Stress Disorders

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

Stress, Coping, and the Anxiety Response • 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, Coping, and the Anxiety Response • 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

Stress, Coping, and the Anxiety Response • 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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Stress and Arousal: The Fight-or-Flight Response • 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

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

Stress and Arousal: The Fight-or-Flight Response • 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

Stress and Arousal: The Fight-or-Flight Response • 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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 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

What Triggers a Psychological Stress Disorder? • 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

What Triggers a Psychological Stress Disorder? • 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

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

What Triggers a Psychological Stress Disorder? • 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

What Triggers a Psychological Stress Disorder? • Victimization and stress disorders • Ongoing victimization and abuse in the family may also lead to stress disorders Comer, Abnormal Psychology, 8e DSM-5 Update

What Triggers a Psychological Stress Disorder? • 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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

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 Comer, Abnormal Psychology, 8e DSM-5 Update

How Do Clinicians Treat the Psychological Stress Disorders? • 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

The Physical Stress Disorders: Psychophysiological Disorders • 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

The Physical Stress Disorders: Psychophysiological Disorders • 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

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

Traditional Psychophysiological Disorders • 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

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

Traditional Psychophysiological Disorders • 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

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 • 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

Traditional Psychophysiological Disorders • 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

Traditional Psychophysiological Disorders • 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

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 Comer, Abnormal Psychology, 8e DSM-5 Update

Traditional Psychophysiological Disorders • 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

Traditional Psychophysiological Disorders • 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

Stress Disorders