Stress Disorders
Chapter 6
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology
DSM-5 Update, 8e
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
Comer, Abnormal Psychology, 8e
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Stress, Coping, and the Anxiety
Response

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
Comer, Abnormal Psychology, 8e
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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-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
Comer, Abnormal Psychology, 8e
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Stress, Coping, and the Anxiety
Response

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
Comer, Abnormal Psychology, 8e
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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
Comer, Abnormal Psychology, 8e
DSM-5 Update
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The Autonomic Nervous System
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Stress and Arousal:
The Fight-or- Flight Response

The second pathway is the hypothalamicpituitary-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
Comer, Abnormal Psychology, 8e
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The Endocrine System
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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…
Comer, Abnormal Psychology, 8e
DSM-5 Update
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Pathways of Arousal and Fear
Comer, Abnormal Psychology, 8e
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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)
Comer, Abnormal Psychology, 8e
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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 the 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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The Psychological
Stress Disorders

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
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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



Around two-thirds seek treatment at some point
Ratio of women to men is 2:1



7–9% of people in the U.S. are affected sometime during their lifetime
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
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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



As many as 29% of Vietnam combat veterans suffered
acute or posttraumatic stress disorders



Called “shell shock” or “combat fatigue”
Post-Vietnam War clinicians discovered that soldiers also
experienced psychological distress after combat
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
Comer, Abnormal Psychology, 8e
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What Triggers a Psychological
Stress 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
Comer, Abnormal Psychology, 8e
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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

As many as half of those directly exposed to
terrorism or torture may develop this disorder
Comer, Abnormal Psychology, 8e
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What Triggers a Psychological
Stress Disorder?

Victimization and stress disorders

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
Comer, Abnormal Psychology, 8e
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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
Comer, Abnormal Psychology, 8e
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What Triggers a Psychological
Stress 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
Comer, Abnormal Psychology, 8e
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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 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
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Why Do People Develop a
Psychological Stress Disorder?

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
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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
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Why Do People Develop a
Psychological Stress 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
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Why Do People Develop a
Psychological Stress 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
Comer, Abnormal Psychology, 8e
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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

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


Behavioral exposure techniques




Reduce specific symptoms, increase overall adjustment
Use flooding and relaxation training
Use eye movement desensitization and reprocessing (EMDR)
Insight therapy


Antianxiety and antidepressant medications are most common
Bring out deep-seated feelings, create acceptance, lessen guilt
Often use couple, family, or group therapy formats; rap
groups
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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
Comer, Abnormal Psychology, 8e
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How Do Clinicians Treat the
Psychological Stress 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
Comer, Abnormal Psychology, 8e
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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
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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-5 labels them as psychological factors affecting
medical condition
Comer, Abnormal Psychology, 8e
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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 somatic
symptom disorders, which will be discussed in
Chapter 7
Comer, Abnormal Psychology, 8e
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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 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
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Traditional Psychophysiological
Disorders

Asthma

A narrowing of the body’s airways that makes breathing difficult

Affects up to 25 million people in the U.S. each year


Causal psychosocial factors:


Most victims are children at the time of first attack
Environmental pressures or anxiety
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 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
Comer, Abnormal Psychology, 8e
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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 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
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Traditional Psychophysiological
Disorders

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
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Traditional Psychophysiological
Disorders

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


Causal psychosocial factors:


It is the leading cause of death in men older than 35 years and women
older than 40
Job stress, high levels of anger or depression
Causal physiological factors:

High level of cholesterol, obesity, hypertension, the effects of smoking,
lack of exercise
Comer, Abnormal Psychology, 8e
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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
Comer, Abnormal Psychology, 8e
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Traditional Psychophysiological
Disorders

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
Comer, Abnormal Psychology, 8e
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Traditional Psychophysiological
Disorders

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
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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
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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, 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
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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
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Psychoneuroimmunology

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 Tcells, and B-cells
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Psychoneuroimmunology

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
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Psychoneuroimmunology

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
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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 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
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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, support groups, and
therapies designed to increase awareness and
expression of emotion
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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 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
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Psychological Treatments for
Physical Disorders

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
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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 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
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Psychological Treatments for
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
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)
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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 stress inoculation training, in
which patients are taught to rid themselves of
negative self-statements and to replace these with
coping self-statements
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Psychological Treatments for
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
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
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Psychological Treatments for
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
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
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