Comer, Abnormal Psychology, 7e

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Stress Disorders

• Chapter 6

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Stress, Coping, and the Anxiety Response

• The state of stress has two components
• Stressor event that creates demands
• Stress response persons reactions to the
  demands
• Influenced by how we appraise 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 constructively

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Stress, Coping, and the Anxiety Response

• When we appraise a stressor as threatening, the
  natural reaction is 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

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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-IV-TR lists these patterns as
  anxiety disorders
• as well as certain physical disorders, called
  psychophysiological disorders
• These disorders are listed in the DSM-IV-TR under
  psychological factors affecting medical
  condition

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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

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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

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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

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Stress and Arousal The Fight-or- Flight Response

• The second pathway is the hypothalamic-pituitary-a
  drenal (HPA) pathway
• When confronted by stressors, the hypothalamus
  signals the pituitary gland, which stimulates the
  adrenal cortex to release corticosteroids
  stress hormones into the bloodstream

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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

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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)

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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 other anxiety
  disorders)

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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

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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
• 79 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 21
• After trauma, around 20 of women and 8 of men
  develop disorders
• Some events including combat, disasters, abuse,
  and victimization are more likely to cause
  disorders than others

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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 Iraq and Afghanistan

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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
• Civilian traumas have been implicated in stress
  disorders at least 10 times as often as combat
  traumas

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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
• 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

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What Triggers a Psychological Stress Disorder?

• Victimization and stress disorders
• Ongoing victimization and abuse in the family may
  also lead to stress disorders
• The experience of terrorism or the threat of
  terrorism often leads to posttraumatic stress
  symptoms, as does the experience of torture

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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

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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 other biological changes
  and damage may also occur (especially in the
  hippocampus and amygdala) as a stress disorder
  sets in
• There may be a biological/genetic predisposition
  to such reactions

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Why Do People Develop a Psychological Stress
Disorder?

• Personality factors
• Some studies suggest that people with certain
  personality profiles, attitudes, and coping
  styles are particularly likely to develop stress
  disorders
• Risk factors include
• Preexisting high anxiety
• A history of psychological problems
• Negative worldview
• A set of positive attitudes (called resiliency or
  hardiness) is protective against developing
  stress disorders

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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

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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
• Multicultural factors
• A careful look at research literature suggests
  that there may be important cultural differences
  in the occurrence of PTSD
• It seems that Hispanic Americans might be more
  vulnerable to PTSD than other racial or ethnic
  groups
• Possible explanations include early dissociative
  reactions to trauma, cultural beliefs systems,
  and the cultural emphasis on social relationships

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Why Do People Develop a Psychological Stress
Disorder?

• Severity of the trauma
• The more severe the trauma and the more direct
  ones 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

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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
• Symptoms have been found to last an average of 3
  years with treatment and 5½ years without
  treatment
• Treatment procedures vary depending on type of
  trauma
• General goals
• End lingering stress reactions
• Gain perspective on painful experiences
• Return to constructive living

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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 family or group therapy formats rap
  groups
• Usually used in combinations

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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
• Relief workers themselves may become overwhelmed
• Research on this type of intervention continues
  to call into question its effectiveness

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The Physical Stress Disorders Psychophysiological
Disorders

• In addition to affecting psychological
  functioning, stress can also have an enormous
  impact on physical functioning
• The idea that stress and related psychosocial
  factors may contribute to somatic illnesses has
  ancient roots, but had few supporters before the
  20th century
• 17th century philosopher René Descartes called a
  variation on the idea mindbody dualism

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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-IV-TR calls them psychological factors
  affecting medical condition

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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 somatoform
  disorders, which will be discussed in Chapter 7

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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

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Traditional Psychophysiological Disorders

• Ulcers
• Lesions in the wall of the stomach that result in
  burning sensations or pain, vomiting, and stomach
  bleeding
• Experienced by 20 million people at some point in
  their lives
• Causal psychosocial factors
• Environmental pressure, anger, anxiety, dependent
  personality style
• Causal physiological factors
• Bacterial infection

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Traditional Psychophysiological Disorders

• Asthma
• A narrowing of the bodys airways that makes
  breathing difficult
• Affects up to 20 million people in the U.S. each
  year
• Most victims are children at the time of first
  attack
• Causal psychosocial factors
• Environmental pressures, troubled family
  relationships, anxiety, high dependency
• Causal physiological factors
• Allergies, a slow-acting sympathetic nervous
  system, weakened respiratory system

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Traditional Psychophysiological Disorders

• Insomnia
• Difficulty falling asleep or maintaining sleep
• Affects 35 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

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Traditional Psychophysiological Disorders

• Chronic headaches
• Frequent intense aches of the head or neck that
  are not caused by another physical disorder
• Tension headaches affect 40 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

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Traditional Psychophysiological Disorders

• Hypertension
• Chronic high blood pressure, usually producing no
  outward symptoms
• Affects 65 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 individuals blood vessels

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Traditional Psychophysiological Disorders

• Coronary heart disease
• Caused by blockage in the coronary arteries
• Includes angina pectoris (chest pain), coronary
  occlusion (complete blockage of a coronary
  artery), and myocardial infarction (heart attack)
• Leading cause of death in men older than 35 years
  and women older than 40 years in the U.S.
• 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

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Traditional Psychophysiological Disorders

• A number of variables contribute to the
  development of psychophysiological disorders,
  including
• Biological factors
• Psychological factors
• Sociocultural factors

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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

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Traditional Psychophysiological Disorders

• Psychological factors
• According to many theorists, certain needs,
  attitudes, emotions, or coping styles may cause
  people to repeatedly overreact to stressors
  increasing their chances of developing
  psychophysiological disorders
• Examples a repressive coping style, a Type A
  personality style

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Traditional Psychophysiological Disorders

• Sociocultural factors
• Adverse social conditions may set the stage for
  psychophysiological disorders
• Stressors may be wide-ranging (e.g., nuclear
  threat, like Three Mile Island) or local (e.g.,
  living in a crime-ridden neighborhood)
• One of societys 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

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Traditional 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

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New Psychophysiological Disorders

• Since the 1960s, researchers have found many
  links between psychosocial stress and a wide
  range of physical illnesses

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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

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New Psychophysiological Disorders

• 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

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New Psychophysiological Disorders

• 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, women and men have been shown to
  react differently to certain life changes
  measured by the scale

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New Psychophysiological Disorders

• Researchers have increasingly looked to the
  bodys immune system as the key to the
  relationship between stress and infection
• This area of study is called psychoneuroimmunology

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New Psychophysiological Disorders

• Psychoneuroimmunology
• The immune system is the bodys 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

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Researchers now believe that stress can interfere
  with the activity of lymphocytes, slowing them
  down and increasing a persons 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

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Biochemical activity
• Stress leads to increased activity of 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 bodys endocrine glands reduce
  immune system functioning during periods of
  prolonged stress through the release of
  corticosteroids

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New Psychophysiological Disorders

• Psychoneuroimmunology
• 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 individuals personality style (including
  their level of optimism, constructive coping
  strategies, and resilience) may also play a role
  in determining how much the immune system is
  slowed down by stress

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New Psychophysiological Disorders

• Psychoneuroimmunology
• 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

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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,
  insight therapy, and support groups

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Psychological Treatments for Physical Disorders

• The field of treatment that combines
  psychological and physical interventions to treat
  or prevent medical problems is known as
  behavioral medicine

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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 be of help in preventing
  or treating 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

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Psychological Treatments for Physical Disorders

• Biofeedback training
• Patients given biofeedback training are connected
  to machinery that gives them continuous readings
  about their involuntary bodily activities
• 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 asthma, irregular heartbeat,
  migraine headaches, high blood pressure,
  stuttering, and pain from burns

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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
• Meditation is a technique of turning ones
  concentration inward and achieving a slightly
  changed state of consciousness
• Meditation has been used to treat pain, high
  blood pressure, heart problems, insomnia, and
  asthma

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Psychological Treatments for Physical Disorders

• Hypnosis
• Individuals undergoing 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)

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Psychological Treatments for Physical Disorders

• 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

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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 self-instruction training, in
  which patients are taught to rid themselves of
  negative self-statements and to replace these
  with positive self-statements

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Psychological Treatments for Physical Disorders

• Insight therapy and support groups
• If negative psychological symptoms (e.g.,
  depression, anxiety) contribute to a persons
  physical ills, therapy to address 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

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Psychological Treatments for Physical Disorders

• Combination approaches
• Studies have found that the various psychological
  treatments for physical problems tend to be equal
  in effectiveness
• Psychological treatments are often of greatest
  help when used in combination and with medical
  treatment
• With these combined approaches, todays
  practitioners are moving away from the mindbody
  dualism of centuries past