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AbnormalPsychology PSY404

Lesson 30

STRESS

What is stress?

Stress is a process of adjusting to circumstancesthat disrupt or threaten a person'sequilibrium.

Scientistsdefine stress as anychallenging event that requires physiological, cognitive, or behavioral

adaptation.

Why study stress?

Scientistsonce thought that stresscontributed only to a fewphysical diseases, likeulcers, migraine

headaches, hypertension (high blood pressure),asthma, and otherpsychosomatic disorders, a term

indicatingthat a disease is a product of both the psyche (mind)and the soma (body).

Howstress effectsus?

Medicalscientists now viewevery physicalillness--from colds to cancerand AIDS--as a product of the

interactionbetween the mind andbody.

Stressors and Stress Reactions

Stressorsare events and situations to which people adjust (exam,job interview, an operation).

Stressreactions are the responses to stress which can be physiological, cognitive and behavioral.

Examples:nausea, nervousness andtired.

Psychophysiological Responses to Stress

· Canadian physiologist Hans Selye offered a different hypothesis based on his concept of the general

adaptation syndrome (GAS).

· Seyle'sGAS consists of threestages: alarm, resistance,and exhaustion.

· Thestage of alarmoccursfirst and involves the mobilization of the body in reaction to threat.

· Thestage of resistancecomesnext and is a period of timeduring which the body is physiologically

activatedand prepared to respond to the threat.

· Exhaustionis the final stage, and it occurs if the body's resources aredepleted by chronic stress.

· Selye viewed the stage of exhaustion as the key in the development of physical illnessfrom stress.

· At this stage, the body is damaged by continuous, failed attempts to reactivate the GAS.

Coping

· Twogeneral coping strategies are problem-focused and emotion-focused coping.

· Problem-focused coping involves attempts to change a stressor.

· Emotion-focused coping is an attempt to alter internaldistress.

· Optimism is a basic key to effective coping.

· Peoplewith an optimistic coping stylehave a positive attitudetoward dealing with stress,even

when it cannot be changed, while pessimistsare defeated from the outset.

· Positive thinking is linked with better health habits and less illness in general, and for thosewith

heartdisease, AIDS and otherserious physicalillnesses.

HealthBehavior

· Stressmay also cause illnessindirectly by disrupting healthy behavior.

· Healthbehavior is action that promotesgood health, including positiveefforts like eating,sleeping,

andexercising adequately andavoiding unhealthy activities such as cigarette smoking,excessive

alcohol consumption, and drug use.

· Stressmay also be related to the very important health behavior of followingmedical advice,

somethingthat as many as 93 percent of all patients failto do fully.

· Illnessbehavior--behaving as if you are sick--alsoappears to be stressrelated.

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Considerableresearch indicates thatincreased stress is correlatedwith such illness behaviors as

making more frequent office visits to physicians or allowing chronic pain to interfere witheveryday

activities.

The fact that many people consultphysicians for psychological rather than physicalconcerns

underscores the value of socialsupport in coping with stress.

Socialsupport not only canencourage positive health behavior,but research shows thatsocial

supportcan have direct, physiological benefits.

Of all potential sources of social support--or conflict--agood marriage may be most critical to

physical health.

Stresscan cause illness, butillness also causesstress.

Helping children, adults, and families to cope with chronic illness is another important role of

experts in behavioral medicine or health psychologists.

At the beginning of the twentieth century, infectious diseases were the mostcommon causes of

death in the United States.

Thanks to advances in medical science,and especially in public health, far fewer people are dying of

infectious diseases at the beginning of the twenty-first century.

Today,most of the leading causes of death are lifestyle diseases thatare affected in many ways by

stressand health behavior.

1- Cancer

· Cancer is the second leading cause of mortality in the United Statestoday, accounting for 23

percent of all deaths.

· Psychologicalfactors are associated with the course of cancer.

· Allcancer patients often areanxious or depressed, andtheir negative emotions canlead to increase

in negative health behavior such as alcohol consumption and decrease in positive health behavior

such as exercise.

· Cancerpatients who are emotionallymore expressive have fewermedical appointments, better

quality of life, and better health status.

· Theabsence of social support alsocan undermine compliance withunpleasant but vitallyimportant

medicaltreatments forcancer.

· Someresearch also indicates thatstress may directlyaffect the course of cancer.

· Adverseeffects on the immune system may explain how stress may exacerbate the course of

cancer.

· Variouspsychological treatments havebeen offered to cancerpatients in an attempt to improve

theirquality of life.

2- Acquired Immune DeficiencySyndrome (AIDS)

· Acquired immune deficiency syndrome (AIDS) is caused by the humanimmunodeficiency virus

(HIV),whichattacks the immune system andleaves the patient vulnerable to infection,

neurological complications, and cancersthat rarely affect thosewith normal immune function.

· Behavioral factors play a critical role in the transmission of AIDS.

· Scientistsand policymakers havelaunched large-scale mediacampaigns to educate the publicabout

HIV and AIDS and to change risky behavior.

· Recentevidence has linkedincreased stress with a morerapid progression of HIV, and the

availability of social support is associatedwith a more gradual onset of symptoms.

3- Pain Management

· Someevidence links reports of increasedpain with depression and anxiety, and conversely, higher

levels of positive affect predict lower levels of reported pain.

· Peoplewho are anxious or depressedmay be more sensitive to pain, less able to cope withit, and

morewilling to complain than are people who have similar levels of suffering.

· Psychologistshave tried a number of treatments to reduce pain.

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Directtreatments include hypnosis, biofeedback, relaxation training, and cognitive therapy.

Researchersreport a degree of successwith each of theseapproaches, but painreduction typically

is modest.

As a result, most current effortsfocus on painmanagement, notpain reduction.

Thegoal of pain management is to help people to cope with pain in a waythat minimizes itsimpact

on their lives, even if the pain cannot be eliminated or controlledentirely.

4- Sleep Disorders

In 1994, DSM first included a diagnostic category forprimarysleep disorder, a condition where the

difficulty in sleeping is the principal complaint.

Twotypes of primary sleep disordersare listed in DSM-IV-TR.

i) Dysomnias aredifficulties in the amount, quality, or timing of sleep.

ii) Parasomnias arecharacterized by abnormal events thatoccur during sleep, forexample,

nightmares.

Thedyssomnias include primary insomnia, primary hypersomnia,narcolepsy, breathing-related sleep

disorder, and circadian rhythm sleep disorder.

Primaryinsomnia involvesdifficulties initiating or maintaining sleep, or poor quality of sleeping (e.g.,

restlesssleep) that last for at least a month and significantly impair lifefunctioning.

Effectivetreatments have been developed for insomnia that involvestimulus control (onlystaying in

bedduring sleep) and resettingcircadian rhythms by going to bed and getting up at set times, as

well as not napping, regardless of the length of sleep.

· Primary hypersomnia is excessive sleepiness characterized by prolonged or daytime sleep,lasting

at least a month and significantly interfering with lifefunctioning.

· Primaryhypersomnia is similar to narcolepsy, irresistible attacks of refreshing sleep, lasting at least

3 months.

· Breathing-relatedsleep disorder involves the disruption in sleep due to breathing problems such

as sleepapnea, the temporary obstruction of the respiratory airway.

· Circadianrhythm sleep disorder is a mismatch between the patients' 24-hoursleeping patterns

andtheir 24-hour life demandsthat causes significant lifedistress.

· Theparasomnias include nightmare disorder, sleepterror disorder, and sleepwalking disorder.

· Peoplewith nightmaredisorder arefrequently awakened by terrifyingdreams.

· Sleepterror disorder alsoinvolves abrupt awakeningfrom sleep, typically with a scream, but it

differsfrom nightmare disorder in importantrespects.

· Peoplewith nightmare disorder recall theirdreams and quickly orient to being awaken; people with

sleepterror disorder recall little of their dreams, show intense autonomic arousal, and aredifficult

to soothe.

· Moreover, a person with sleep terrortypically returns to sleepfairly quickly and recallslittle, if

anythinghappen, about the episode the following morning.

· Sleepwalkingdisorder involves rising from the bed duringsleep and walking about in a general

unresponsivestate.

· Occasionalepisodes of sleepwalking arefairly common, especiallyamong children.

· Likeall sleep disorders,sleepwalking disorder tends to be diagnosed only if it causes significant

distress or impairs the person's ability to function.

5- Cardiovascular disease(CVD)

· Cardiovasculardisease (CVD) is a group of disorders that affect the heartand circulatory system.

· Themost important of theseillnesses are hypertension(highblood pressure) andcoronaryheart

disease(CHD).

· Themost deadly and well-knownform of coronary heart disease is myocardial infarction (MI),

commonly called a heartattack.

· Hypertensionincreases the risk for CHD, as well as for other seriousdisorders, such as stroke.

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Cardiovasculardisorders are the leadingcause of mortality not only in the United States, where they

accountfor over one-third of alldeaths, but also in most industrialized countries.

An individual's risk for developing CVD,and particularly CHD, is associatedwith a number of

health behaviors, including weight, diet, exercise, and cigarettesmoking.

In addition to health behavior, personality styles, behavior patterns,and forms of emotional

expressionappear to contribute directly to the development of CVD.

Symptoms of Hypertension and CHD

Hypertension is often referred to as the "silentkiller" because it produces no obvious symptoms.

Generally, hypertension is defined by a systolicreading above 140 and/or a diastolic reading above 90

when measured while the patient is in a relaxed state.

Diagnosis of CVD

Myocardialinfarction and anginapectoris are the two major forms of coronary heart disease.

Anginapectoris involves intermittent chestpains that are usuallybrought on by some form of exertion.

Attacks of angina do not damage the heart, but the chest paincan be a sign of underlyingpathology that

puts the patient at risk for a myocardialinfarction.

MI (heart attack) does involvedamage to the heart, and as noted, it often causes sudden cardiacdeath,

which is usually defined as deathwithin 24 hours of a coronary episode.

Hypertensioncan be primary or secondary.

Secondaryhypertension resultsfrom a known problem such as a diagnosed kidney or endocrine

disorder. It is called secondary hypertension because the high bloodpressure is secondary to--thatis, a

consequenceof--the principal physical disorder.

Primaryor essentialhypertension is the major concern of behavioral medicine and health

psychology. In case of essential hypertension, the high blood pressure is the principal disorder.

Multiplephysical and behavioral risk factorscontribute to the elevated bloodpressure.

Frequency of CVD

· Menare twice as likely to suffer from CHD as are women,and sex differences areeven greater with

moresevere forms of the disorder.

· Formen, risk for CHD increases in a linear fashion with increasing age after 40.

· Forwomen, risk for CHDaccelerates more slowly until they reach menopause andincreases

sharplyafterwards.

· Rates of CHD also are higher among low-income groups, a finding thatlikely accounts for the

higher rates of CHD among blackthan among whiteAmericans.

· Finally, a positive family history is also linked to an increased risk for CHD, due at least in part to

geneticfactors.

· The risk for CHD is two to threetimes greater among thosewho smoke a pack or more of

cigarettes a day.

· Obesity, a fatty diet, elevated serumcholesterol levels, heavy alcohol consumption, and lack of

exercisealso increase the risk forCHD.

· CHDalso is associated withpsychological characteristics, includingdepression.

· About 30 percent of all U.S.adults suffer from hypertension, andmany of the same risk factors

that predict CHD also predict highblood pressure, includinggenetic factors, a high-salt diet, health

behavior,and lifestyle factors.

· Hypertension is more common in industrialized countries;and in the United States,high blood

pressure is found with greaterfrequency among men, AfricanAmericans, low-income groups,and

people exposed to high levels of chronic life stress.

Causes of CVD

· Theimmediate cause of CHD is the deprivation of oxygen to the heartmuscle.

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No permanent damage is caused by the temporary oxygen deprivation (myocardialischemia) that

accompaniesangina pectoris, but part of the heart muscle dies in cases of myocardialinfarction.

Oxygen deprivation can be caused by temporarily increased oxygen demands on the heart, for

example, as a result of exercise.

More problematic is when atherosclerosis causes the gradual deprivation of the flow of blood (and

the oxygen it carries) to the heart.

Theimmediate biological causes of hypertension are less well understood, as are the more distant

biologicalcauses of both hypertension andCHD.

A positive family history is a risk factor for both hypertension and CHD, and mostexperts

interpret this as a genetic contribution.

However,research using animal models of CVD suggests that heritable risk interacts with

environmental risk.

Themost important of the knownpsychological contributions to CVDare the wide variety of

health behaviors that (1) have a well-documented association with heartdisease; (2) decrease the

risk for CVD when they aremodified; and (3) oftenare difficult to change.

Improved health behavior--including avoiding or quitting smoking, maintaining a proper weight,

following a low-cholesterol diet, exercising frequently,monitoring blood pressure regularly, and

taking antihypertensive medication as prescribed--can reduce the risk of heart disease.

Stressalso contributes to CVD, in twodifferent ways.

First, stress taxes the cardiovascularsystem through increasedheart rate and bloodpressure and

can precipitate immediate symptoms or broader episodes of CHD.

Second,over the long run, the heartmay be damaged by constantstress.

We consider four areas that this can happen: cardiovascular reactivity to stress, actual exposure to

lifestress, characteristic styles of responding to stress, and depressionand anxiety.

In a study of patients with coronary artery disease, patients whoreacted to mental stress in the

laboratorywith greater myocardialischemia (oxygen deprivation to the heart) had a higher rate of

fatal and nonfatal cardiac eventsover the next 5 years in comparison to their lessreactive

counterparts.

In fact, mental stress was a better predictor of subsequent cardiacevents than was physicalstress

(exercisetesting).

Researchshows that exposure to chronic stress increases risk forcardiovascular disease.

Severalstudies have found a relationship between job strain andCHD.

Suchstrains are not limited to employment, but include work that is performed in other liferoles.

Characteristicstyles of responding to stress mayalso increase the risk forCVD, particularly the

Type A behavior pattern--a competitive, hostile, urgent, impatient, and achievement-striving

style of responding to challenge.

Type B individuals, in contrast, are more calmand content.

TheNational Blood, Heart, andLung Institute concluded in 1981 that Type A was a risk factor for

CHD, independent of other risks, forexample, diet.

Manystudies conducted since 1980have failed to supportearlier findings.

Hostilitypredictsfuture heart disease better than other aspects of Type A behavior or the pattern as

a whole.

Depression is three times more common among patients with CHDthan in the generalpopulation,

anddepression doubles the risk forfuture cardiacevents.

Anxietyseems to be associated withone crucial aspect of CHD:sudden cardiac death.

Socialfactors can influence the risk forCVD in many ways.

Friendsand family members canencourage a healthy--or an unhealthy--lifestyle.

Interpersonalconflict can create the anger and hostility thatcan increase the risk for coronary heart

disease,whereas a spouse's confidence in coping with heart disease predicts patients' increases

survival over 4 years.

Economic resources, being married, and/or having a close confidant all predict a more positive

prognosisamong patients with coronary artery disease.

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Finally,societal values, such as attitudes about health behaviorslike smoking and cultural norms

about competition in the workplace also can affect the risk for CVD.

CVD is an excellent example of the value of the systems approach.

CVD is caused by a combination of geneticmakeup, an occasional structural defect,maintenance in

the form of health behavior, andhow hard the heart is driven by stress, depression, coping, and

societalstandards.

Prevention and Treatment of CVD

· Severalmedications known as antihypertensiveare effective treatments for reducinghigh blood

pressure.

· Numerous public service advertisements attempt to prevent CVD by encouraging people to quit

smoking,eat well, exercise, monitortheir blood pressure, andotherwise improve their health

behavior.

· The treatment of essential hypertension is one of the most important attempts at the secondary

prevention of CHD.

· Treatments of hypertension fall intotwo categories.

· One focuses on improving healthbehavior, and the other emphasizes stressmanagement,

attempts to teach more effective coping skills.

· The major form of stress managementused to treat hypertension is behavior therapy, particularly

relaxation training and biofeedback.

· Biofeedbackuseslaboratory equipment to monitor physiological processes that generallyoccur

outsideconscious awareness and to provide the patient withconscious feedback about these

processes.

· Biofeedback tries to teach the person to control the functions of their autonomic nervous system.

· Both relaxation training and biofeedback produce reliable, reductions in bloodpressure.

· Unfortunately, the reductions are small,often temporary, and considerablyless than those

produced by antihypertensive medications.

· Overall,stress management appears to improve quality of life buthas little effect on disease.

· Biofeedback is a particularly dubious treatment, one thatsome well-respected investigatorssuggest

should be abandoned as a treatment for hypertension.

· TheTrials of Hypertension Prevention(TOHP) is an important ongoingstudy of whether stress

managementand health behavior interventionssucceed in lowering highblood pressure.

· Resultsfrom Phase I of the study indicated that only the weight reductionand the saltreduction

programswere successful in loweringblood pressure over a follow-up period of up to 11.2 years.

· Findings from Phase II of the TOHPunderscored the importance of weight loss, as even a modest

reduction in weight lowered produced clinically significant reductions in blood pressure.

· TheMultiple Risk Factor InterventionTrial (MRFIT) is another important investigation, of over

12,000men at risk for CHD whowere assigned at random to interventionand control groups.

· Carefully developed intervention programs,including both education andsocial support, produced

improved health behavior, including reduced smoking and lower serumcholesterol.

· However, the men randomly assigned to the treatment groups did not have a lower incidence of

heartdisease during the 7 yearsfollowing intervention.

· Tertiaryprevention of CHD targetspatients who have alreadyhad a cardiac event,typically a

myocardialinfarction.

· The hope is to reduce the incidence of recurrence of the illness.

· Exerciseprograms are probably the most common treatment recommended forcardiac patients,

butevidence of their effectiveness is limited.

· Themost effective programs areindividualized for each patient.

· Some of the most optimistic evidence on the treatment of CHD comes fromstudies of

interventionsdesigned to alter the Type A behavior pattern, a somewhat surprisingcircumstance

given the controversies about the risk research on Type A.

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Somevaluable treatments focus on the effects of heart disease on life stress rather than the other

way around.

Thelink between stress andphysical health clearly is a reciprocalone.

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