Comer, Abnormal Psychology DSM-5 Update, 8e Stress Disorders Chapter 6 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

Comer, Abnormal PsychologyDSM-5 Update, 8e

Stress Disorders

Chapter 6

Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System

2Comer, Abnormal Psychology, 8e

DSM-5 Update

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


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


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


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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

The Autonomic Nervous System


DSM-5 Update


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

The Endocrine System


DSM-5 Update


DSM-5 Update


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…

Pathways of Arousal and Fear


DSM-5 Update


DSM-5 Update


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)

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)


DSM-5 Update


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


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


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


DSM-5 Update



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


DSM-5 Update


DSM-5 Update



Ongoing victimization and abuse in the family may also lead to stress disorders


DSM-5 Update


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


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


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


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


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

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


DSM-5 Update


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


DSM-5 Update


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


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


DSM-5 Update


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


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


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


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


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


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


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


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


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


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


DSM-5 Update


DSM-5 Update


A number of variables contribute to the development of psychophysiological disorders, including: Biological factors

Psychological factors

Sociocultural factors


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


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


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


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


DSM-5 Update


DSM-5 Update


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


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


DSM-5 Update


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


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

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


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


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


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


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


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


DSM-5 Update


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


DSM-5 Update


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


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


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


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


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)


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


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


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


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


DSM-5 Update

Documents

Comer, Abnormal Psychology DSM-5 Update, 8e Stress Disorders Chapter 6 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System