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
Disorders
• 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
trauma
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
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
emotions
– Heightened autonomic arousal or reactivity
• Hypervigilance
Diagnosis of Acute and Post-Traumatic
Stress Disorders (cont’d.)
Rape & PTSD Listen to a young woman described her symptoms of post-traumatic
stress disorder after being raped.
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
– Rape and sexual assault
– Individual characteristics:
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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
reactivity
– Exaggerated sensitivity to stimuli
– Diminished ability to inhibit fear response
Biological Dimension (cont’d.)
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•
•
•
•
Role of the amygdala
Hypothalamic-pituitary-adrenal (HPA) axis
Epinephrine and cortisol
Effect on medial prefrontal cortex
Individuals with specific biological
vulnerabilities have an increased risk of PTSD
• Epigenetic factors may be involved
The Stress reaction: Hypothalamus-Pituitary- Adrenal Axis
The HPA axis includes three specific parts of your body:
• 1) the hypothalamus (part of your forebrain);
• 2) the pituitary gland (just below the
hypothalamus);
• 3) the adrenal glands (at the top of the
kidneys).
• These three parts work together to regulate
functions such as stress response, mood,
digestion, immune system, libido, metabolism
• These three parts work together to regulate
functions such as stress response, mood,
digestion, immune system, libido, metabolism
and energy levels. Before understanding how
to fix your HPA axis, it’s important to
understand how the axis works in the first
place, so let’s dive into the specific chemicals
utilized by your HPA axis.
• 1. Corticotropin-Releasing Hormone (CRH)
• Also referred to as corticotropin-releasing
factor (CRF), this hormone is produced and
secreted by the hypothalamus in response to
stress, and it then stimulates your pituitary
gland to secrete adrenocorticotropic hormone.
The more stressed your body is (from diet,
lifestyle, work, or anything else) the more CRH
your hypothalamus will churn out.
• 2. Adrenocorticotropic Hormone (ACTH)
• ACTH is released by the pituitary gland, and travels to
your kidneys to stimulate the adrenal glands to
increase production of glucocorticoids.
• 3. Glucocorticoids
• The glucocorticoids produced in the adrenal glands
are steroids that are necessary regulating metabolic
rate, inflammation and immune response. You’ve
already learned about the most notorious
glucocorticoids: cortisol.
• 4. Cortisol
• Cortisol is best known for activating our
physical response to stress, including injury,
lack of sleep, excessive exercise, anxiety, and
depression. It prepares your body to withstand
these stressful triggers by stimulating
norepinephrine (also known as noradrenaline)
to active your fight-and-flight reaction.
•
• It’s important to understand is that your HPA axis
operates on feedback loops.
• So let’s take a look at how a feedback loop would
take place in the HPA – in this case with regards to
cortisol. At the same time that cortisol activates your
fight and flight stress response, it also sends a signal
back to your hypothalamus to inhibit CRH production
and your pituitary gland to inhibit ACTH. In this
feedback loop, cortisol is also able to reduce
norepinephrine activity, gradually calming you down
and creating a well-functioning checks-and-balances
system
Psychological Dimension
• Preexisting conditions such as anxiety and
depression found to be risk factors for PTSD
• Dysfunctional cognitions regarding oneself or
environment
• 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
• Lack of social support after trauma may be
most important factor
Sociocultural Dimension
• Ethnic differences, possibly due to pre-existing
variables
• Perceived discrimination
• Women are twice as likely as men to suffer
stress disorder
• Moderate amount of adversity can generate
resiliency
Treatment of Acute and Post-Traumatic
Stress Disorders
• Biological:
– SSRI antidepressants
• 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
Conditions
• Medical evidence suggests attitudes and
emotional states have impact on physical wellbeing
• Psychophysiological disorder:
– Physical disorder that has a strong psychological
basis or component
• Psychological or behavioral factors adversely
influence medical disorder (DSM-5)
Characteristics of Psychophysiological
Disorders
• Actual tissue damage, a disease process, or
physiological dysfunction
• Medical treatment and psychotherapy usually
required
• 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
– 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
– 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
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
– In U.S., prevalence has increased dramatically
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
functioning
Stress and the Immune System (cont’d.)
• Exposure to chronic stress appears to increase
vulnerability to infection and accelerates
progression of disease by decreasing
immunity
• Connection between stress and naturally
occurring cancer has yet to be demonstrated
Etiology of Psychophysiological
Disorders
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)
• 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
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Discrimination
Cultural expectations
Conflicts with societal standards
Women more likely to be impacted by stress
due to care-giving role
• Exposure to racism
Treatment of Psychophysiological
Disorders
• Relaxation training:
– Learn to relax muscles of the body in almost any
circumstance
• Biofeedback training:
– Learn voluntary control of specific physiological
function of interest (e.g., heart rate, blood
pressure)
Treatment of Psychophysiological
Disorders (cont’d.)
ABC Video: Biofeedback Training Discover how an at-home biofeedback machine can
help manage stress, and learn the theories of how biofeedback works.
Treatment of Psychophysiological
Disorders (cont’d.)
• Cognitive-behavioral intervention:
– Anger management and assertiveness training
– Social-cognitive processing programs to help to
adjust and find validation and meaning
– Improve coping skills and manage stress