune functioning drop.-Learned helplessness seems to occur in overcrowded conditions --i.e., dogs, harnessed, electrocuted, unharnessed -Won�t learn even when they can, perhaps they learned that their actions do not control the environment. --i.e., humans and loud noise --very low attributions/self-esteem; tend to blame themselves. -Feelings of helplessness seem to trigger stress hormones, which if experienced for an extended period, makes immune functioning drop.

25. Mediating the Effects of Stressors In a study of graves in Scotland, those with the costliest and highest headstones tended to live the longest. -Poor people tend to die earlier. -Among primates, those at the bottom of the social hierarchy tend to die earliest. -What might cause this. Perhaps, simply income lets us buy healthcare, what about the primates? Perhaps it is stressful to be at the bottom and this stress leads to poorer health.-Poor people tend to die earlier. -Among primates, those at the bottom of the social hierarchy tend to die earliest. -What might cause this. Perhaps, simply income lets us buy healthcare, what about the primates? Perhaps it is stressful to be at the bottom and this stress leads to poorer health.

26. Mediating the Effects of Stressors -Equality and Longevity, as the inequality in income rises in an area, lifespan goes down. Perhaps the risk of violent death is greater, perhaps a low relative income evokes feelings of frustration and anger.-Equality and Longevity, as the inequality in income rises in an area, lifespan goes down. Perhaps the risk of violent death is greater, perhaps a low relative income evokes feelings of frustration and anger.

27. Mediating the Effects of Stressors Hardiness: The ability to deal well with stress. Hardy people are more resistant to illness. Stress resistant people show: Openness to change Feelings of involvement and commitment Sense of control over life Self-efficacy and optimism, optimistic people tend to be better at fighting illnesses. Over confidence is far better than under confidence.

28. Mediating the Effects of Stressors

29. Personality, Mood States, and Illness Influence of laughter and humor Patch Adams Humor may have direct link on physiological functioning. Humor may change beliefs and give more confidence. Humor may work to increase social support.

30. Psychological Involvement in Physical Disorders Coronary Heart Disease Clogging of the vessels that nourish the heart muscle Leading cause of death in the United States Uncommon before 1900 Could be because of increasingly bad diets or increasingly stressful lives. In 1950�s wives were found to have similar diets, but much less heart disease, could it be the stress from working? -With the conquering of the major infectious diseases, diseases influenced by behavior have now emerged as the major causes of death. The story is much the same in Canada, Australia, New Zealand, and most European countries. -With the conquering of the major infectious diseases, diseases influenced by behavior have now emerged as the major causes of death. The story is much the same in Canada, Australia, New Zealand, and most European countries.

31. Psychological Involvement in Physical Disorders Type A Friedman and Rosenman�s term for competitive, hard-driving, impatient, verbally aggressive, and anger-prone people. The negative emotions, such as irritability and hostility, seem to lead to problems. Type B Friedman and Rosenman�s term for easygoing, relaxed people. -Friedman and Rosenman followed 3000 healthy men aged 35-59 for nine years. At the end of nine years 257 of the men had suffered heart attacks. 69% of the heart attacks were suffered by Type A people. Also, none of the �pure� type B men had a heart attack.-Friedman and Rosenman followed 3000 healthy men aged 35-59 for nine years. At the end of nine years 257 of the men had suffered heart attacks. 69% of the heart attacks were suffered by Type A people. Also, none of the �pure� type B men had a heart attack.

32. Psychological Involvement in Physical Disorders People scoring high on anger three times more likely to have a heart attack. Those reporting themselves to be �hot-tempered� five times more likely to experience a heart attack by age 55. As the number of depressive symptoms rises, so does heart disease. -Chronic stress keeps the body in constant state of fight or flight -Part of the reaction is to send blood to the arms and legs. -If blood is sent to extremities, less is available to sweep away harmful cholesterol which then accumulates. -Table 7.2: Anxiety Questionnaire Items That Correlated with Eventual Onset of Fatal Heart Attacks-Chronic stress keeps the body in constant state of fight or flight -Part of the reaction is to send blood to the arms and legs. -If blood is sent to extremities, less is available to sweep away harmful cholesterol which then accumulates. -Table 7.2: Anxiety Questionnaire Items That Correlated with Eventual Onset of Fatal Heart Attacks

33. Psychological Involvement in Physical DisordersStress and Hypertension Essential Hypertension: Chronic high blood pressure, usually with no known biological cause (the most common disease in the United States). Emotional reactions and exposure to more stress increases risk of arteriosclerosis, stroke, and heart attack. Anger and anxiety increase blood pressure Gender differences (anger in/anger out) related to socialization. Ethnic differences related to genetic, biological, and psychological factors. -Men had less of a coronary reaction when allowed to let their anger out. -Women had less of a coronary reaction when they turn their anger in. -However, this difference appears to be due to the upbringing. -In countries where women are socialized to be more assertive, lower coronary reactions are associated with anger out.-Men had less of a coronary reaction when allowed to let their anger out. -Women had less of a coronary reaction when they turn their anger in. -However, this difference appears to be due to the upbringing. -In countries where women are socialized to be more assertive, lower coronary reactions are associated with anger out.

34. -Figure 7.3: Gender and Ethnic Differences in Hypertension Among U.S. Adults. The highest prevalence (percentage) of chronic high blood pressure occurs most frequently among African Americans and among all individuals over the age of fifty. Women tend to score somewhat lower than other groups. Biological, lifestyle, and psychological factors have been implicated in the gender and ethnic differences in hypertension.-Figure 7.3: Gender and Ethnic Differences in Hypertension Among U.S. Adults. The highest prevalence (percentage) of chronic high blood pressure occurs most frequently among African Americans and among all individuals over the age of fifty. Women tend to score somewhat lower than other groups. Biological, lifestyle, and psychological factors have been implicated in the gender and ethnic differences in hypertension.

35. Psychological Involvement in Physical DisordersHeadaches -Figure 7.4: Three Types of Headaches.-Figure 7.4: Three Types of Headaches.

36. Migraine: Characterized by constriction of cranial arteries followed by dilation of cerebral blood vessels, resulting in moderate to severe pain. Tension: Less severe than migraines Prolonged contraction of scalp and neck muscles results in vascular constriction, but other studies do not support this. Cluster: Excruciating headache that produces stabbing or burning sensations in eye or cheek. -Intense constriction of blood vessels diminishes blood supply in the brain, this is followed by a distension of the vessels to allow blood back in the brain. As the blood flows back in, it pushes on hypersensitive nerves thus creating a throbbing.-Intense constriction of blood vessels diminishes blood supply in the brain, this is followed by a distension of the vessels to allow blood back in the brain. As the blood flows back in, it pushes on hypersensitive nerves thus creating a throbbing.

37. Asthma: Chronic inflammatory disease of the airways in the lungs, in which the airways become constricted, making it difficult to empty the lungs and therefore reducing the amount of air that can be inhaled. The most common chronic disease of childhood Pollution Psychological factors Stressful situations Negative family environment Emotional arousal -Symptoms of asthma are worse at night and in the early morning. -Ethnic minority children living in inner cities are especially prone to asthma.-Symptoms of asthma are worse at night and in the early morning. -Ethnic minority children living in inner cities are especially prone to asthma.

38. Psychological Involvement in Physical DisordersAsthma -Figure 7.5: An Asthma Attack. Asthma attacks and deaths have increase dramatically during the past fifteen years. -Figure 7.5: An Asthma Attack. Asthma attacks and deaths have increase dramatically during the past fifteen years.

39. Psychological Involvement in Physical DisordersUnconscious Correlates to Certain Physical Disorders

40. Perspectives on Etiology Psychodynamic: Unconscious conflict Biological: Genetic basis Somatic weakness hypothesis Previous illness makes a particular organ the weakest point in the chain, thus increasing susceptibility to further problems. Autonomic response specificity General Adaptation Syndrome Behavioral: Classical conditioning -Autonomic response specificity: Some individuals respond to different stressors with the same physiological response. An individual that shows an exaggerated cardiac response to a variety of stimuli is more likely to develop hypertension. -If asthmatic patients told they were being exposed to substances they were allergic to, even though they were actually being exposed to saline. -Half developed asthma responses and over 25% had full blown asthmatic attacks. -Autonomic response specificity: Some individuals respond to different stressors with the same physiological response. An individual that shows an exaggerated cardiac response to a variety of stimuli is more likely to develop hypertension. -If asthmatic patients told they were being exposed to substances they were allergic to, even though they were actually being exposed to saline. -Half developed asthma responses and over 25% had full blown asthmatic attacks.

41. Treatment of Psychophysiological Disorders Behavioral Medicine: A number of disciplines that study social, psychological, and lifestyle influences on health. Relaxation Training: Learn to relax muscles of the body in almost any circumstances. Progressive Relaxation: Tense and relax different muscle groups repeatedly in order to learn what relaxation feels like. Biofeedback Training: Learn voluntary control of specific physiological function of interest (e.g., heart rate, blood pressure).

42. Treatment of Psychophysiological Disorders Cognitive-Behavioral Interventions: Learn to reduce expression of hostility Learn muscle relaxation Assertiveness training Role-playing Self-instructional techniques and cognitive restructuring Improve coping skills and stress management Changes in lifestyle, attitudes, and perceptions

43. Acute and Post-traumatic Stress Disorder Anxiety disorder that follows exposure to a life threatening or other extreme event that caused feelings of horror or helplessness. Symptoms include Flashbacks, nightmares, impaired concentration, emotional numbing, depression. Symptoms can last for years Common after Sexual assault, rape, robbery, aggravated assault Combat veterans Group therapy seems to work best Getting and giving support -Unique symptoms, detachment from others, restricted range of affect, nightmares, and loss of interest in activities.-Unique symptoms, detachment from others, restricted range of affect, nightmares, and loss of interest in activities.

44. Acute and Posttraumatic Stress Disorders Acute Stress Disorder (ASD): Exposure to a traumatic stressor resulting in dissociation, reliving the experience, and attempts to avoid reminders of the event (lasts more than 2 and less than 30 days). Posttraumatic Stress Disorder (PTSD): In response to specific extreme stressor, characterized by intrusive memories of traumatic event, emotional withdrawal, and heightened autonomic arousal (lasts more than 30 days). -�I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling. Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn�t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.�-�I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling. Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn�t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.�

45. Diagnosis of ASD and PTSD DSM-IV-TR Criteria: Re-experience event in disturbing dreams or intrusive memories Emotional numbing or avoiding stimuli associated with the trauma Concentration camp survivor, �What is there to say? There was just killing and death.� Heightened autonomic arousal, on edge Symptoms may be normative response to overwhelming/traumatic stimulus Individual�s perception of the event are a factor -As in other cases, the cognitive labels one gives to an event can greatly influence how the event affects the individual. -PTSD is a relatively new diagnosis, arising in popularity following the first Iraq War. -Because the symptoms are vague, there is a concern about malingering.-As in other cases, the cognitive labels one gives to an event can greatly influence how the event affects the individual. -PTSD is a relatively new diagnosis, arising in popularity following the first Iraq War. -Because the symptoms are vague, there is a concern about malingering.

46. -Table 7.1: Lifetime Prevalence Exposure to Stressors by Gender and PTSD Risk.-Table 7.1: Lifetime Prevalence Exposure to Stressors by Gender and PTSD Risk.

47. Etiology and Treatment of ASD and PTSD Depends on: Nature of traumatic event Cognitive reaction involving intense fear and horror Vulnerability factors; past psychiatric history Effects can be reduced by: Effective coping style Supportive recovery environment

48. Etiology and Treatment of ASD and PTSDProcessing a Catastrophic Event -Figure 5.8: Processing a Catastrophic Event. A Working Model. Factors such as the coping style and characteristics of the individual, the way traumatic events are processed, and whether or not social supports are available have an impact of whether PTSD develops.-Figure 5.8: Processing a Catastrophic Event. A Working Model. Factors such as the coping style and characteristics of the individual, the way traumatic events are processed, and whether or not social supports are available have an impact of whether PTSD develops.

49. Etiology and Treatment of ASD and PTSD Behavioral perspective: Etiology: Classical conditioning with generalization Influenced by individual characteristics, perception of the event, social support Treatment: Exposure allows for extinction; virtual reality -The etiology of PTSD may be similar to that of phobias, with a good deal of generalization thrown in.-The etiology of PTSD may be similar to that of phobias, with a good deal of generalization thrown in.

50. Etiology and Treatment of ASD and PTSD Cognitive factors: Etiology: Guilt, self-blame, cognitive set Treatment: Psychoeducation, exposure, identify faulty thinking, stress management/ muscle relaxation

51. Etiology and Treatment of ASD and PTSD Biological perspective: Etiology: Hypersensitized neural and biological systems Enhanced startle response to even neutral cues. Treatment: Tricyclic antidepressants and SSRIs

52. -Figure 7.1: Multipath Model for PTSD. The dimensions interact with one another and combine in different ways to result in PTSD.-Figure 7.1: Multipath Model for PTSD. The dimensions interact with one another and combine in different ways to result in PTSD.