Module 01: Principles and Perspectives 1
Stress, Burnout, and Secondary Trauma Parts 1-3
Dr. Joyce Ann N. Maglaque, MBA, DSBPP | Asynchronous
TABLE OF CONTENTS
LEARNING OBJECTIVES ....................................................................... 1
I. STRESS ............................................................................................... 1
BIOLOGICAL PERSPECTIVES OF STRESS ..................................... 1
II. COMMON STRESSORS ..................................................................... 2
PSYCHOLOGICAL & SOCIAL FACTORS THAT CONTRIBUTE TO
STRESS............................................................................................. 2
III. BURNOUT AND SECONDARY TRAUMA ........................................... 4
A. PSYCHOLOGICAL AND SOCIAL FACTORS THAT CONTRIBUTE
TO STRESS ....................................................................................... 4
B. ALLOSTATIC OVERLOAD EFFECTS OF CHRONIC LEVELS OF
HIGH STRESS ................................................................................... 4
C. SUMMARY .................................................................................... 5
QUICK REVIEW ...................................................................................... 5
QUESTIONS ...................................................................................... 5
RATIONALE ....................................................................................... 5
REFERENCES ........................................................................................ 6
SUPPLEMENTARY ............................................................................ 6
FREEDOM SPACE.................................................................................. 6
LEARNING OBJECTIVES
1.
2.
3.
To describe the features of stress, burnout, and
secondary trauma
To determine the factors contributing to stress
To understand burnout and secondary trauma and its
effects
I.
Figure 1. The Allostatic Reaction
● Primitive reflex
→ These are life-saving reflexes developed through evolution
that helped our ancestors survive
→ This “caveman mind” aids humans to respond to stress
from their environment quickly.
→ Quickly reacts to stress
→ Regarded as the “default mode of survival”
→ E.g. being wary in a quiet environment or running away
from a raging fire
STRESS
A. BIOLOGICAL PERSPECTIVES OF STRESS
●
Stress
→ Helped our human ancestors survive and evolve
→ Group of bodily changes in response to a perceived
“stressor”; normal physiological response of the body
→ Initiates body reflexes such as fight or flight
●
Cortisol
→ Stress hormone released by the adrenal glands
→ Causes bodily changes to elicit a response due to a
stressor (e.g., fight or flight response)
●
Allostasis
→ Maintenance of homeostasis by eliciting
physiological changes due to a trigger/stressor for the
organism to adapt to the perceived or increased
demands.
→ E.g. Increased heart rate, decreased blood pressure
or perspiration
→ Both stress response and allostasis are automatic
●
Emotions
→ Sensations of the mind
●
Anxiety
→ The ominous feeling that has life-saving
characteristics
→ It initiates body’s stress reaction
→ It indicative of the brain’s alarm system
→ A normal biological function that can become
pathological at times
● Getting triggered/anxious → amygdala alarms the adrenal
glands to release cortisol → body carries out physiological
changes
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Figure 2. General Adaptation Syndrome identified by Dr. Hans
Selye, our stress response system defends, then fatigues
● Natural stress goes down, but modern world stressors make it
difficult to do so
→ Reason: current stressors are not as black and white unlike
before; the end is not clear resulting in chronic stress
→ Example of modern world stressors:
◼ Pandemic
◼ Adulting
◼ Existential crisis
◼ Emotional pain (e.g. heartbreak)
● Chronic stress = repeated allostasis (especially when stressors
seemed to have no end)
→ Stress is a build up, not episodic
◼ We feel tired even right after taking a break or when we
are not doing anything because our body always
remembers the built up stress from past activities and
experiences
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■ Increased BP
● As stress persists, allostatic changes continue.
ALLOSTATIC CHANGES IN OUR BRAIN
Figure 3. The Stress Cycle
● Resetting allostatic load is necessary
→
When body is pushed to limits without resetting the
allostatic load, the baseline of stress response shifts
→ Eventually leads to a ‘point of no return’ because
intervention is already necessary
→ Distress or burnout makes someone vulnerable to
physical, emotional and cognitive changes
● Self-care is not self-indulgence
→ Sometimes, coping can lengthen allostasis
◼ Example of distractions or
“quick fixes” as coping
mechanisms
− Eating
− Smoking
− Drinking
− Shopping
→ Frequent indulgence will shift the allostatic load
Figure 4. Baseline shift, (Left) initial basal stress reaction is
steady even in mild stress; (Right) several spikes are seen even
in mild stress
● Allostatic load is changed → baseline will change → mild stress
will feel like a severe one already in the future
SYMPTOMS OF STRESS
● Physical:
→ Back and shoulder stiffness and pain, headaches,
stomach upset, heart palpitations, chest tightness, fast
breathing, sleep problems, restlessness
● Behavior:
→ Drug or alcohol use, increased smoking, social
withdrawal, relationship conflicts. Poor adherence to
treatment regimen if with medical illness, high-risk sexual
behavior
● Emotional:
→ Irritability, anxiety, sadness, anger, frustration,
impatience, urge to cry or run and hide
● Cognitive:
→ Lack of focus, difficulty making decisions, low selfesteem
● Other Symptoms:
→ More allostatic load leads to more changes in the brain
→ Whenever that stressor activity is hypersensitive, this is
what happens to the rest of the systems during stress:
■ Weaken the immune system, making it less able to
fight off infection
■ More sensitive to pain
■ Dysregulated hormones
■ Missed menstrual periods
■ Skin and pH changes
■ Sugar metabolism dysregulation
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● Hyper-sensitive, over stimulated amygdala
→ Makes you more sensitive to stress, even if it is
mild
→ Increased anxiety reactivity
→ Stress becomes pathological
→ Ex. When someone experiences sleep deprivation
for years, his brain will adapt to “the new normal”
and alter his reactivity, leading to anxiety disorders
and depression.
● Reduction in the size of your hippocampus
→ The hippocampus helps control emotions,
concentration and learning
→ First reduces in function and then in size
● Decrease/dysregulated serotonin
→ Serotonin is important for neurogenesis (growth of
brain cells)
■ Dysregulated serotonin leads to low
neurogenesis
→ Promoting brain derived natural factor (BDNF)
■ BDNF ensures brain is happy, well and is doing
normal function
→ This is associated with the pathophysiology of
clinical depression and pathological anxiety
Allostasis
● Physiological changes after stress help the organism to
adapt to increased demands and maintain homeostasis
● These are both very important functions
● Factors that may complicate this are:
→ Social factors (The way we cope)
→ Biological factors (illnesses)
● At the end of the day, our bodies will fatigue which will
lead to Allostatic overload
● Chronic stress makes you more susceptible to mental
health illnesses
Active Recall Box
1. Which of the following is responsible in controlling
emotions, concentration and learning
d. Amygdala
e. Hippocampus
f. Thalamus
g. Hypothalamus
2. T/F. Stress is only episodic and does not buildup
3. Drug or alcohol use, increased smoking, social
withdrawal, and relationship conflicts refers to what kind
of stress?
a. Physical
b. Emotional
c. Behavioral
d. Cognitive
Answers: 1B, 2B, 3C
II. COMMON STRESSORS
A. PSYCHOLOGICAL & SOCIAL FACTORS THAT
CONTRIBUTE TO STRESS
● Emotional transactions matter
→ Emotions are important for learning
→ We have been socialized to “push aside” our
emotions, but they are sometimes not so easily
controlled
● Likening ourselves to empty glasses,
→ 1. As babies, we start out EMPTY
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■ We learn about our world through mirroring (and by
the use of our mirroring neurons)
■ Mirroring proves that we are influenced by our
environment
→ 2. INFLUENCE (first “fill” of the empty glass)
■ The first source of influence is the family, which is
especially reinforced during one’s formative years
■ Influence can be introduced via implicit or explicit
environmental cues
→ 3. BELIEFS (glass is now filled)
■ Reinforcement of influence creates beliefs
→ 4. IDENTITY (hand over the glass)
■ Typically occurs during teenage years (after the
formative years) onwards
- Beliefs can be reinforced to an adolescent via
group identification (influence is external)
→ 5. JUDGE (stirring of the pot)
■ Refining of all accumulated influences
● Social factors that create our perception of the world are as
important as the biological factors
→ Can be introduced both formally (e.g. schooling) and
informally (e.g. interpersonal interactions)
→ They all get planted deep within brains and affect the
way we perceive
■ Emotion (amygdala) and memory centers occupy
neighboring regions of the brain
● Our perception of stress is affected by transactions
→ An invalidating social environment can make it very hard
to regulate emotions
■ Invalidating environment = ignores emotional
reactions, labeling them as invalid, weird, wrong, or
bad
→ In formative years, the deeper comprehension area of
the brain is still developing
■ Comprehension at this formative stage is in black and
white
■ Ex: A grade 1 student may believe what another
superior says without being aware, reinforcing
whatever beliefs are forming in place
■ A child at this age may not contextually understand
information
- Resulting in misinterpretation and unintended
reinforcement of certain beliefs
■ Some may also be subject to high levels of stress and
pressure or may simply have too few resources to
allocate on themselves
■ There may just be a poor fit between a person and
his/her social environment
→ An ineffective social environment may harm one’s ability
to regulate emotions and actions
■ If people give in when you get out of control, it will be
difficult for you to get in control
■ If people command you to change but don’t coach
you on how to do this, it will be difficult to keep on
trying to change
■ Modeling of behaviors from social interactions is also
possible
BIO SOCIAL THEORY IN ADULTHOOD
● Bio Social Theory in Adulthood
→ Stress threshold / frustration tolerance
■ Stress threshold and frustration tolerance is affected
by prior experiences, coping strategies, modeling,
mental and physical health
→ Coping strategies
→ Mental & physical health
→ How we relate with life (perception)
● Adverse childhood events + biological predisposition
→ Trauma affects the development / sensitivity of one’s
stress response
■ If one experiences trauma at an early age, their
development of stress threshold and understanding of
certain environmental factors is affected
● Stress threshold/frustration tolerance → coping strategies →
mental & physical health → how we relate with life
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● Stress affects how we relate with life (our perception of
ourselves)
→ When we deal with future stressors, our affected
prescriptions of ourselves will always come to mind
SOCIAL FACTORS: SOURCES OF STRESS
MASLOW’S HIERARCHY OF NEEDS
● Needs are not met = distress
Figure no. 5 Maslow’s Hierarchy of Needs
I. EXTERNAL SOURCES OF STRESS
● Tasks are never done
→ Demands of work, time-management problems, &
worries about the past, present & future
● Multiple complex roles to fulfill/role overload
→ Worker, child, friend, partner, etc.
→ Lots of cognitive load to deal with
● Distance from family/friends
● Lack of support & conflicts in work community
→ Issues with peers, bullying, gossip
DIGITAL FATIGUE IN COVID-19 (“ZOOM FATIGUE”)
● Tiredness worry & stress due to overusing virtual platforms
of communication
● Current average screen time: 10 hours per day
→ Previous recommended screen time: 2 hours
● Positive association between screen time & poor mental
health
→ Lack of perceived reward
■ Face-to-face interactions have greater activation in
brain regions involved with reward
→ Increased cognitive effort/cost
■ Learning new platform & navigating
■ Must be more conscious on how to show
listening/communication
→ Over-constant external self-awareness
■ Hyper-aware of your look, mannerisms, etc.
→ Sedentary pandemic rhythm
■ Movement = 40% reduced risk of fatigue
→ “Blue Light”
■ Stimulates brain = poor sleep
■ Extended exposure = strains eyes = brain in
overdrive
● Many factors contribute to fatigue, not just screen time but
also psychosocial factors
→ Work from home blurs boundaries between work and
home
→ Extended working hours (classes not finishing on time)
→ Multiple responsibilities (study and home chores)
■ Same or more productivity even with a different setup
→ Inability of businesses/society to evolve with time
■ Stuck on PAST indicators of success
■ What makes stress stressful : CULTURE of stress =
weakness, not a symptom that marks need for
improvement in well-being
■ Negative judgment towards stress instead of looking
why people get stressed
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II. INTERNAL SOURCES OF STRESS
● Difference between (idealistic) expectation vs reality
→ Setting expectations is normal, the intention motivates us
but it becomes distressing when we want it to be the
reality
→ We tend to look at the things that are out of our control
given that there are a lot of unknowns in life.
● Externalized source of validation and motivation
→ Internal Source of Motivation : personally drives you (ex :
emotions)
→
Stress or fatigue that the body goes through eventually
reaches a breaking point for the body
BURNOUT
● Different from stress (physiological reaction)
● Nearing the edge, build up of stress
● Happens with chronic stress
→ External Source of Motivation : taking cues from the
environment (ex : grades)
■ When sense of self is based on this, it will falter
→ Comparison with peers / friends / relatives
■ Normal - to look at other people as inspiration; Not
good - To be like them, rather than looking at how
they achieved that
→ Perceived lack of support or perceived pressure
■ Some of us put pressure on ourselves
■ Put pressure on someone already pressured = body
will not move - Anxiety
Figure 6. Cartoon depicting stress and burnout
Active Recall Box
1. What is at the top of Maslow’s Hierarchy of Needs?
a. Love and Belonging
b. Safety and Security
c. Self-Actualization
2. There is a positive association between screentime and
______ mental health
a. Positive
b. Poor
3. Which of the following is an External Factor of Stress?
a. Distance from family/friends
b. Lack of ability to go outside
c. Time spent on gadgets
Answers: 1C, 2B, 3A
III.
BURNOUT AND SECONDARY TRAUMA
A. PSYCHOLOGICAL & SOCIAL FACTORS THAT
CONTRIBUTE TO STRESS
● Biology is affected by our environment
● Psychology influences how we perceive our environment, and
in turn influences our biology
→ What we have learned
→ Assumptions we have learned growing up
● Biology influences our psychosocial response to stress (ex: if
you are sick)
● There’s a metaphor about our brain being a “Dam”
→ The valley is like your mind, we are able to efficiently
have enough water in that mind
→ The water is likened to our thoughts, emotions, and
actions
● With every allostatic load, that dam fatigues
→ As we grow older, and experience more stress the dam
may fatigue
→ Not optimal anymore to regulate the flow of water
● Eventually it would be an overload and everything would flood
in the mind
→ This is what we experience in burnout and secondary
trauma
B. ALLOSTATIC OVERLOAD: EFFECTS OF CHRONIC
LEVELS OF HIGH STRESS
● Allostatic Overload
→ One of the theories of pathology such as the
development of cancers, etc.
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High workload, high work
Stress, high work
Expectations
Cynicism, Indifference
Despair, Helplessness, Aversion
Diminished sense of personal accomplishment
Demoralization
Symptoms of Poor Mental Health
● Characterized by:
→ Absenteeism
■ Literally being absent
■ Intentional or habitual absence at work
→ Presenteeism
■ There physically but checked out mentally
■ Lost productivity that occurs when employees
come to work ill and perform below par
The Effects of Poor Mental Health
● Burnout has been responsible for a lot of health effects
● Majority who seek consult with doctors have burnout
related medical problems rather than those who have
chronic illnesses
Nice!
• Cost associated with poor employee mental well-being is
at least 2-3 times greater than direct health care
expenses
• In 2014, the British Economy faced a recession because
of burnout
● Burnout is now a ICD diagnosis and refers as to a
significant source of stress
→ Prequel to development of mental health problems,
specifically, depression
SECONDARY TRAUMA
● All kinds of helping professions and frontline responders
are vulnerable to secondary traumatic stress
● May not simply hear about the trauma but also first hand
witness unfolding of experiences
● HCW’s vulnerability to secondary trauma is increased
when it comes with physical fatigue
→ Ex: when we’re exhausted it’s easy to become
emotionally exhausted → HCW during pandemic
→ Brain and the body is connected
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The Perils of Physician Fatigue
When to Seek Help
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Figure 7. The Perils of Physician Fatigue
Precursors to clinical depression and other mental health
problems:
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Burnout
→ Increases suicide risk
●
Compassion fatigue
→ Secondary trauma is a precursor to more fatigue
such as compassion fatigue
→ Makes you less empathic with the patient
→ Your service suffers
●
PTSD
→ Secondary trauma is like having symptoms of
hyperarousal in PTSD
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Vicarious Trauma
→ Can develop from symptoms of hyperarousal in
PTSD
■ Cognitively, spiritually, and being checked out
of humanity
■ Disillusionment of humanity
■ Difficult to relate or trust others
C. SUMMARY
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Stress is a normal, bodily reaction to a stimuli to help
our bodies be more reactive for survival
The signal that this stress reaction works is the feeling
of anxiety
Stress response is intrinsic in our brains and we are still
using it now
There are some situations in the present day that do not
need further activation of stress response, but we
haven't really been taught how to manage this
Everytime your body reacts to a stressor, it goes
through chemical changes to deal with the stimuli in an
event we call: “allostasis”
When allostasis is chronic and we do not get to take
pauses, our bodies will overload leading to chronic
changes
Changes in the brain hamper the more reflective parts
of our brain, leading to an “amygdala hijack” making us
susceptible to
→ Burnout
→ Secondary Trauma
→ Mental health problems
These biological changes are the body’s reaction to
prolonged exposure to cortisol – it’s not PERSONAL.
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Increase substance (alcohol or drug) use
Feeling or expressing that there is no reason for living;
no sense of purpose in life
Anxiety, agitation, difficulty sleeping, or sleeping all the
time
Feeling trapped, like there’s no way out
Hopelessness
Withdrawal from friends, family and society
Rage, uncontrolled anger, seeking revenge
Acting reckless or engaging in risky activities, seemingly
without thinking
Mood changes
Threatening or talking about self-harm and/or suicide
Looking for ways to kill oneself by seeking access to
firearms, pills or other means
Talking or writing about death, dying or suicide when
these actions are unusual for the person
Patient is severely delusional or depressed over a long
time
Patient has substance abuse or dependence problem
Patient is suicidal
Patient’s social function is seriously impaired although
depressive disorder is mild
Patient develops symptoms (i.e depression) while
taking a particular medication
QUICK REVIEW
QUESTIONS
1. Cortisol is a hormone that is released by the adrenal glands.
Which of the following scenario exhibits cortisol secretion
a. A person performing yoga
b. A person competing in a boxing match
2. All are precursors to clinical depression and other mental
health problems. EXCEPT:
a. PTSD
b. Compassion Fatigue
c. Ineffective social environment
d. Vicarious Trauma
3. Taking cues from the environment is an example of an
Internal source of motivation.
a. True
b. False
4. Christian refuses to attend important group meetings and also
fails to contribute to the part assigned to him. What
characteristic of burnout is Christian exhibiting?
a. Presenteeism
b. Absenteeism
5. An ineffective social environment can cause harm to selfregulation of emotions. Which of the following is an example
of said social environment?
a. Your teacher motivates you to get better grades by
voluntarily enrolling you into a tutoring center.
b. Two parents scold their son for coming home late. They
prohibit him from going out for the next month.
Answer Key
1B, 2C, 3B, 4B, 5B
RATIONALE
1. B. A person competing in a boxing match – Cortisol is the
primary stress hormone and is secreted at “fight or flight”
situations.
2. C. Ineffective social environment – Burnout, Compassion
Fatigue, PTSD, and Vicarious trauma are precursors to
clinical depression that a physician experiences.
3. B. False – The type of externalized source of validation and
motivation that takes cues from the environment is the
External Source of Motivation.
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4. B. Absenteeism – Christian represents the characteristic of
burnout, Absenteeism, as he intentionally does not want
others to feel his presence.
5. B. Two parents scold their son for coming home late.
They prohibit him from going out for the next month. –
This is an example of an ineffective social environment
because instead of guiding their son to become better and
change his attitude, they penalize him and leave him alone.
REFERENCES
REQUIRED
I. Cee, S. (2022, August 7). Part 1 Biological Perspective of
Stress [Video]. Youtube.
[https://www.youtube.com/watch?v=6lOCMr5tC64]
II. Cee, S. (2022, August 7). Part 2 Psychological and Social
Aspects of Stress [Video]. Youtube.
[https://youtu.be/EldNN4b4gW0]
III. Cee, S. (2022, August 7). Part 3 Burnout, Secondary Trauma
and Summary [Video]. Youtube.
[https://www.youtube.com/watch?v=EldNN4b4gW0]
SUPPLEMENTARY
Kaplan, J.A and Weichenthal, L. (2018). Rosen's Emergency
Medicine:Concepts and Clinical Practice (9th ed). Elsevier, Inc.
Retrieved from
https://www.clinicalkey.com.asmphlibrary.remotexs.co/#!/content/
book/3-s2.0-B9780323354790002208?scrollTo=%23hl0000089
FREEDOM SPACE
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Stress, Burnout and Secondary Trauma
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