Chapter Five

1. Chapter Five Trauma and Stress-Related Disorders

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 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.

8. 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

9. 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)

10. 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

11. 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)

12. Psychological Dimension • Preexisting conditions such as anxiety and depression found to be risk factors for PTSD • Dysfunctional cognitions regarding oneself or environment • 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

13. 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 PTSD. • Lack of social support after trauma may be most important factor

14. 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 resiliency • > increased “toughness,” sense of control, and belief that challenges can be overcome

15. Treatment of Acute and Post-Traumatic Stress Disorders • Biological: • SSRI antidepressants appear to desensitize fear network • Psychological: • Psychotherapy focus on extinguishing fear or to correct dysfunctional cognitions • Exposure to cues associated with trauma • Identify and challenge dysfunctional cognitions • Mindfulness training

16. Psychological Factors Affecting Medical Conditions • Psychophysiological disorder: • Physical disorder that has a strong psychological basis or component • “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)

17. 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

18. 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

19. 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

20. 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

21. 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 periods. • 55 percent of individuals experiencing a cluster headache report suicidal thoughts

22. 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

23. 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

24. 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.

25. 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 stress-responsive neurobiological systems due to early environmental influences • Genetic influences

26. 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

27. 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

28. 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 support • 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

29. Treatment of Psychophysiological Disorders • 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 circumstance • 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)

30. 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