Stress and anxiety

Page 1

Stress and its evolving conceptualisation

Definitions of stress

An external stimuli, also known as a stressor, that causes a change in an individual's physical, mental and emotional state

An experienced biological and psychological response towards a perceived threat that an individual does not have the resources to cope with

While both agree on biological/psychological changes as responses towards stress, one perceives stress as an external stimuli while the other defines it as an individual perception towards a situation and their resources to deal with it.

Biological conceptualisation

Stress results in biological changes.

Upon perceiving stress, the hypothalamus releases hormones adrenaline and cortisol to prepare the body for a fight or flight response.

Pupils dilate, heart rate increases, blood flow to muscles increases, sweat is produced etc.

Limitations

It explains the consequences/impacts of stress, but fails to explain the cause of an individual's response towards stressors.

Stress as an external stimuli

Stress was conceptualised as an external event called stressors.

It assumes that individuals would react similarly to these stressors by having the same coping response.

Reference: Social Readjustment Rating Scale (Holmes & Rahe)

Limitations

Stress as an external stimuli does not take into account how life event changes over time.

It assumes that everyone perceives/responds to these events in the same way.

Stress as a response

Does the type of stress matter?

Acute stress

Transient but large in magnitude; could be excitatory events

Episodic stress

Chronic stress

Note: Looking at stress as a stimuli and stress as a response is like looking at different sides of the same coin.

Personality types and their response to stress

Initially type A and type B.

Type A: Competitive, urgency to complete tasks

Type B: Calmed, relaxed and completes tasks at their own time

A was projected to respond worse to stress (measured in illness) than B

However, A and B were poor descriptors of the broad range of personalities that existed.

It has been expanded into the Big 5 traits:

O - Openness

C - Conscientiousness

E - Extraversion

A - Agreeableness

N - Neuroticism

Stimuli ---> Individual ---> Response

It highlighted the importance of individual differences in stressors and their response, however...

Limitations

Given that a person's personality doesn't change much over time, it didn't explain why a person would react differently to the same external stimuli at different times. The models above were static. Hence...

Transactional model of stress

Event ---> Individual appraisal ---> Coping responses

It factors in individual appraisal .(i.e. Do I have the resources to deal with the situation?)

How one thinks/perceives the event which is influenced by individual psychological processes AND their environment e.g. culture

Individual psychological process include personality, adaptability, hardiness etc.

Their coping responses (which links back to apprasial) determine how they react to the stressor. (i.e. Do I deal with it, or avoid it?)

Things that infulence coping resources are concurrent stressors.

This model has great implications for treatment as it recognises individual psychological processes.

It means changing the way one thinks would lead to a change in the way they cope with stress.

Good stress, bad stress

Stress vs quality of function

Good stress (eustress) is when it improves one's quality of functioning. It has a motivating infulence.

Bad stress (distress) is when it negatively impacts one's quality of functioning.

The tipping point is where stress goes from optimal to excess.

All encompassing stress: Comorbidity

Stress coexist with many negative mood states.

While people who experience stress do not necessarily develop a disorder, people with disorders generally experience stress.

Page 2

Anxiety and their disorders

Anxiety

A negative mood state characterised by apprehension about the future. It is adaptive.

It encompasses:

Fear

An immediate alarm experienced towards real and immediate danger. It reflects the present. It is adaptive.

Panic

An abrupt experience of intense fear or acute discomfort. It is accompanied by several physical symptoms.

What characterises an anxiety disorder?

Excessiveness, impairment.

Excessive anxiety that causes a clinically significant distress and impairment. It involves excessive avoidance and escapist tendencies.

It becomes a problem when it has an impact on the person's life.

Although anxiety disorders are generally quite prevalent, people don't use mental health services as much.

This could be due to

Cost

Stigma

Inaccessibility to MHS/lack of services

Anxiety in seeking help

Types of anxiety disorder

Generalised anxiety disorder

Post tramautic stress disorder

Seperation anxiety disorder

Panic disorder

Generally AD's are more prevalent in females.

Higher in those who were single/seperated than married/in a relationship. This underscores the importance of social support/networks when dealing with ADs.

Higher in those who were jobless. Probably more concurrent stressors to deal with like paying bills.

Higher in those who only had high school education (lower education). This could be due to the number of opportunities they experience in life etc.

Not associated to country of birth.

Generalised anxiety disorder (GDA)

It's the same as that of an anxiety disorder i.e.

Excessive anxiety that causes a clinically significant impairment or distress. Impacts an individual's functioning.

It is also...

Not due to physiological effects (e.g. drug abuse or thyroid)

Unspecified; there is no specific cause

Has high comorbidity with other mental disorder.

Diagnostic criteria for GAD

Length: 6 months or more

Symptoms: 3 or more

Risk factors

Genetics

Temperament/individual nature

Early childhood experiences e.g. bullying, divorce within family

Female

Parenting style

Illness

Psychological processes - How do people with GAD think?

They are hyper vigilant and tend to pay more attention to potential threats in the environment.

They tend to interpret these situations as dangerous, even though they might be ambiguous.

They tend to attribute negative outcomes to the situations.

Biased thinking and reasoning.

They worry as a short term coping mechanism.

Excessive worry has been shown to reduce physical arousal symptoms e.g. reduced heart rate.

Worrying however does not deal with the fear and might also interfere to solve problems.

It might also result in meta worrying.

Worry as avoidance.

Page 3

PTSD

Post traumatic stress disorder (PTSD)

Development of characteristic symptoms with exposure to traumatic events.

How one interprets traumatic depends on the individual.

Criteria for diagnosis

5 criteria + duration of symptoms

A: Exposure to stressor

B: Intrusive symptoms

C: Avoidance

D: Alterations in cognitions (memory) and mood

E: Alteration in arousal

Duration: 1 month or more

If it is less than 1 month, it is classified under acute stress reaction.

Risk factors for PTSD

Pre-trauma factors

Gender - Female

Personality - Neurotic

Age - Young

Lower education/intelligence

Family history of mood disorders

Unstable family environment during childhood

Preexisting mood disorders

During trauma

Type of trauma (some bring about more stress than others)

Level of perceived threat

How in control you are at that time/predictability of the trauma (refer to WT example; preparedness in dealing with the event is important)

Duration and frequency of exposure

Post trauma

Social/positive support after trauma

Opportunities to 'process' the experience i.e. whether you acknowledge it happened

Validation of the experience

Page 4

Seperation anxiety

Seperation anxiety from childhood has been associated with adult anxiety disorders.

Seperation anxiety

Definition

Developmentally inappropriate (age wise) and excessive fear or anxiety when seperated from an attached figure.

Begins during childhood

Often develops following a life stressor; acute onset

Generally disappears after 2 years and reappears during episodic events e.g. going to a new school

Appears more in girls than boys

Large variation of prevalence between cultures; parenting style

Symptoms

Excessive distress when experiencing detachment from attached figure or about possible harm to attached figure.

Reluctance to go to school due to fear of seperation.

Reluctance to be alone when attached figure is absent.

Consequences

Child is unable to make friends as child does not participate in school or social activities.

Always at home; refuses to participate in independent activities.

Parents might feel fustrated as a consequence.

Might have difficulty dealing with seperation as they grow up/mature.

Seperation anxiety disorder and Panic disorder

A strong genetic link has been found between childhood SAD and adult onset PA.

Both disorders are associated with increased sensitivity to O2.

Comorbidity is high (73%) between young people with SAD and PA.

Influenced by childhood (temporary?) parental loss.

Page 5

Panic disorder

Panic attack

Definition

Abrupt experience of intense fear and acute discomfort.

Comes with physical symptoms that occurs out of context i.e. not in a dangerous situation.

Prevalence

While 40% have experienced PA, most will not have repeated attacks.

Most experience onset at 15 - 25 years. This could be due to massive life changes, or hormones.

Not as common in those after 40 years.

Most sufferers are women. Plausible cultural causes.

High comorbidity with other mental illness.

DSM Criteria

4 or more symptoms, 1 being cognitive

Somatic:

Chest pain

Shortness of breath

Sweating

Numbness

Depersonalization

Cognitive:

Fear of losing control (e.g. having the attack again)

Fear of dying

Characteristics of PA

Transient; lasts for less that 10mins

Sufferer is in no real physical danger

Sufferer's perception of their panic will affect how long it lasts

Biology of PA

Fear

---> Activation of sympathetic NS and release of adrenaline

---> Increased heart rate, hyperventilation, muscle tension

---> Light headedness, less oxygen in lungs, tingling, numbness (symptoms)

---> PA

In Clarke's cognitive model of PA, PA results from the misintepretation of events, a.k.a. threat perception.

Physical/cognitive symptoms are those 4 inclusive of 1 cognitive.

PA + fear about future PA = PD,

Self perpetuating model of anxiety/panic.

Safety behaviours e.g. taking a friend to consult them

Avoidance behaviours e.g. completely extricating oneself from a similar situation

It leads to restriction in the environment one interacts in.

Both lead to the perpetuation of PA's as one isn't confronting the problem.

The best yet hardest treatment is exposure to the problem.

Wait for the panic to subside and keep your control instead of running away.

CBT by thinking that one isn't about to die/lose control also helps.

Risk factors for PD

Genetics

Major life stressors

Physically and sexually abused in childhood

Abnormally sensitive fear network

Page 6

Specific phobia

Rehash

Anxiety vs Phobia

Anxiety is apprehension out of proportion to threats in the environment. It is future orientated. It can be adaptive if anxiety is not too excessive.

Fear is present and immediate danger. It is present orientated. It is adaptive; fight/flight action.

Specific phobia

DSMV Criteria

Duration more than 6 months

Irrational fear/significant anxiety of an object/situation (i.e. when something isn't actually harmful but one fears it e.g. an orange)

Has a significant impact in one's functioning

Individual recognises their fear is excessive and unreasonable

Exposure to stimulus results in an anxiety response

Active avoidance or endured with extreme distress when exposed to stimuli

Types

People in costumes

Environment e.g. heights

Animals e.g. spiders or insects

Situations e.g. enclosed spaces, aeroplanes, crowds

Prevalence

Higher in European countries

Specific types of phobias are highly prevelant e.g. fear of snakes

Only 5% in children - this could be due to the symptoms of phobia expressing itself in forms like crying where parents attribute it to other causes

16% in 13 - 17 year olds

75% diagnosed have more than 1 fearful situation of that object

More common in females than males

Only those severely impaired in their daily functioning seek treatment; possible reasons could be due to lack of access, cost, inability to face their fears (part of treatment)

Theories of the origins of SP

Conditioning theory of fear

Social learning

Evolutionary persective

Conditioning of Fear

Hello Freud.

Has roots in the psychodynamic theory - phobias originate from a fear which then projects onto other situations

Little Albert Study

Baby does not fear furry rat

Baby fears loud noises

When furry rat is presented with a loud noise to the baby, the baby starts to fear furry rats

The baby then projects this fear onto furry objects like toys, blankets etc.

Avoidance maintains the fear; no chance for reality check

Fear of threatening stimulus ---> Association of fear with non threatening stimulus ---> Fears non threatening stimulus ---> Avoidance ---> Maintenance of phobia

Issues with CT

Some people fear objects they have never come into contact with i.e. no association

There is no obvious environmental cause for some phobias

Social learning

Watching/observing others suffer thus developing a fear

Hearing the experiences of others

Instructional/being told to fear certain objects e.g. Fire is harmful, you should not play with it

Evolutionary perspective

People fear certain things because it is harmful to their survival; survival/reproductive advantage

Page 7

Social anxiety disorder

Social anxiety disorder

DSMV Criteria

Marked fear (different levels/degrees) of 1 or more social situations

Social situation provokes fear/anxiety

Fear out of proportion to the situation

Individual would act in a way that causes their actions to be negatively perceived

Individual goes to lengths to avoid the situation or endure it with intense distress

Significantly impacts individual's life

Not better explained by other mental disorders

Duration: 6 months or more

Note: The DSM doesn't always capture a characterised disorder.

Shyness vs SAD

Shyness is more of a personality trait; shy people would feel more comfortable in a social situation overtime.

SA however is a persistent fear that does not get better in the same social situation with time.

Note: Prevalence of social phobia among shy persons (18%) is significantly higher than in non shy people (3%).

Risk factors for SA

Negative social experiences <----> Negative appraisal of social interactions (a possible feedback loop)

Genetics - heritable emotional disorders

Lack of social skills (which comes first?)

Personality - shyness

Page 8

Agoraphobia

Agoraphobia

Like SAD, it is a marked fear. Unlike SAD, it is a fear of being in public places, not so much social situations.

2 or more: Being outside of home alone, being in a crowd, taking public transport etc.

Prevalence

Most commonly diagnosed in late adolescence/early adulthood

Females twice that of males

Rare for full recovery; full remission at 10%

There might be a genetic predisposition (neural pathways) to this.

Page 9

Treatment for AD

Treatment

Medication

CBT

Cognitive behavioural therapy (CBT)

ABC approach

A: Triggering event ------> B: Thoughts ---------> C: Emotional and behavioural responses

How does it work?

Over time - around 16 weeks

Focuses on the problem present during therapy

Treatment plan given is based on existing literature and it's evaluation on its effectiveness

Continual assessment and feedback that takes place between patient and therapist - tests out hypothesis which pinpoints the cause and allows for effective treatment to assess it's efficacy

Therapist <======> Patient; therapist must make sure they give patient what they can cope with

Patient must do their part by practising what they learnt

1. Dearousal techniques

Slow breathing

Muscle relaxing techniques

Meditation (being in the moment of fear)

2. Graded exposure

Step up; gentle

Patient chooses their exposure level

3. Change cognitive thoughts

4. Solve the problem