All you need to know about STRESS Megan Crowe, 2015

1. All you need to know about STRESSMegan Crowe, 2015

2. Game Plan What is STRESS? Stress theories and theorists Measuring stress Stress and disease

3. What is Stress? • Textbook definition • a negative emotional experience accompanied by a predictable biochemical, physiological, cognitive and behavioural changes

4. Stress Theories

5. Walter Cannon Flight or fight Threat perceived Nervous stem arousal  Response (f or f)

6. Theories of Stress Stimulus - Response Selye – General Adaptation Syndrome

7. GAS – Stage 1 - ALARM • Non specific stress response which disrupts homeostasis – the natural balance • Alarm reaction- • initial stage in response to immediate danger • Hypothalamic cells alerted to state of emergency • ANS stimulation – temporary breakdown of resistance • Duration = mins-hours depending on intensity of stressor and vulnerability of individual Characteristic of fight or flight response

8. GAS – Stage 2- Resistance • Resistance • dramatic reduction in alarm reaction • Full resistance to stressor is established • Attempt to maintain higher level functioning • Coping mechanisms mobilized • Attempt at survival

9. GAS – Stage 3 - Exhaustion Inability to return to normal level of resistance (pre alarm reaction homeostasis) Cortisol exerts destructive effects (circulatory, digestive, immune) Defense resources depleted intense prolonged stress results in physical consequences (wear and tear/death)

10. Criticisms of GAS • Limited role of psych factors • Assumes uniform responses to stress • Failed to clarify sociological and psychological processes • Assessed stress as an outcome • Effects of stress are experienced in anticipation of an event

11. Lazarus and Folkman • Transactional Model • Critical aspect – the person’s perceptionof his/her stressors • Components: • Primary Appraisal • Secondary Appraisal

12. Primary Appraisal • situation assessed • Irrelevant – no implications therefore no investment in possible outcomes • benign positive – positive interpretation of outcome - characterized by pleasurable emotions, (joy, happiness, excitement) • Stressful – harm, loss, threat

13. Secondary Appraisal • capability to respond is evaluated • what might or can be done? • Determines degree of stress and strength/quality of the emotional reaction • Sense of control • Coping options

14. Good Stress • Is all stress negative • No! • EUSRESS!!! • In the face of challenge stress can be motivational

15. Aspects of Stress • Cognitive • Beliefs about harm, controllability • Emotional • fear, anxiety, excitement, embarrassment • Behavioural • confrontational versus withdrawal

16. Dimensions of Stress What makes stress stressful? • Negative Events • More likely to produce stress • Uncontrollable Events • Unpredictable events increase stress • Ambiguous Events • Time/ resource heavy • Must interpret/understand stressor • Must determine if situation is benign or dangerous

17. Considering Context and Timing • Environmental context • Stress is a response to some environmental demand or pressure • Variable timing • Proximal and distal factors – childhood experiences (trauma, abuse)

18. Sources of Stress • Daily hassles • minor stressful events • Reduce psychological well being & produce physical symptoms • Stressful life events • Minor (moving) to devastating (death of a spouse) which disrupts all aspects of life

19. Measuring Stress Self report inventories Life events Emotional distress Behaviour measures Performance under stress  Physiological measures of arousal Biochemical markers

20. Stress research in practice • Stress is distinguished from distress or psychopathology • However, depression inventories commonly used in clinical settings to assess stress • Do not detect small improvements • Are inventories of mood disorders effective surrogate measure of the stress construct?

21. PSM-9

22. Perceived Stress Questionnaire (PSQ) paper and pencil instrument based on aspects of stress seen by gastroenterologists and patients as relevant to UC activity completed monthly at home (subjects instructed not to complete retrospectively) completed Recent and General version of PSQ at 6 month visits

24. The Paykel Life Events Interview

25. Challenges in Stress Measurement • Short term stressors – some events may tap into ongoing life strain • Vague inventory of events – injury/illness • Subjectivity of ‘stressful’ events – +/- • Ex. Divorce • Timing of events– determining temporality and establishing causal relationship is difficult • Over reporting – more intense experiences are remembered

26. Effects of stress DISEASE PROCESSES APPRAISAL Stress can initiate, exacerbate or impair recovery of health conditions It is a predictor of disease

27. Stress and Disease • Ways in which psychological stress influences disease risk • Physiological changes result in disruption to health • Behaviour changes in response to stress • Smoking • decreased exercise • decreased sleep • poor adherence to medical regimes

28. Mediating the stress response • Can we cope? • Managing stress is a balancing act • Dependent upon resources and affect • Disposition can affect stress response • Optimism versus pessimism • External coping mechanisms • time, $, education, social support • Sense of control • Self efficacy

29. The Stress Disease RelationshipStress and IBD Stressors Stress  IBD – Inflammatory Bowel Disease IMID – Immune mediated inflammatory diseases

30. IBD? Inflammatory Bowel Disease Abnormal response of body’s immune system Causes intestinal inflammation and ulceration Lifelong and chronic – remitting and relapsing NOT IBS – Irritable Bowel Syndrome (a functional disease)

31. What do we know about causation?

32. Stress and IBD • Behaviour and central nervous system function can influence the immune system and inflammation • Occurs at systemic and local tissue levels • Acute stress and immune function • HPA ↑ cortisol • ANS activation increase in proinflammatory cytokines • Chronic Stress • Parts of immune system downregulate - ↓ CD8 cells, natural killer cells and macrophages

33. Acute vs. Long Term Stress Lenensteinet al – perceived stress, depressive symptoms and stressful life events measured high perceived stress among patients with inactive disease will increase the risk of subsequent exacerbation (flare up) high long-term stress tripled the risk of exacerbation during the next 8 months short-term stress does not trigger exacerbation in ulcerative colitis

34. Psychological Stress and IBD Animal models indicate probable biological mechanisms by which stress exacerbates disease by altering immune function Research need to clarify role of stress in development of IDB (stress as causal vs stress as trigger for ↑ symptoms) Research is accumulating on the role of stress in the severity of IBD and other autoimmune diseases (RA, psoriasis) Psychoneuroimmunology – offers humoral routes by which the HPA axis and the nervous system can alter the inflammatory immune response

35. Counseling and IBD Therapy included – CBT & solution focused therapy to address IBD related and external events IBD-focused counseling may ↑ not only psychological well-being, but also the course of IBD in individuals with psychosocial stress

36. Habituation to stress Stroopcolour word interference task to elicit psychological stress Observe BOLD responses Stress evoking tasks show ↑ activity in the dorso-lateral prefrontal cortex and ↓ activity in a network of limbic structures Triggers behavioural, neuroendocrine and autonomic responses to stress Allows for adaptation to stress (rapid mobilization and termination of response) Habituation to stress is adaptive and minimizes stress evoked response and inflammatory responses RESULTS: BOLD response observed in CD patients opposite to controls – suggests impaired habituation

37. Measures and Methodology • Chicken or Egg? • It is difficult to prove psych stress causes IBD because: • difficult to completely eliminate the possibility that Crohn’s disease may have predated the onset of the mood disorder/stress • Because some patients have subclincalCrohn’s disease for an extended period of time before symptoms begin, and it is not uncommon to have a delay in diagnosis even after the onset of symptoms • Prospective studies offer the advantage that one can confirm that the psychological condition preceded the onset of IBD but require large populations to be followed for long periods of time • Retrospective studies can suffer from recall bias that leads to the difficulty of differentiating whether IBD or the psychological disorder was present first

38. Discussion Would you prefer to see physiological/biological measures or self report measures used for stress assessment? Chronic disease and life stressors? Are those who develop disease simply more prone to adverse effects of stress? How does the chronic nature of disease increase the difficulty of parsing of the effects of stress/ relating stress to disease? What do you think of therapeutic implications should future research indicate the benefit of psychological interventions for AD’s?