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Another individual may avoid crowded places in fear of an assault or to circumvent strong emotional memories about an earlier assault that took place in a crowded area. Avoidance can come in many forms. A key ingredient in trauma recovery is learning to manage triggers, memories, and emotions without avoidance—in essence, becoming desensitized to traumatic memories and associated symptoms. A key ingredient in the early stage of TIC is to establish, confirm, or reestablish a support system, including culturally appropriate activities, as soon as possible. Social supports and relationships can be protective factors against traumatic stress.
However, trauma typically affects relationships significantly, regardless of whether the trauma is interpersonal or is of some other type. In natural disasters, social and community supports can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.
Survivors may readily rely on family members, friends, or other social supports—or they may avoid support, either because they believe that no one will be understanding or trustworthy or because they perceive their own needs as a burden to others. Survivors who have strong emotional or physical reactions, including outbursts during nightmares, may pull away further in fear of being unable to predict their own reactions or to protect their own safety and that of others. Often, trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use their support systems and resources adequately.
Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer supports and counseling. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including behavioral health service providers.
It is exceptionally difficult to override the feeling that someone is going to hurt you, take advantage of you, or, minimally, disappoint you. Each age group is vulnerable in unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, e. School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worse school performance.
Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, and sleep and eating disturbances Hamblen, Adults may display sleep problems, increased agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs. These chemical responses can then negatively affect critical neural growth during specific sensitive periods of childhood development and can even lead to cell death.
Heim, Mletzko et al. The researchers concluded that the association of study scores with these outcomes can serve as a theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for the resulting impairment seen in multiple brain structures and functions.
Materials are available for counselors, educators, parents, and caregivers. Many trauma survivors experience symptoms that, although they do not meet the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally e. Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, oran other mental illness.
Likewise, clients who have experienced trauma may link some of their symptoms to their trauma and diagnose themselves as having PTSD, even though they do not meet all criteria for that disorder. A phenomenon unique to war, and one that counselors need to understand well, is combat stress reaction CSR. CSR is an acute anxiety reaction occurring during or shortly after participating in military conflicts and wars as well as other operations within the war zone, known as the theater.
It is similar to acute stress reaction, except that the precipitating event or events affect military personnel and civilians exposed to the events in an armed conflict situation. Frank is a year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized for 3. For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the situation.
He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a year. They leave Frank feeling even more isolated from others and alienated from those who love him. He reports that he cannot watch certain television shows that depict violent anger; he has to stop watching when such scenes occur.
He sometimes daydreams about getting revenge on the people who assaulted him. Other than these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support group regularly, has acquired friends who are also abstinent, and has reconciled with his family of origin. In recounting the traumatic event in counseling, Frank acknowledges that he thought he was going to die as a result of the fight, especially when he realized he had been stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear.
After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions to address his subthreshold trauma symptoms. With a combination of cognitive— behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms when he recalled the assault. He started having more control of his anger when memories of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships. CSR can vary from manageable and mild to debilitating and severe.
Common, less severe symptoms of CSR include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. Common causes of CSR are events such as a direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive device, but combat stressors encompass a diverse array of traumatizing events, such as seeing grave injuries, watching others die, and making on-the-spot decisions in ambiguous conditions e. Such circumstances can lead to combat stress.
Military personnel also serve in noncombat positions e. Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman explains how a prolonged combat-ready stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. This complicates the transition to civilian life. The following are just a few of the many resources and reports focused on combat-related psychological and stress issues:. Part of the definition of trauma is that the individual responds with intense fear, helplessness, or horror.
Beyond that, in both the short term and the long term, trauma comprises a range of reactions from normal e. Most people who experience trauma have no long-lasting disabling effects; their coping skills and the support of those around them are sufficient to help them overcome their difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though, the symptoms of trauma are more severe and last longer.
The most common diagnoses associated with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental disorders—particularly substance use disorders, mood disorders, various anxiety disorders, and personality disorders. Trauma also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter.
ASD represents a normal response to stress. Symptoms develop within 4 weeks of the trauma and can cause significant levels of distress. Most individuals who have acute stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term exposure to chronic traumatic stress.
Diagnostic criteria are presented in Exhibit 1. Exposure to actual or threatened death, serious injury, or sexual violation in one or more of the following ways: Directly experiencing the traumatic event s. The primary presentation of an individual with an acute stress reaction is often that of someone who appears overwhelmed by the traumatic experience. The need to talk about the experience can lead the client to seem self-centered and unconcerned about the needs of others. He or she may need to describe, in repetitive detail, what happened, or may seem obsessed with trying to understand what happened in an effort to make sense of the experience.
The client is often hypervigilant and avoids circumstances that are reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD, and the individual may repetitively question others to fill in details. The next case illustration demonstrates the time-limited nature of ASD. The primary difference is the amount of time the symptoms have been present.
The diagnosis of ASD can change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks. ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These symptoms can occur at the time of the trauma or in the following month. However, many people with PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking treatment for or receiving a diagnosis of PTSD. Two months ago, Sheila, a year-old married woman, experienced a tornado in her home town.
In the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She regarded it as a mark of personal maturity; it improved her relationship with her husband, and their business had flourished as a result of her abstinence.
During the tornado, an employee reported that Sheila had become very agitated and had grabbed her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside.
- Sequence of Trauma Reactions.
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She stated that nothing felt real and it was all like a dream. Following the tornado, Sheila experienced emotional numbness and detachment, even from people close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that made no real sense to her. She was unwilling to return to the building where she had been during the storm, despite having maintained a business at this location for 15 years.
In addition, she began smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members. As a result of her earlier contact with a treatment program, Sheila returned to that program and engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand the link between the trauma and her relapse, regained support from her spouse, and again felt in control of her life.
Intervention for ASD also helps the individual develop coping skills that can effectively prevent the recurrence of ASD after later traumas. Although predictive science for ASD and PTSD will continue to evolve, both disorders are associated with increased substance use and mental disorders and increased risk of relapse; therefore, effective screening for ASD and PTSD is important for all clients with these disorders. Individuals in early recovery—lacking well-practiced coping skills, lacking environmental supports, and already operating at high levels of anxiety—are particularly susceptible to ASD.
Events that would not normally be disabling can produce symptoms of intense helplessness and fear, numbing and depersonalization, disabling anxiety, and an inability to handle normal life events. The trauma-related disorder that receives the greatest attention is PTSD; it is the most commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to remember that PTSD symptoms are represented in a number of other mental illnesses, including major depressive disorder MDD , anxiety disorders, and psychotic disorders Foa et al.
Individuals must have been exposed to actual or threatened death, serious injury, or sexual violence, and the symptoms must produce significant distress and impairment for more than 4 weeks Exhibit 1. The following criteria apply to adults, adolescents, and children older than 6 years. Michael is a year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren.
Both of his parents were dependent on alcohol. He describes his childhood as isolated. His father physically and psychologically abused him e. By age 10, his parents regarded him as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol and was frequently truant from school. At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel.
In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty.
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His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that he lacked purpose in his life.
In the s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mids, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that these symptoms seemed to relate to his childhood abuse and his experiences in Vietnam.
In treatment, he expressed relief that he now understood the connection between his symptoms and his history. People with PTSD often present varying clinical profiles and histories. They can experience symptoms that are activated by environmental triggers and then recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms particularly depression and anxiety are misdiagnosed and go untreated for their primary condition.
For many people, the trauma experience and diagnosis are obscured by co-occurring substance use disorder symptoms. Although symptoms of PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or even years before symptoms appear for some people. Some people may have minimal symptoms after a trauma but then experience a crisis later in life.
Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed response triggered by something that happens to them as adults. For example, seeing a movie about child abuse can trigger symptoms related to the trauma. Other triggers include returning to the scene of the trauma, being reminded of it in some other way, or noting the anniversary of an event. Likewise, combat veterans and survivors of community-wide disasters may seem to be coping well shortly after a trauma, only to have symptoms emerge later when their life situations seem to have stabilized.
Some clients in substance abuse recovery only begin to experience trauma symptoms when they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating behaviors, trauma memories and symptoms can emerge. In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These include somatic and psychological symptoms and beliefs about the origins and nature of traumatic events.
Moreover, religious and spiritual beliefs can affect how a survivor experiences a traumatic event and whether he or she reports the distress. For example, in societies where attitudes toward karma and the glorification of war veterans are predominant, it is harder for war veterans to come forward and disclose that they are emotionally overwhelmed or struggling. It would be perceived as inappropriate and possibly demoralizing to focus on the emotional distress that he or she still bears.
For a review of cultural competence in treating trauma, refer to Brown, Methods for measuring PTSD are also culturally specific. As part of a project begun in , the World Health Organization WHO and the National Institutes of Health NIH embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified apparently universal factors of psychological disorders and developed specific instruments to measure them. The patient must have been exposed to a stressful event or situation either brief or long-lasting of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.
When individuals experience multiple traumas, prolonged and repeated trauma during childhood, or repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma have unique characteristics Herman, Overall, literature reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and more impairing clinical presentation of complex trauma.
Even though current research in the study of traumatology is prolific, it is still in the early stages of development. The symptoms of PTSD and other mental disorders overlap considerably; these disorders often coexist and in clude mood, anxiety, substance use, and personality disorders. The following sections present a brief overview of some mental disorders that can result from or be worsened by traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly influence mental and physical health in clients who already have behavioral health disorders.
Co-occurring disorders are common among individuals who have a history of trauma and are seeking help. Only people specifically trained and licensed in mental health assessment should make diagnoses; trauma can result in complicated cases, and many symptoms can be present, whether or not they meet full diagnostic criteria for a specific disorder.
Only a trained assessor can distinguish accurately among various symptoms and in the presence of co-occurring disorders. However, behavioral health professionals without specific assessment training can still serve an important role in screening for possible mental disorders using established screening tools CSAT, c ; see also Chapter 4 of this TIP.
In agencies and clinics, it is critical to provide such screenings systematically—for each client—as PTSD and other co-occurring disorders are typically under diagnosed or misdiagnosed. A well-established causal relationship exists between stressful events and depression, and a prior history of MDD is predictive of PTSD after exposure to major trauma Foa et al.
For others, additional mental health supports may be necessary. Co-occurrence is also linked with greater impairment and more severe symptoms of both disorders, and the person is less likely to experience remission of symptoms within 6 months. Generalized anxiety, obsessive—compulsive, and other anxiety disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is also likely that preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD.
Preexisting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as personality and somatization disorders, are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment. The relationship between PTSD and other disorders is complex. More research is now examining the multiple potential pathways among PTSD and other disorders and how various sequences affect clinical presentation. There is clearly a correlation between trauma including individual, group, or mass trauma and substance use as well as the presence of posttraumatic stress and other trauma-related disorders and substance use disorders.
Alcohol and drug use can be, for some, an effort to manage traumatic stress and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of developing PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use disorders have to be particularly aware of the possibility of the other disorder arising.
Knowing whether substance abuse or PTSD came first informs whether a causal relationship exists, but learning this requires thorough assessment of clients and access to complete data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset of substance use not abuse , so determining causal relationships can be difficult.
The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: Each disorder can mask or hide the symptoms of the other, and both need to be assessed and treated if the individual is to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. People in treatment for PTSD tend to abuse a wide range of substances, more Maria is a year-old woman diagnosed with PTSD and alcohol dependence.
From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. When she came in for treatment, she described her emotions and thoughts as out of control. Maria often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself from them do not always work. She often drinks in response to these thoughts or his presence, as she has found that alcohol can dull her level of distress.
Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert and cannot go back to sleep. Maria tries to avoid family gatherings but often feels pressured to go. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She also describes feeling physically ill and shaky.
At these times, she often isolates herself, stays in her apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed his affection, but more recently, she has begun to feel anxious and unsettled around him.
Maria tries to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings. Unfortunately, any initially helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. People with alcohol dependence report multiple types of sleep disturbances over time, and it is not unusual for clients to report that they cannot fall asleep without first having a drink.
Both REM and slow wave sleep are reduced in clients with alcohol dependence, which is also associated with an increase in the amount of time it takes before sleep occurs, decreased overall sleep time, more nightmares, and reduced sleep efficiency. Confounding changes in the biology of sleep that occur in clients with PTSD and substance use disorders often add to the problems of recovery. Sleep can fail to return to normal for months or even years after abstinence, and the persistence of sleep disruptions appears related to the likelihood of relapse.
This cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as a whole, can take place for clients with PTSD as well as for clients with substance use disorders. There are effective cognitive—behavioral therapies and nonaddictive pharmacological interventions for sleep difficulties. Turn recording back on. National Center for Biotechnology Information , U. Chapter 3 Understanding the Impact of Trauma. Numbing Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories.
Sadhanna Sadhanna is a year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. Physical Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but some people who have experienced traumatic stress may present initially with physical symptoms. Somatization Somatization indicates a focus on bodily symptoms or dysfunctions to express emotional distress. Support your clients and provide a message of hope—that they are not alone, they are not at fault, and recovery is possible and anticipated. Biology of trauma Trauma biology is an area of burgeoning research, with the promise of more complex and explanatory findings yet to come.
Changes in limbic system functioning. Hypothalamic—pituitary—adrenal axis activity changes with variable cortisol levels. Hyperarousal and sleep disturbances A common symptom that arises from traumatic experiences is hyperarousal also called hypervigilance. Kimi Kimi is a year-old Native American woman who was group raped at the age of 16 on her walk home from a suburban high school. Cognitive Traumatic experiences can affect and alter cognitions. Cognitions and Trauma The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.
Feeling different An integral part of experiencing trauma is feeling different from others, whether or not the trauma was an individual or group experience. Triggers and flashbacks Triggers A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience.
Flashbacks A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. Helping Clients Manage Flashbacks and Triggers If a client is triggered in a session or during some aspect of treatment, help the client focus on what is happening in the here and now; that is, use grounding techniques.
Behavioral Traumatic stress reactions vary widely; often, people engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects of the traumatic experience. Reenactments A hallmark symptom of trauma is reexperiencing the trauma in various ways. Self-harm and self-destructive behaviors Self-harm is any type of intentionally self-inflicted harm, regardless of the severity of injury or whether suicide is intended. Resilient Responses to Trauma Many people find healthy ways to cope with, respond to, and heal from trauma. Such resilient responses include: Increased bonding with family and community.
Marco Marco, a year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety symptoms. Working With Clients Who Are Self-Injurious Counselors who are unqualified or uncomfortable working with clients who demonstrate self-harming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such clients to other counselors.
Trauma-Informed Care in Behavioral Health Services.
To respond appropriately to a client who engages in self-harm, counselors should: Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment. Teach the client coping skills that improve his or her management of emotions without self-harm. Help the client obtain the level of care needed to manage genuine risk of suicide or severe self-injury. This might include hospitalization, more intensive programming e. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses.
Document such consultations and the decisions made as a result of them thoroughly and frequently. Help the client identify how substance use affects self-harm. In some cases, it can increase the behavior e. In other cases, it can decrease the behavior e. In either case, continue to help the client understand how abstinence from substances is necessary so that he or she can learn more adaptive coping. Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next.
Allow the client to define what safety means to him or her. Consumption of substances Substance use often is initiated or increased after trauma. Avoidance Avoidance often coincides with anxiety and the promotion of anxiety symptoms. We conclude with a consideration of treatment implications. Childhood abuse is also associated with negative views toward learning and poor school performance Lowenthal Children of divorced parents have more reported antisocial behavior, anxiety, and depression than their peers Short Adult offspring of divorced parents report more current life stress, family conflict, and lack of friend support compared with those whose parents did not divorce Short Studies have also addressed the psychological consequences of exposure to war and terrorism during childhood Shaw A majority of children exposed to war experience significant psychological morbidity, including both post-traumatic stress disorder PTSD and depressive symptoms.
For example, Nader et al. Some effects are long lasting: Exposure to intense and chronic stressors during the developmental years has long-lasting neurobiological effects and puts one at increased risk for anxiety and mood disorders, aggressive dyscontrol problems, hypo-immune dysfunction, medical morbidity, structural changes in the CNS, and early death Shaw It is well known that first depressive episodes often develop following the occurrence of a major negative life event Paykel Furthermore, there is evidence that stressful life events are causal for the onset of depression see Hammen , Kendler et al.
A study of 13, patients in Denmark, with first psychiatric admissions diagnosed with depression, found more recent divorces, unemployment, and suicides by relatives compared with age- and gender-matched controls Kessing et al. The diagnosis of a major medical illness often has been considered a severe life stressor and often is accompanied by high rates of depression Cassem In fact, in prospective studies, patients with anxiety are most likely to develop major depression after stressful life events occur Brown et al.
Both these disorders have as prominent features a traumatic event involving actual or threatened death or serious injury and symptom clusters including re-experiencing of the traumatic event e. The time frame for ASD is shorter lasting two days to four weeks , with diagnosis limited to within one month of the incident. Surveys of the general population indicate that PTSD affects 1 in 12 adults at some time in their life Kessler et al. Trauma and disasters are related not only to PTSD, but also to concurrent depression, other anxiety disorders, cognitive impairment, and substance abuse David et al.
Other consequences of stress that could provide linkages to health have been identified, such as increases in smoking, substance use, accidents, sleep problems, and eating disorders. Populations that live in more stressful environments communities with higher divorce rates, business failures, natural disasters, etc. A longitudinal study following seamen in a naval training center found that more cigarette smoking occurred on high-stress days Conway et al.
Life events stress and chronically stressful conditions have also been linked to higher consumption of alcohol Linsky et al. In addition, the possibility that alcohol may be used as self-medication for stress-related disorders such as anxiety has been proposed. For example, a prospective community study of adolescents and young adults Zimmerman et al. Another variable related to stress that could provide a link to health is the increased sleep problems that have been reported after sychological trauma Harvey et al. New onset of sleep problems mediated the relationship between post-traumatic stress symptoms and decreased natural killer NK cell cytotoxicity in Hurricane Andrew victims Ironson et al.
Certain characteristics of a situation are associated with greater stress responses. These include the intensity or severity of the stressor and controllability of the stressor, as well as features that determine the nature of the cognitive responses or appraisals. Life event dimensions of loss, humiliation, and danger are related to the development of major depression and generalized anxiety Kendler et al. Factors associated with the development of symptoms of PTSD and mental health disorders include injury, damage to property, loss of resources, bereavement, and perceived life threat Freedy et al.
Recovery from a stressor can also be affected by secondary traumatization Pfefferbaum et al. Other studies have found that multiple facets of stress that may work synergistically are more potent than a single facet; for example, in the area of work stress, time pressure in combination with threat Stanton et al. Stress-related outcomes also vary according to personal and environmental factors. Personal risk factors for the development of depression, anxiety, or PTSD after a serious life event, disaster, or trauma include prior psychiatric history, neuroticism, female gender, and other sociodemographic variables Green , McNally , Patton et al.
There is also some evidence that the relationship between personality and environmental adversity may be bidirectional Kendler et al. Attaching meaning to the event is another protective factor against the development of PTSD, even when horrific torture has occurred.
Finally, human beings are resilient and in general are able to cope with adverse situations. A recent illustration is provided by a study of a nationally representative sample of Israelis after 19 months of ongoing exposure to the Palestinian intifada. Despite considerable distress, most Israelis reported adapting to the situation without substantial mental health symptoms or impairment Bleich et al. Following the perception of an acute stressful event, there is a cascade of changes in the nervous, cardiovascular, endocrine, and immune systems.
These changes constitute the stress response and are generally adaptive, at least in the short term Selye Two features in particular make the stress response adaptive. Second, a new pattern of energy distribution emerges. Energy is diverted to the tissues that become more active during stress, primarily the skeletal muscles and the brain. Less critical activities are suspended, such as digestion and the production of growth and gonadal hormones. Simply put, during times of acute crisis, eating, growth, and sexual activity may be a detriment to physical integrity and even survival.
Stress hormones are produced by the SNS and hypothalamic-pituitary adrenocortical axis. The SNS stimulates the adrenal medulla to produce catecholamines e. In parallel, the paraventricular nucleus of the hypothalamus produces corticotropin releasing factor, which in turn stimulates the pituitary to produce adrenocorticotropin. Adrenocorticotropin then stimulates the adrenal cortex to secrete cortisol.
STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants
Together, catecholamines and cortisol increase available sources of energy by promoting lipolysis and the conversion of glycogen into glucose i. Lipolysis is the process of breaking down fats into usable sources of energy i. Energy is then distributed to the organs that need it most by increasing blood pressure levels and contracting certain blood vessels while dilating others. Blood pressure is increased with one of two hemodynamic mechanisms Llabre et al.
The myocardial mechanism increases blood pressure through enhanced cardiac output; that is, increases in heart rate and stroke volume i. The vascular mechanism constricts the vasculature, thereby increasing blood pressure much like constricting a hose increases water pressure. Specific stressors tend to elicit either myocardial or vascular responses, providing evidence of situational stereotypy Saab et al. Laboratory stressors that call for active coping strategies, such as giving a speech or performing mental arithmetic, require the participant to do something and are associated with myocardial responses.
From an evolutionary perspective, cardiac responses are believed to facilitate active coping by shunting blood to skeletal muscles, consistent with the fight-or-flight response. In situations where decisive action would not be appropriate, but instead skeletal muscle inhibition and vigilance are called for, a vascular hemodynamic response is adaptive.
The vascular response shunts blood away from the periphery to the internal organs, thereby minimizing potential bleeding in the case of physical assault. Finally, in addition to the increased availability and redistribution of energy, the acute stress response includes activation of the immune system. Cells of the innate immune system e. From there, the immune cells migrate into tissues that are most likely to suffer damage during physical confrontation e.
The acute stress response can become maladaptive if it is repeatedly or continuously activated Selye For example, chronic SNS stimulation of the cardiovascular system due to stress leads to sustained increases in blood pressure and vascular hypertrophy Henry et al. That is, the muscles that constrict the vasculature thicken, producing elevated resting blood pressure and response stereotypy, or a tendency to respond to all types of stressors with a vascular response. Chronically elevated blood pressure forces the heart to work harder, which leads to hypertrophy of the left ventricle Brownley et al.
Over time, the chronically elevated and rapidly shifting levels of blood pressure can lead to damaged arteries and plaque formation. The elevated basal levels of stress hormones associated with chronic stress also suppress immunity by directly affecting cytokine profiles. Cytokines are communicatory molecules produced primarily by immune cells see Roitt et al. There are three classes of cytokines. Proinflammatory cytokines mediate acute inflammatory reactions. Th1 cytokines mediate cellular immunity by stimulating natural killer cells and cytotoxic T cells, immune cells that target intracellular pathogens e.
A Th2 shift has the effect of suppressing cellular immunity in favor of humoral immunity. In response to more chronic stressors e. Intermediate and chronic stressors are associated with slower wound healing and recovery from surgery, poorer antibody responses to vaccination, and antiviral deficits that are believed to contribute to increased vulnerability to viral infections e. Chronic stress is particularly problematic for elderly people in light of immunosenescence, the gradual loss of immune function associated with aging.
Older adults are less able to produce antibody responses to vaccinations or combat viral infections Ferguson et al. Although research has yet to link poor vaccination responses to early mortality, influenza and other infectious illnesses are a major cause of mortality in the elderly, even among those who have received vaccinations e.
Both epidemiological and controlled studies have demonstrated relationships between psychosocial stressors and disease. The underlying mediators, however, are unclear in most cases, although possible mechanisms have been explored in some experimental studies. An occupational gradient in coronary heart disease CHD risk has been documented in which men with relatively low socioeconomic status have the poorest health outcomes Marmot Much of the risk gradient in CHD can be eliminated, however, by taking into account lack of perceived job control, which is a potent stressor Marmot et al.
Other factors include risky behaviors such as smoking, alcohol use, and sedentary lifestyle Lantz et al. Among men Schnall et al. However, in women with existing CHD, marital stress is a better predictor of poor prognosis than is work stress Orth-Gomer et al. Although the observational studies cited thus far reveal provocative associations between psychosocial stressors and disease, they are limited in what they can tell us about the exact contribution of these stressors or about how stress mediates disease processes.
Animal models provide an important tool for helping to understand the specific influences of stressors on disease processes. This is especially true of atherosclerotic CHD, which takes multiple decades to develop in humans and is influenced by a great many constitutional, demographic, and environmental factors. It would also be unethical to induce disease in humans by experimental means. Perhaps the best-known animal model relating stress to atherosclerosis was developed by Kaplan et al.
Their study was carried out on male cynomolgus monkeys, who normally live in social groups. The investigators stressed half the animals by reorganizing five-member social groups at one- to three-month intervals on a schedule that ensured that each monkey would be housed with several new animals during each reorganization. The other half of the animals lived in stable social groups. All animals were maintained on a moderately atherogenic diet for 22 months. Animals were also assessed for their social status i. The major findings were that a socially dominant animals living in unstable groups had significantly more atherosclerosis than did less dominant animals living in unstable groups; and b socially dominant male animals living in unstable groups had significantly more atherosclerosis than did socially dominant animals living in stable groups.
Other important findings based upon this model have been that heart-rate reactivity to the threat of capture predicts severity of atherosclerosis Manuck et al. In contrast to the findings in males, subordinate premenstrual females develop greater atherosclerosis than do dominant females Kaplan et al. Whereas the studies in cynomolgus monkeys indicate that emotionally stressful behavior can accelerate the progression of atherosclerosis, McCabe et al.
This rabbit model has a genetic defect in lipoprotein clearance such that it exhibits hypercholesterolemia and severe atherosclerosis. The rabbits were assigned to one of three social or behavioral groups: The stable group exhibited more affiliative behavior and less agonistic behavior than the unstable group and significantly less atherosclerosis than each of the other two groups. The study emphasizes the importance of behavioral factors in atherogenesis, even in a model of disease with extremely strong genetic determinants.
The hypothesis that stress predicts susceptibility to the common cold received support from observational studies Graham et al. One problem with such studies is that they do not control for exposure. Stressed people, for instance, might seek more outside contact and thus be exposed to more viruses. Therefore, in a more controlled study, people were exposed to a rhinovirus and then quarantined to control for exposure to other viruses Cohen et al.
Those individuals with the most stressful life events and highest levels of perceived stress and negative affect had the greatest probability of developing cold symptoms. In a subsequent study of volunteers inoculated with a cold virus, it was found that people enduring chronic, stressful life events i. The impact of life stressors has also been studied within the context of human immunodeficiency virus HIV spectrum disease.
Despite the stress-mediated immunosuppressive effects reviewed above, stress has also been associated with exacerbations of autoimmune disease Harbuz et al. Evidence suggests that a chronically activated, dysregulated acute stress response is responsible for these associations. Recall that the acute stress response includes the activation and migration of cells of the innate immune system.
This effect is mediated by proinflammatory cytokines. During periods of chronic stress, in the otherwise healthy individual, cortisol eventually suppresses proinflammatory cytokine production. But in individuals with autoimmune disease or CHD, prolonged stress can cause proinflammatory cytokine production to remain chronically activated, leading to an exacerbation of pathophysiology and symptomatology.
With cortisol unable to suppress inflammation, stress continues to promote proinflammatory cytokine production indefinitely. Although there is only preliminary empirical support for this model, it could have implications for diseases of inflammation. For example, in rheumatoid arthritis, excessive inflammation is responsible for joint damage, swelling, pain, and reduced mobility. Stress is associated with more swelling and reduced mobility in rheumatoid arthritis patients Affleck et al. Similarly, in multiple sclerosis MS , an overactive immune system targets and destroys the myelin surrounding nerves, contributing to a host of symptoms that include paralysis and blindness.
Again, stress is associated with an exacerbation of disease Mohr et al. Even in CHD, inflammation plays a role. The immune system responds to vascular injury just as it would any other wound: Immune cells migrate to and infiltrate the arterial wall, setting off a cascade of biochemical processes that can ultimately lead to a thrombosis i. Elevated levels of inflammatory markers, such as C-reactive protein CRP , are predictive of heart attacks, even when controlling for other traditional risk factors e.
Interestingly, a history of major depressive episodes has been associated with elevated levels of CRP in men Danner et al. In addition to its effects on physical health, prolonged proinflammatory cytokine production may also adversely affect mental health in vulnerable individuals. During times of illness e. It was once thought that these symptoms were directly caused by infectious pathogens, but more recently, it has become clear that proinflammatory cytokines are both sufficient and necessary i.
Sickness behavior has been suggested to be a highly organized strategy that mammals use to combat infection Dantzer Symptoms of illness, as previously thought, are not inconsequential or even maladaptive. On the contrary, sickness behavior is thought to promote resistance and facilitate recovery. For example, an overall decrease in activity allows the sick individual to preserve energy resources that can be redirected toward enhancing immune activity.
Similarly, limiting exploration, mating, and foraging further preserves energy resources and reduces the likelihood of risky encounters e. Furthermore, decreasing food intake also decreases the level of iron in the blood, thereby decreasing bacterial replication. Thus, for a limited period, sickness behavior may be looked upon as an adaptive response to the stress of illness. Much like other aspects of the acute stress response, however, sickness behavior can become maladaptive when repeatedly or continuously activated.
Many features of the sickness behavior response overlap with major depression. Indeed, compared with healthy controls, elevated rates of depression are reported in patients with inflammatory diseases such as MS Mohr et al. Granted, MS patients face a number of stressors and reports of depression are not surprising. However, when compared with individuals facing similar disability who do not have MS e.
In both MS Fassbender et al. Thus, there is evidence to suggest that stress contributes to both physical and mental disease through the mediating effects of proinflammatory cytokines. The changes in biological set points that occur across the life span as a function of chronic stressors are referred to as allostasis, and the biological cost of these adjustments is known as allostatic load McEwen McEwen has also suggested that cumulative increases in allostatic load are related to chronic illness.
These are intriguing hypotheses that emphasize the role that stressors may play in disease. The challenge, however, is to show the exact interactions that occur among stressors, pathogens, host vulnerability both constitutional and genetic , and such poor health behaviors as smoking, alcohol abuse, and excessive caloric consumption.
Evidence of a lifetime trajectory of comorbidities does not necessarily imply that allostatic load is involved since immunosenescence, genetic predisposition, pathogen exposure, and poor health behaviors may act as culprits. It is not clear, for example, that changes in set point for variables such as blood pressure are related to cumulative stressors per se, at least in healthy young individuals. Thus, for example, British soldiers subjected to battlefield conditions for more than a year in World War II showed chronic elevations in blood pressure, which returned to normal after a couple of months away from the front Graham In contrast, individuals with chronic illnesses such as chronic fatigue syndrome may show a high rate of relapse after a relatively acute stressor such as a hurricane Lutgendorf et al.
Nevertheless, by emphasizing the role that chronic stressors may play in multiple disease outcomes, McEwen has helped to emphasize an important area of study. Psychopharmacological approaches have also been suggested Berlant In addition, writing about trauma has been helpful both for affective recovery and for potential health benefit Pennebaker However, the presence of sleep problems or hypercortisolemia is associated with poorer response to psychotherapy Thase The combination of psychotherapy and pharmacotherapy seems to offer a substantial advantage over psychotherapy alone for the subset of patients who are more severely depressed or have recurrent depression Thase et al.
STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants
For the treatment of anxiety, it depends partly on the specific disorder [e. Antidepressants such as selective serotonin reuptake inhibitors also show efficacy in anxiety Ballenger et al. Patients dealing with chronic, life-threatening diseases must often confront daily stressors that can threaten to undermine even the most resilient coping strategies and overwhelm the most abundant interpersonal resources. Psychosocial interventions, such as cognitive-behavioral stress management CBSM , have a positive effect on the quality of life of patients with chronic disease Schneiderman et al.
Such interventions decrease perceived stress and negative mood e. Psychosocial interventions also appear to help chronic pain patients reduce their distress and perceived pain as well as increase their physical activity and ability to return to work Morley et al. There is also some evidence that psychosocial interventions may have a favorable influence on disease progression Schneiderman et al.
Psychosocial intervention trials conducted upon patients following acute myocardial infarction MI have reported both positive and null results. Most of these studies were carried out in men. Thus, because primarily white men, but not other subgroups, may have benefited from the ENRICHD intervention, future studies need to attend to variables that may have prevented morbidity and mortality benefits among gender and ethnic subgroups other than white men.
Psychosocial intervention trials conducted upon patients with cancer have reported both positive and null results with regard to survival Classen A number of factors that generally characterized intervention trials that observed significant positive effects on survival were relatively absent in trials that failed to show improved survival. In one study that reported positive results, Fawzy et al.
The intervention also significantly reduced distress, enhanced active coping, and increased NK cell cytotoxicity compared with controls. These variables associated with disease progression include distress, depressed affect, denial coping, low perceived social support, and elevated serum cortisol Ickovics et al. Those in the intervention condition showed lower distress, anxiety, and depressed mood than did those in the control condition as well as lower antibody titers of herpesviruses and higher levels of T-helper CD4 cells, NK cells, and lymphocyte proliferation Antoni et al.
Improvement in perceived social support and adaptive coping skills mediated the decreases in distress Lutgendorf et al. Stress is a central concept for understanding both life and evolution. All creatures face threats to homeostasis, which must be met with adaptive responses. Our future as individuals and as a species depends on our ability to adapt to potent stressors. At a societal level, we face a lack of institutional resources e. At an individual level, we live with the insecurities of our daily existence including job stress, marital stress, and unsafe schools and neighborhoods.
These are not an entirely new condition as, in the last century alone, the world suffered from instances of mass starvation, genocide, revolutions, civil wars, major infectious disease epidemics, two world wars, and a pernicious cold war that threatened the world order. Although we have chosen not to focus on these global threats in this paper, they do provide the backdrop for our consideration of the relationship between stress and health.
It is clear that all of us are exposed to stressful situations at the societal, community, and interpersonal level. How we meet these challenges will tell us about the health of our society and ourselves.