CHAPTER 5: STRESS AND PHYSICAL AND MENTAL HEALTH

 The field of health psychology is concerned with the effects of stress and other
psychological factors in the development and maintenance of physical problems.
 Health psychology is a subspecialty within behavioral medicine.
 A behavioral medicine approach to physical illness is concerned with psychological
factors that may predispose an individual to medical problems.
Health psychology – Subspecialty within behavioral medicine that deals with
psychology’s contributions to the diagnosis, treatment, and prevention of psychological
components of physical dysfunction.
Behavioral medicine – Broad interdisciplinary approach to the treatment of physical
disorders thought to have psychological factors as major aspects in their causation or
maintenance.

5.1 WHAT IS STRESS?

 When we experience or perceive challenges to our physical or emotional well-

being that exceed our coping resources and abilities, the psychological condition
that results is typically referred to as stress.
 To avoid confusion, we will refer to external demands as stressors, to the effects they
create within the organism as stress, and to efforts to deal with stress as coping
strategies.
 Stress is fundamentally an interactive and dynamic construct because it reflects the
interaction between the organism and the environment over time.
 Both kinds of stress can tax a person’s resources and coping skills, although bad
stress (distress) typically has the potential to do more damage.
Stressor – Adjustive demands that require coping behavior on the part of an individual or
group.
Stress – Effects created within an organism by the application of a stressor.
Coping strategies – Efforts to deal with stress.
Distress – Negative stress, associated with pain, anxiety, or sorrow.

STRESS AND THE DSM

 The relationship between stress and psychopathology is considered so important
that the role of stress is recognized in diagnostic formulations.
 DSM-5 introduced a new diagnostic category called trauma and stressor related
disorders.
FACTORS PREDISPOSING A PERSON TO STRESS
 People perceive and interpret similar situations differently and also because,
objectively, no two people are faced with exactly the same pattern of stressors.
 The amount of stress we experience early in life may also make us more sensitive to
stress later on
 The term stress tolerance refers to a person’s ability to withstand stress without
becoming seriously impaired.
 Stressful experiences may also create a self-perpetuating cycle by changing how
we think about, or appraise, the things that happen to us.
Stress tolerance – A person’s ability to withstand stress without becoming seriously
impaired.

CHARACTERISTICS OF STRESSORS
 The key factors involve
- the severity of the stressor,
- its chronicity (i.e., how long it lasts),
- its timing,
- how closely it affects our own lives,
- how expected it is, and (6) how controllable it is.
 Recovery from the stress created by major surgery can be improved when a patient
is given realistic expectations beforehand; knowing what to expect adds
predictability to the situation.
 With an uncontrollable stressor, there is no way to reduce its impact, such as by
escape or avoidance.
 The term crisis is used to refer to times when a stressful situation threatens to exceed
or exceeds the adaptive capacities of a person or a group.
Crisis – Stressful situation that approaches or exceeds the adaptive capacities of an
individual or a group.

MEASURING LIFE STRESS

 The faster life changes occur, the greater the stress that is experienced.

RESILENCE
 Kind of healthy psychological and physical functioning after a potentially traumatic
event is called resilience.
 Resilience is not rare, in fact, resilience is the most common reaction following loss
or trauma.
 The people who showed most resilience in the months after their injuries were those
who, when interviewed shortly after arriving in the hospital, reported that they
generally had an optimistic approach to life.
Resilience – The ability to adapt successfully to even very difficult circumstances.

5.2 STRESS AND THE STRESS RESPONSE

 Two distinct systems are involved here

- The sympathetic-adrenomedullary (SAM) system
- The hypothalamuspituitary-adrenal (HPA) system
Sympathetic-adrenomedullary (SAM) system
 - Designed to mobilize resources and prepare for a fight-or-flight response.
- The stress response begins in the hypothalamus, which stimulates the sympathetic
nervous system (SNS).
- They also get the body to metabolize glucose more rapidly
Hypothalamuspituitary-adrenal (HPA) system
- To stimulating the SNS, the hypothalamus releases a hormone called corticotropin-
releasing hormone (CRH).
- The stress glucocorticoid that is produced is called cortisol.
- Cortisol – Human stress hormone released by the cortex of the adrenal glands.
- Cortisol is a good hormone to have around in an emergency.
Allostatic load – The biological cost of adapting to stress. Under conditions of high stress
our allostatic load is high. When we are calm, our allostatic load is low and our bodies
are not experiencing any of the physiological consequences of stress (racing heart, high
levels of cortisol, etc.).

THE MIND AND THE BODY CONNECTION

 The link between stress and physical illness involves diseases (like colds) that are not
directly related to nervous system activity.
 Psychoneuroimmunology is the study of the interactions between the nervous
system and the immune system.
 The nervous system and the immune system communicate in ways that we are now
beginning to understand.
 Glucocorticoids can cause stress induced immunosuppression.
Psychoneuroimmunology – Study of the interactions between the immune system and
the nervous system and the influence of these factors on behavior.
Immunosuppression – A downregulation or dampening of the immune system. This can
be short or long term and can be triggered by injury, stress, illness, and other factors.

UNDERSTANDING THE IMMUNE SYSTEM

 The word immune comes from the Latin immunis, which means “exempt.”
 The immune system protects the body from such things as viruses and bacteria.
 The front line of defense in the immune system is the white blood cells.
 These leukocytes (or lymphocytes) are produced in the bone marrow and then
stored in various places throughout the body, such as the spleen and the lymph
nodes.
 There are two important types of leukocytes.
- B-cell
- T-cell
B-cell
- A type of white blood cell, produced in the bone marrow, that is (along with T-
cells) very important in the immune system. B-cells produce specific antibodies in
response to specific antigens.
- The word is a contraction of antibody generator
- produces specific antibodies that are designed to respond to specific antigens.
- Antigens are foreign bodies such as viruses and bacteria, as well as internal
invaders such as tumors and cancer cells.
- B-cells are different in structure from T-cells.
 - When a B-cell recognizes an antigen, it begins to divide and to produce
antibodies that circulate in the blood.
T-cell
- A type of white blood cell that, when activated, can recognize specific antigens.
T-cells play an important role in the immune system.
- Named because it matures in the thymus, which is an important endocrine gland
- Circulate through the blood and lymph systems in an inactive form.
- They become activated when immune cells called macrophages detect antigens
and start to engulf and digest them.
- To activate the T-cells, the macrophages release a chemical known as interleukin-
1.
 When the immune system is stimulated, B-cells and T-cells become activated and
multiply rapidly, mounting various forms of counterattack.
 The protective activity of the B- and T-cells is supported and reinforced by other
specialized components of the system, most notably natural killer cells,
macrophages and granulocytes.
 The immune system’s response to antigen invasion is intricately orchestrated,
requiring the intact functioning of numerous components.
 Cytokines play an important role in mediating the inflammatory and immune
response.
Immune system – The body’s principal means of defending itself against the intrusion of
foreign substances.
Leukocytes – Generalized term for white blood cells involved in immune protection.
Antigen – A foreign body (e.g., a virus or bacteria) or an internal threat (e.g., a tumor)
that can trigger an immune response.
Cytokines – Small protein molecules that enable the brain and the immune system to
communicate with each other. Cytokines can augment or enhance an immune system
response or cause immunosuppression, depending on the specific cytokine that is
released.

5.3 STRESS AND PHYSICAL HEALTH

 The brain influences the immune system, psychological factors are of great
importance to our health and well-being.
Positive psychology – A new field that focuses on human traits (e.g., optimism) and
resources that are potentially important for health and well-being.

CARDIOVASCULAR DISEASE
 Hypertension
- The definition of hypertension is having a persisting systolic blood pressure of 140
to more and a diastolic blood pressure of 90 or higher.
- When we are stressed, the blood vessels supplying our internal organs constrict
and blood flows in greater quantity to the muscles of the trunks and limbs.
- When the period of stress is over, blood pressure returns to normal.
- Ideally, blood pressure should be below 120/80.
- Essential hypertension – High blood pressure with no specific physical cause.
- Not being able to express anger in a constructive way may also increase a
person’s risk for hypertension.
  Coronary Heart Disease
- The heart is a pump, made of muscles.
- CHD is a potentially lethal blockage of the arteries that supply blood to the heart
muscle, or myocardium.

RISK AND CAUSAL FACTORS IN CARDIVASCULAR DISEASE

 Stress increases the risk of having a heart attack.
 Everyday forms of stress can also elevate the risk for CHD and death.
 Attempts to explore the psychological contribution to the development of heart
disease date back to the identification of the Type A behavior pattern.
 Type A behavior is characterized by excessive competitive drive, extreme
commitment to work, impatience or time urgency, and hostility.
 A subsequent major study called the Framingham Heart Study not only confirmed
the findings of the earlier study but extended them to women as well.
 A more recent development is the identification of the “distressed” or Type D
personality type.
 People with Type D personality have a tendency to experience negative emotions
and also to feel insecure and anxious.
 People with higher scores on the negative affectivity component of Type D
personality are also at increased risk of having more problems after cardiac surgery.
Type A behavior pattern – Excessive competitive drive even when it is unnecessary,
impatience or time urgency, and hostility.
Type D personality – Type D (for distressed) personality is characterized by high levels of
negative emotions and social anxiety. Research suggests that Type D personality is linked
to heart attacks.
 Like stress, depression is associated with disrupted immune.
 Depression is also a factor in heart disease.
 People with heart disease are approximately three times more likely than healthy
people to be depressed
 Depression also appears to be a risk factor for the development of CHD.
 Prospective studies of women who were free of cardiac disease at the start of the
study have also linked phobic anxiety with a higher risk of sudden cardiac death.
 A lack of social support triggers an inflammatory response in the immune system,
causing depression and heart problems as a result.

5.4 TREATMET OF STRESS-RELATED PHYSICAL DISORDERS

BIOLOGICAL INTERVENTION
 People who have serious physical diseases obviously require medical treatment for
their problems.
 Most people with clinical depression go untreated, resulting in an unnecessary
added risk for CHD.

PSYCHOLOGICAL INTERVENTIONS
 Developing effective emotion regulation skills is probably beneficial.
 “Opening up” and writing expressively about life problems in a systematic way does
seem to be an effective therapy for many people with illnesses.
  Expressive writing also seems to provide some modest benefits for people who have
been diagnosed with autoimmune illnesses such as lupus and rheumatoid arthritis.
 Expressive writing may even get in the way of emotional recovery in people who
have experienced a marital separation.
 In studies that involve emotional disclosure, patients often experience initial
increases in emotional distress during the writing phase but then show improvement
in their medical status over follow-up.
 Biofeedback procedures aim to make patients more aware of such things as their
heart rate, level of muscle tension, or blood pressure.
 Biofeedback seems to be helpful in treating some conditions, such as headaches.
 Patients who practiced Transcendental Meditation for 20 minutes twice a day
reduced their diastolic blood pressure significantly more than did patients who
practiced muscle relaxation or who received sound health care advice.
 CBT has been shown to be an effective intervention for headache as well as for
other types of pain.

5.5 STRESS AND MENTAL HEALTH

ADJUSTMENT DISORDER
 An adjustment disorder is a psychological response to a common stressor that results
in clinically significant behavioral or emotional symptoms.
 In adjustment disorder, the person’s symptoms lessen or disappear when the stressor
ends or when the person learns to adapt to the stressor.
 Adjustment disorder is probably the least stigmatizing and mildest diagnosis a
therapist can assign to a client.
 Managing the stress associated with unemployment requires great coping strength,
especially for people who have previously earned an adequate living.
 One of the most disturbing findings is that unemployment, especially if it is
prolonged, increases the risk of suicide.

POSTTRAUMATIC STRESS DISORDER

 In DSM-5 posttraumatic stress disorder is grouped with other disorders in a new
diagnostic category called trauma and stressor-related disorders.
 The diagnosis of PTSD first entered the DSM in 1980
 In the case of PTSD, however, the stress symptoms fail to abate even when the
traumatic event has passed and the danger is over.
 Although being able to remember potentially life-threatening experiences is highly
adaptive for our overall survival, having prolonged, intense, and intrusive memories
that cause extreme stress symptoms is not.
 PTSD involve exposure to a more traumatic stressor.
 This can lead to more long-term and intense difficulties that can be debilitating
(PTSD).
 PTSD is not the only disorder that can develop after a traumatic experience.

ACUTE STRESS DISORDER

 Acute stress disorder is a diagnostic category that can be used when symptoms
develop shortly after experiencing a traumatic event and last for at least 2 days.
  The existence of this diagnosis means that people with symptoms do not have to
wait a whole month to be diagnosed with PTSD.

The clinical symptoms of PTSD are shown in the Criteria for Posttraumatic Stress Disorder
box. Note that these symptoms are grouped into four main areas and concern the
following:
1. Intrusion: Recurrent reexperiencing of the traumatic event through nightmares,
intrusive images, and physiological reactivity to reminders of the trauma.
2. Avoidance: Efforts to avoid thoughts, feelings, or reminders of the trauma.
3. Negative alterations in cognitions and mood: This includes such symptoms as
feelings of detachment as well as negative emotional states such as shame or
anger, or distorted blame of oneself or others.
4. Arousal and reactivity: Hypervigilance, excessive response when startled,
aggression, and reckless behavior.

CAUSAL FACTORS IN POSTTRAUMATIC STRESS DISORDDER

 Individual Risk Factors
- There is risk for experiencing trauma and there is also risk for PTSD given that there
has been exposure to trauma.
- People who have disturbing thoughts or images about traumatic events that
could happen in the future may be at elevated risk of developing PTSD later.
- Perhaps people with higher cognitive abilities are more naturally able to
incorporate their traumatic experiences into their life narratives in ways that are
ultimately adaptive and emotionally protective.
 Biological Factors
- Women with PTSD do seem to have higher levels of baseline cortisol than women
without PTSD.
- . Another interesting finding is that levels of cortisol tend to be lower in people
with PTSD who have experienced physical or sexual abuse.
- There is also a possibility that trauma reduces the size of the hippocampus to
some extent.
- PTSD and depression are highly comorbid and co-occurring disorders, it is
therefore hard for researchers to be sure which brain abnormalities are specific
to PTSD and which might stem from depression.
 Sociocultural Factors
- Returning to a negative and unsupportive social environment can also increase
vulnerability to posttraumatic stress.
- Sociocultural variables also appear to play a role in determining a person’s
adjustment to combat.

LONG TERM EFFECTS OF POSTTRAUMATIC STRESS

 The nature and extent of PTSD are somewhat controversial, however.
 The delayed version of PTSD is less well defined and more difficult to diagnose than
disorders that emerge shortly after the precipitating incident.
 Some authorities have questioned whether a delayed reaction should be
diagnosed as PTSD at all; instead, some would categorize such a reaction as
another type of disorder.
5.6 PREVENTION AND TREATMENT OF STRESS DISORDERS

PREVENTION
 One way to prevent PTSD is to reduce the frequency of traumatic events.
 It is also worth considering whether it is possible to prevent maladaptive responses
to stress by preparing people in advance and providing them with information and
coping skills.
 Adequate training and preparation for extreme stressors may also help soldiers,
firefighters, and others for whom exposure to traumatic events is highly likely.
 The use of cognitive-behavioral techniques to help people manage potentially
stressful situations or difficult events has been widely explored.
 This preventive strategy, often referred to as stress inoculation training, prepares
people to tolerate an anticipated threat by changing the things they say to
themselves before or during a stressful event.

TREATMENT FOR STRESS DISORDER

 National and local telephone hotlines provide help for people under severe stress
and for people who are suicidal.
 Studies also suggest that the most positive outcomes are seen when helpers show
empathy and respect for callers.
 Crisis intervention has emerged in response to especially stressful situations, be they
disasters or family situations that have become intolerable.
 Short-term crisis therapy is of brief duration and focuses on the immediate problem
with which an individual or family is having difficulty.
 A central assumption in crisis-oriented therapy is that the individual was functioning
well psychologically before the trauma.

PSYCHOLOGICAL DEBRIEFING
 Psychological debriefing approaches are designed to help and speed up the
healing process in people who have experienced disasters or been exposed to
other traumatic situations.
 Psychological debriefing is currently quite controversial.
 Trauma survivors should not be left alone to pick up the pieces of their lives.
 Caring, kindness, and common sense can go a long way to helping trauma survivors
along the path to healing.
 One behaviorally oriented treatment strategy that is now being used for PTSD is
prolonged exposure.
 This procedure also involves repeated or extended exposure, either in vivo or in the
imagination, to feared stimuli that the patient is avoiding because of trauma-
related fear.
 Prolonged exposure can also be supplemented by other behavioral techniques.
 Because prolonged exposure therapy involves persuading clients to confront the
traumatic memories they fear, the therapeutic relationship may be of great
importance in this kind of clinical intervention.
 Prolonged exposure is an effective treatment for PTSD.
Stress-inoculation training – Preventive strategy that prepares people to tolerate an
anticipated threat by changing the things they say to themselves before the crisis.
Debriefing session – Psychological debriefing is a brief, directive treatment method that
is used in helping people who have undergone a traumatic situation. Debriefing sessions
are usually conducted with small groups of trauma victims shortly after the incident for
the purpose of helping them deal with the emotional residuals of the event.
Prolonged exposure – A behaviorally oriented treatment strategy in which a patient is
asked to vividly recount the traumatic event over and over until the patient experiences
a decrease in his or her emotional response.

Medications are sometimes used in the treatment of PTSD, although they are not
especially effective. Some SSRIs provide modest benefits.
Psychological treatments include prolonged exposure therapy and cognitive therapy. A
new approach that appears promising is the use of virtual reality exposure therapy.