RECENT UNDERSTANDING ABOUT STRESS

SATYAKAM MOHAPATRA JUNIOR RESIDENT –II DEPARTMENT OF PSYCHIATRY

INTRODUCTION

Stress is a common problem that affects almost all of us at some point in our lives. Learning to identify when we are under stress, what is stressing us and different ways of coping with stress can greatly improve both our mental and physical well being.

Stress is one of the central concepts in Psychiatry.

Stress has been invoked as a cause of major psychopathology, a precipitator or trigger of psychiatric illness and a contributor to considerable mental anguish.

ORIGIN AND TERMINOLOGY Stress is a word derived from the Latin

word stringere, meaning to draw tight . The term stress was first employed in a

biological context by Hans Selye in the 1930s.

He explained stress as an inappropriate physiological response to any demand.

In his usage stress refers to a condition and stressor to the stimulus causing it.

It covers a wide range of phenomena, from mild irritation to drastic dysfunction that may cause severe health breakdown.

DEFINITION A state of affair involving demand on

physical or mental energy-Oxford Dictionary.

A physical or psychological stimulus that can produce mental tension or physiological reactions that may lead to illness.

Now, the most commonly accepted definition of stress (mainly attributed to Richard S Lazarus) is that stress is a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.

DIFFERENT MODELS OF STRESS

General adaptation model: By Selye Alarm is the first stage. When the stressor is identified the

body's stress response is a state of alarm. Adrenaline will be produced in order to bring about the fight-or-flight response. There is also some activation of the HPA axis, producing cortisol.

Resistance is the second stage. If the stressor persists, it becomes necessary to attempt some means of coping with the stress. Although the body begins to try to adapt to the strains or demands of the environment, the body cannot keep this up indefinitely, so its resources are gradually depleted.

Exhaustion is the third. At this point all of the body's resources are eventually depleted and the body is unable to maintain normal function. The initial autonomic nervous system symptoms may reappear. If stage three is extended, long term damage may result as the body, and the immune system is exhausted and function is impaired resulting in decompensation.

DIFFERENT MODELS OF STRESS(CONDT.)

COGNITIVE APPRAISAL MODEL: LAZARUS Lazarus  argued that in order for a psychosocial

situation to be stressful, it must be appraised as such. He argued that cognitive processes of appraisal are central in determining whether a situation is potentially threatening or is benign.

Both person and environmental factors influence this primary appraisal, which then triggers the selection of coping processes. Problem-focused coping is directed at managing the problem, while emotion-focused coping processes are directed at managing the negative emotions. Secondary appraisal refers to the evaluation of the resources available to cope with the problem and may alter the primary appraisal.

RECENT VIEWS

There are renewed laboratory research into the neuroendocrine, molecular and immunological bases of stress.

By the 1990s, "stress" had become an integral part of modern scientific understanding in all areas of physiology and human functioning.

The confusion between STRESS as ‘cause’ versus ‘trigger’ of illness has hindered progress.

Views that a stressor caused an illness is difficult to demonstrate in most human studies that impose a short-term stressor and examine the resultant physiological changes.

There is, however, an alternative hypothesis that provides very strong evidence for a link between stressors and illness. This argument emphasizes that stressors trigger illness in individuals whose underlying illness is latent or subclinical.

CAUSES OF STRESS

Common external causes of stress  Major life changes Work Relationship difficulties Financial problems Children and family Personal Health and Safety

Common internal causes of stress Inability to accept uncertainty Pessimism Negative self-talk Unrealistic expectations Perfectionism Lack of assertiveness

TYPES OF STRESS(1)EUSTRESS Also called "good stress" or "positive stress". They are able to exert a healthy

effect on us. It gives one a feeling of fulfilment or contentment and also makes one excited about life. Unfortunately, it is a type of stress that only occurs for a short period of time. Eustress is also often called the curative stress because it gives a person the ability to generate the best performance or maximum output.

 

(2)DISTRESS 

Distress is a “negative stress”. It is a stress disorder that is caused by adverse events and it often influences a person’s ability to cope. Distress can be classified further as acute stress or chronic stress..

(a) Acute Stress Acute stress is the type of stress that comes immediately with a change of routine.

It is an intense type of stress, but it passes quickly. Acute stress is the body's way of getting a person to stand up and take inventory of what is going on, to make sure that everything is OK. 

(b)Chronic Stress Chronic stress will occur if there is a constant change of routine for week after

week. Chronic stress affects the body for a long period of time. This is the type of stress experienced by someone who constantly faces moves or job changes. 

   

WARNING SIGNS AND SYMPTOMS OF STRESS 

SIDE EFFECTS OF STRESS

DEPRESSION : one of the side effects of stress, caused actually by the excess of stress

WEIGHT GAIN :The calories intake increases significantly during stressful moments. When we are stressed, we try to compensate the problems we are facing by eating more than we need. 

WEAK IMMUNE SYSTEM: Stress has a big role in weakening our immune System.

INSOMNIA

PHYSIOLOGICAL RESPONSES TO STRESS

(A)NEUROTRANSMITTER RESPONSE TO STRESS STRESS activates Noradrenergic system Serotonergic system Dopaminergic system Amino acid and peptinergic neurotransmitter system

(B)ENDOCRINE RESPONSE TO STRESS STRESS activates HPA AXIS CRH acts at the anterior pituitary to trigger release of

adrenocorticotropic hormone (ACTH)which acts at the adrenal cortex to stimulate the synthesis and release of glucocorticoids.

Glucocorticoids themselves have myriad effects within the body, but their actions can be summarized in the very short term as promoting energy use, increasing cardiovascular activity (in the service of the flight-or-fight response), and inhibiting functions such as growth, reproduction, and immunity.

PSYCHONEUROIMMUNOLOGY

Recent research has shown that immune system is a key player in stress physiology.

Psychoneuroimmunology is the study of the bidirectional interactions between brain, behaviour, and the immune system.

BIOLOGICAL CONNECTIONS BETWEEN THE CENTRAL NERVOUS SYSTEM AND IMMUNE SYSTEM:

Autonomic Nervous System Sympathetic nervous system activation can

reduce cellular immune response activation by suppressing the activity of diverse populations of immune cells, including natural killer (NK) cells and T lymphocytes.

Sympathetic nervous system activation enhance the humoral immune response by enhancing , the production of antibodies by B cells and the ability of macrophages to release cytokines .

BIOLOGICAL CONNECTIONS BETWEEN THE CENTRAL NERVOUS SYSTEM AND IMMUNE SYSTEM (CONTD.)NEUROENDOCRINE AXIS: The other way in which the brain can communicate

with the immune system is via the HPA system. Cortisol exerts influence on the actions of various

cells involved in an immune response by suppressing the cellular immune response.

Cortisol can also prompt some immune cells to move out from circulating blood into lymphoid organs or peripheral tissues, such as the skin.

Immune cells can produce neuroendocrine peptides (e.g., endorphin, ACTH), which suggests that the brain, neuroendocrine axis, and immune system use the same molecular signals to communicate with each other.

BEHAVIOURAL AND PSYCHOLOGICAL INFLUENCES ON IMMUNITYBehaviours and emotions are capable of altering immunity.

A) Acute Stress and Immunity in Humans: Acute stressors produce profound and rapid changes in the immune

system due to the redistribution of immunoregulatory cells from lymphoid organs, such as the spleen, into the vascular space.

Such acute stressor elicit decreases in cellular immune responses and increases in the markers of inflammation (IL-6) which are thought to be mediated by release of sympathetic neurotransmitters and beta- adrenergic receptor activation.

Individuals who are aged or are undergoing chronic stress show exaggerated immune responses to acute stress and are likely to take longer to recover from the exposure to stress, which may put them at increased risk of infectious disease.

 

BEHAVIORAL AND PSYCHOLOGICAL INFLUENCES ON IMMUNITY(CONTD.)(B) CHRONIC STRESS, DEPRESSION, AND IMMUNITY: chronic or naturalistic stressors are associated with reliable

decreases of cellular and innate immunity.

A similar pattern of immune alterations is reported in patients with major depression. This latter observation is not surprising, because individuals undergoing stress often report negative emotions and depressive symptoms, and the presence of such affective symptoms is associated with greater immune alterations.

Heterogeneity in the effects of stress and depression on immunity can be accounted for by a number of factors, such as age, gender, ethnicity, health behaviours (e.g., smoking, alcohol consumption), and coping or personality

BEHAVIOURAL AND PSYCHOLOGICAL INFLUENCES ON IMMUNITY(CONTD.) (C)SLEEP, CYTOKINES, AND IMMUNITY: Disordered sleep and loss of sleep are thought to

adversely affect resistance to infectious disease and alter inflammatory disease progression.

Sleep deprivation suppresses NK activity and IL-2 production and induces decrease in specific antibody production to infectious challenges.

In contrast measures of innate immunity and proinflammatory cytokine expression including cellular and genomic markers of inflammation are enhanced following sleep loss.

BEHAVIORAL AND PSYCHOLOGICAL INFLUENCES ON IMMUNITY(CONTD.)(D)Cytokine Influences on the Central Nervous

System and Behaviour: The immune system acts, in many ways, like a

sensory organ, conveying information to the brain that ultimately regulates neuroendocrine and autonomic outflow and the course of the immune response.

IL-1 and, possibly, other inflammatory cytokines communicate with the brain by stimulating peripheral, afferent nerves, such as the vagus.

Human studies have begun to reveal links between peripheral cytokines and behavioural changes.

physiological activation of the immune system with the release of proinflammatory cytokines leads to increases of depressed mood and anxiety and decreases in verbal and nonverbal memory functions.

STRESS AND PSYCHIATRIC ILLNESS

BIOPSYCHOSOCIAL MODEL- proposed by MEYER:

This orientation held that an individual's response to stress is modified by a number of intrinsic and extrinsic factors.

The model incorporated stressful life events as initiating or exacerbating factors and a variety of support networks as potentially modifying factors for the occurrence of mental illness.

For the most part, this multideterminate model of mental illness dominates modern psychiatric thinking.

STRESS AND PSYCHIATRIC ILLNESS(CONTD.)

DSM-IV-TR does not emphasize this Biopsychosocial model of the nature and genesis of psychiatric disorders.

DSM-IV-TR continues to struggle with the best way to classify and incorporate stressful life events into diagnosis.

In the face of this ongoing turbulence, however, much research has been conducted that serves to sharpen thinking about the relationship between stress and psychiatric illness.

STRESS AND PSYCHIATRIC ILLNESS(CONTD.)(A)Stress and Psychotic Disorders There is little reason to suspect that

stress plays a role in the pathogenesis of schizophrenia.

There is, however, ample evidence

that adverse life events and stressful social and familial milieu play an important role in determining the course of illness in general and episodes of relapse in particular.

STRESS AND PSYCHIATRIC ILLNESS(CONTD.) 

(B)Affective Disorders Recent advances in psychiatric epidemiology suggest that a simple

relationship between stressful life events and affective illness may not exist.

Most studies of stress and depression have a number of methodological shortcomings.

There is a tendency for depressed patients to selectively recall negative life events and associate these events with their current difficulties.

Although these effects can be minimized by ascertaining life events when patients are not in episodes of depression, there is additional evidence that depressed patients really do experience more negative life events than nondepressed patients.

Genes and stressful life events operate in consert to elicit depressive episodes.

 

STRESS AND PSYCHIATRIC ILLNESS(CONTD.)

(C)Anxiety Disorders (Other Than PTSD)

In comparison to the voluminous literature on stress and depression, there is less empirical research on the relationship between stress and anxiety disorders.

Nonetheless, it is apparent that panic disorder frequently has its onset or recrudescence in the context of stressful life events.

In terms of the effects of early life stressors, there is growing evidence that certain adverse early life events, such as sexual or physical abuse, may be risk factors for the later development of panic disorder, particularly in women.

STRESS AND PSYCHIATRIC ILLNESS(CONTD.)

(D)POSTTRAUMATIC STRESS DISORDER 

The occurrence of PTSD after severe psychological trauma provides the most persuasive evidence in favour of certain kinds of stress causing psychiatric illness.

It is important to note, however, that the neuroendocrine profile of patients with PTSD is not what one might expect to see after chronic stress, nor in major depression.

Whereas the latter two conditions would be expected to be associated with hypercortisolism, most (but not all) studies of patients with PTSD have demonstrated rather subtle hypocortisolism.

Although the neurobiological implications of this finding remain to be elucidated, the message for stress researchers is clear: There is no longer hope that a uniform neuroendocrine stress response can explain the heterogeneity of psychiatric disorders encountered in the wake of psychological stress.

TREATMENTPHARMACOLOGICAL APPROACHES TO STRESS

MANAGEMENT

As discussed above, stressors worsen many different psychiatric conditions.

When major psychiatric conditions, such as depression or psychosis, are present, the most appropriate medications are those for the Axis I diagnosis.

However, more typically, the picture is primarily one of anxiety or insomnia, perhaps not of as great a magnitude as that found typically in anxiety disorder, but still very distressing to the patient. In such settings, pharmacological therapy with anxiolytic medications or short-term hypnotics can be extremely helpful.

This intervention, in association with supportive psychotherapy, is extremely effective in crisis intervention

COGNITIVE-BEHAVIORAL APPROACHES TO STRESS MANAGEMENT

Cognitive-behavioural therapy methods are increasingly used to help individuals better manage their responses to stressful life events.

These treatment methods are based

on the notion that cognitive appraisals about stressful events and the coping efforts related to these appraisals play a major role in determining stress responding

COGNITIVE-BEHAVIORAL APPROACHES TO STRESS MANAGEMENT(CONTD.)Cognitive-behavioural therapy approaches to stress

management have three major aims:

(1)to help individuals become more aware of their own cognitive appraisals of stressful events.

(2) to educate individuals about how their appraisals of stressful events can influence negative emotional and behavioural responses and to help them reconceptualise their abilities to alter these appraisals

(3) to teach individuals how to develop and maintain the use of a variety of effective cognitive and behavioural stress management skills.

 

STRESS-MANAGEMENT TRAINING

When cognitive-behavioural therapy is used for stress management, training is provided in a wide range of stress-management skills.

Five skills that form the core of almost all stress-management programs: self-observation, cognitive restructuring, relaxation training, time management, and problem solving.

SELF-OBSERVATION

One of the most effective ways to help individuals become more aware of how they respond to problem situations is to have them keep a daily record of their behaviour.

A daily diary format is often used, with patients being asked to keep a record of how they responded to challenging or stressful events that occurred each day.

Individuals who keep daily diary records of stress-related behaviours often make changes in their own behaviour, even before other stress-management methods are introduced

COGNITIVE RESTRUCTURING

A hallmark of cognitive-behavioural therapy is its insistence that cognition plays a central role in the stress and coping process.

In cognitive-behavioural therapy, cognitive appraisals about stressful events are considered to be the key factor in determining stress-related responding.

Given this emphasis on cognition, it is not surprising that a major thrust of cognitive-behavioural therapy approaches to stress management is on helping participants become aware of and change their maladaptive thoughts, beliefs, and expectations.

 RELAXATION TRAINING

Relaxation skills can be very helpful in managing stress.

DIFFERENT RELAXATION TECHNIQUES: DEEP BREATHING EXERCISE. PROGRESSIVE MUSCLE RELAXATION

(PMR) TECHNIQUE involves the progressive or sequential, tensing and then relaxing of specific muscle groups. When individuals learn to relax, their overall muscle tension is reduced, as is their overall level of autonomic arousal.

MUSIC THERAPY DANCE THERAPY

RELAXATION TRAINING(CONTD.) YOGA is a useful stress reducing

exercise; The harmony with which the body moves, in sync with the breath has therapeutic and calming effects.

RELAXATION TRAINING(CONTD.)

PHYSICAL EXERCISE

RELAXATION TRAINING(CONTD.) AROMATHERAPY Essential oils work

because of their small molecular size which allows them to penetrate bodily tissues easily. They also create a pleasant smell that emotionally lifts the user. The neurochemical makeup of the brain is altered through the olfactory sense.

RELAXATION TRAINING(CONTD.)

Individuals who are able to relax are also more likely to be able to think more rationally and restructure negative cognitions when faced with stressful events.

Finally, relaxation skills may be helpful in reducing maladaptive behaviour patterns.

TIME MANAGEMENT

Time-management methods are designed to help individuals restore a sense of balance to their lives.

The first step in training in time-management skills is designed to enhance awareness of current patterns of time use.

The second step in time management

is designed to help individuals set their priorities.

PROBLEM SOLVING Problem solving is a skill that is introduced in the later

stages of stress-management training.

As trainees attempt to apply what they have learned about stress management, they may find that some problem situations are particularly challenging and difficult to manage using only one or two stress-management techniques.

Steps of problem solving:(a)problem identification.(b)generating alternatives.(c)evaluating the alternatives and selecting the best

solution.(d)implementing the solution. 

CONCLUSION Recent advances in the understanding of the many complex

connections between the human mind and body have produced a variety of mainstream approaches to stress-related illness. 

Complete prevention of stress is neither possible nor desirable, because stress is an important stimulus of human growth and creativity, as well as an inevitable part of life.

In addition, specific strategies for stress prevention vary widely from person to person, depending on the nature and number of the stressors in an individual's life, and the amount of control he or she has over these factors.

In general, however, a combination of attitudinal and behavioural changes works well for most patients. The best form of prevention appears to be parental modeling of healthy attitudes and behaviours within the family.

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