Chapter Five
Trauma and Stress-Related Disorders
Trauma and Stress-Related Disorders
• Stressor:
– External event or situation that places a physical
or psychological demand on a person
– Range from chronic irritation to acute an
traumatic events
• Stress:
– Internal psychological or physiological response to
a stressor
Acute and Post-Traumatic Stress
• Acute stress disorder (ASD):
– Flashbacks, hypervigilance, and avoidance
symptoms that occur within one month after
exposure to a traumatic stressor
• Post-traumatic stress disorder (PTSD):
– Flashbacks, hypervigilance, avoidance, and other
symptoms that last for more than one month and
that occur as a result of exposure to extreme
Acute and Post-Traumatic Stress
Disorders (cont’d.)
• Both begin with a normal response to
extremely upsetting circumstances
• Fear response remains even though original
basis for fear is no longer present
• Can also be caused by indirect or
“secondhand” exposure
– In one study, 18 percent of parents who learned
that their child was injured in a car accident
developed PTSD ( Allenou et al., 2010)
Diagnosis of Acute and Post-Traumatic
Stress Disorders
• Both involve:
– Direct or indirect exposure to stressor
– Intrusive symptoms and intense physiological
reactivity associated with traumatic event
– Persistent avoidance of stimuli related to trauma
– Alterations in cognitions and mood associated
with event and inability to experience positive
– Heightened autonomic arousal or reactivity
• Hypervigilance
Diagnosis of Acute and Post-Traumatic
Stress Disorders (cont’d.)
• Differ in duration:
– ASD lasts three days to one month
– PTSD lasts longer than a month
• An individual is likely to receive initial
diagnosis of ASD and then PTSD if symptoms
persist longer than a month
Etiology of Acute and Post-Traumatic
Stress Disorders
Figure 5-1 Multipath Model for PTSD The dimensions interact with one another and
combine in different ways to result in PTSD.
Etiology of Acute and Post-Traumatic
Stress Disorders (cont’d.)
• Factors associated with increased risk:
– Severe trauma and grave physical injuries
• Major burn injuries
– one third of individuals hospitalized with major burn injuries
demonstrated PTSD symptoms
– Rape and sexual assault
– Individual characteristics:
Cognitive style
Childhood history
Genetic vulnerability
Social support
Etiology of Acute and Post-Traumatic
Stress Disorders (cont’d.)
Table 5-12 Lifetime prevalence of Exposure to Stressors by Gender and PTSD Risk
Some traumas are more likely to result in PTSD that others. Significant gender
differences were found in reactions to “being threatened with a weapon” and “physical
attack.” What accounts for the differences in risk for developing PTSD among the specific
traumas and for the two genders?
Source: Callenger et al. (2000)
Biological Dimension
• ASD and PTSD are not biologically normative
stress responses
– Nervous system has become highly reactive to
fear and stress
• In PTSD:
– Individual demonstrates increased biological
– Exaggerated sensitivity to stimuli
– Diminished ability to inhibit fear response
Biological Dimension (cont’d.)
• the amygdala signals the sympathetic nervous
system to prepare the body to fight or to flee
– Hypothalamic-pituitary-adrenal (HPA) axis releases
epinephrine and cortisol which raise blood pressure, blood
sugar level, and heart rate
• PTSD is related to reduced activity in the medial
prefrontal cortex, the part of the brain involved in
the inhibition of fear and emotional reactivity
• Individuals with specific biological vulnerabilities
have an increased risk of PTSD
• Epigenetic factors may be involved (social support
buffers biological vulnerabilities)
Psychological Dimension
• Preexisting conditions such as anxiety and
depression found to be risk factors for PTSD
• Dysfunctional cognitions regarding oneself or
– People with thoughts such as “I am incompetent”
or “The world is a dangerous place,” are more
likely to develop PTSD
• Positive cognitive styles increase resilience
and reduce risk of PTSD
Social Dimension
• Less than optimal social support during
childhood and adulthood
• Pre-existing family conflict or over
protectiveness may increase impact of stress
• Social isolation
– Individuals who are socially isolated and lacking in
support systems appear to be more vulnerable to
• Lack of social support after trauma may be
most important factor
Sociocultural Dimension
• Perceived discrimination based on race or
sexual orientation is also associated with
increased risk for PTSD
• Women are twice as likely as men to suffer
stress disorder
• Moderate amount of adversity can generate
– > increased “toughness,” sense of control, and
belief that challenges can be overcome
Treatment of Acute and Post-Traumatic
Stress Disorders
• Biological:
– SSRI antidepressants appear to desensitize fear
• Psychological:
– Psychotherapy focus on extinguishing fear or to
correct dysfunctional cognitions
– Exposure to cues associated with trauma
– Identify and challenge dysfunctional cognitions
– Mindfulness training
Psychological Factors Affecting Medical
• Psychophysiological disorder:
– Physical disorder that has a strong psychological basis or
• “Psychological Factors Affecting Medical Condition”
is the newest terminology for medical conditions in
which psychological or behavioral factors influence
the course or treatment of a medical disorder,
constitute an additional risk factor for the medical
condition, or make the illness worse (DSM-5)
Characteristics of Psychophysiological
• Actual tissue damage, a disease process, or
physiological dysfunction
• Medical treatment and psychotherapy usually
• Contribution of physical and psychological
factors vary greatly
Characteristics of Psychophysiological
Disorders (cont’d.)
• Coronary heart disease:
– The narrowing of cardiac arteries due to
atherosclerosis, resulting in restriction or partial
blockage of flow of blood and oxygen to heart
– Risk factors:
• High cholesterol, hypertension, obesity, cigarette
smoking, and lack of physical activity
– Psychosocial risk factors:
• Depression, perceived stress, and difficult life events
Characteristics of Psychophysiological
Disorders (cont’d.)
• Hypertension:
– Stressors impact blood pressure
– Chronic condition characterized by blood pressure
of 140 over 90 or higher
– More than 74 million U.S. Americans have high
blood pressure requiring treatment
– most prevalent among African Americans and
older adults
– Found in 34% of men and 22% of women
Characteristics of Psychophysiological
Disorders (cont’d.)
• Migraine, tension, and cluster headaches:
– Migraine headaches:
• Moderate to severe pain resulting from abnormal brain
activity affecting the cranial blood vessels and nerves
– results in inflammation and dilation of cranial arteries
– Tension headaches:
• Produced by prolonged contraction of scalp and neck
muscles, resulting in constriction of the blood vessels
and steady pain
Characteristics of Psychophysiological
Disorders (cont’d.)
• Migraine, tension, and cluster headaches:
– Cluster headaches:
• Excruciating stabbing or burning sensations located in
the eye or cheek
• 20% of headaches are preceded by an aura
• may last from 15 minutes to 3 hours before ending
abruptly. May include tears or a stuffy nose on the
same side of the head on which the pain is felt.
• last from several days to months, followed by pain-free
• 55 percent of individuals experiencing a cluster
headache report suicidal thoughts
Characteristics of Psychophysiological
Disorders (cont’d.): Asthma
• Chronic inflammatory disease of the airways in the lungs
• Reduction in the amount of air that can be inhaled
– Stress or other triggers result in excessive mucus secretion combined
with spasms and swelling of the airways
• People with asthma often underestimate the magnitude of
airflow obstruction during an asthma attack
• Sixth leading cause of death in children 5–14 years of age
• In U.S., prevalence has increased dramatically
• Adolescents with asthma are twice as likely to die from
suicide compared to their peers without asthma
Stress and the Immune System
• Stress itself does not appear to cause
infections, but it may decrease immune
system’s efficiency, thereby increasing
susceptibility to disease
• Part of stress response involves release of
several hormones that can impair immune
Etiology of Psychophysiological
Figure 5-9 Multipath Mode for Psychophysiological Disorders The dimensions
interact with one another and combine in different ways to result in a specific
psychophysiological disorder.
Biological Dimension
• Stressors can dysregulate HPA axis and
sympathetic nervous system through release
of hormones (e.g., epinephrine,
norepinephrine, and cortisol)
– Prepare the body for action and decrease
vulnerability to inflammation
• Changes in brain structure and in the stressresponsive neurobiological systems due to
early environmental influences
• Genetic influences
Psychological Dimension
• Psychological and personality characteristics
can mediate effects of exposure to stressors
– Positive affect:
• Optimism, happiness, joy, and contentment
– Hardiness:
• Commitment, control, and challenge
– Personal control and perception of control
– Positive emotions: optimism
– Negative emotional states can elevate risk:
• Depression, hostility, anxiety, and cynicism
Social Dimension
• Childhood adversities linked to adult onset
headaches and hypertension
• Divorce, separation, and abrasive marital
relations all linked to negative health changes
• Having social support linked to positive health
• High quality relationships linked to reduced
physiological reactivity to stress
Sociocultural Dimension
• Exposure to racism and perceived
discrimination can heighten stress responses
and elevate blood pressure and heart rate
– Especially for those least likely to seek social
• Women more likely to be impacted by stress
due to care-giving role
– high loneliness in women was associated with a
nearly 80 percent increase in coronary heart
disease; this association was not found in men
Treatment of Psychophysiological
• Stress management techniques: related to reduction
in stress hormones and report less pain, less anxiety,
improved sleep, and a higher quality of life
• Relaxation training:
– Learn to relax muscles of the body in almost any
– It is possible that this reduces the fight-or-flight reaction
triggered by muscle tension
• Biofeedback training:
– Learn voluntary control of specific physiological function of
interest (e.g., heart rate, blood pressure)
Treatment of Psychophysiological
Disorders (cont’d.)
• Cognitive-behavioral intervention:
– Anger management and assertiveness training
• Imagine stressful situations while practicing relaxation
• Learn appropriate ways of expressing disagreements
– Social-cognitive processing programs to help to adjust and
find validation and meaning
– Improve coping skills and manage stress
– Can change physiology: Cognitive-behavioral treatment
improved immune functioning and reduced cortisol levels
among breast cancer patients whereas patients in a
control group continued to show deterioration of their
immune response

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