Adjustment Disorders

Order ready-to-submit essays. No Plagiarism Guarantee!

Note: Our papers are 100% human-written, not AI-generated. 

We Write Essays for Students

Tell us about your assignment and we will find the best writer for your paper

Get Help Now!

5 stress and physical and mental health

learning objectives 5

·  5.1 What is stress?

·  5.2 How does the body respond to stress?

·  5.3 What role does our emotional state play in our physical health?

·  5.4 What mental disorders are explicitly recognized as being triggered by stress?

·  5.5 What are the clinical features of posttraumatic stress disorder?

·  5.6 What are the risk factors for PTSD?

·  5.7 What treatment approaches are used for PTSD?

With its deadlines, interpersonal tensions, financial pressures, and everyday hassles, daily life places many demands on us. We are all exposed to stress, and this exposure affects our physical and our psychological well-being. Sometimes even leisure activities can be stressful. For example, a loss in the Superbowl is followed by an increase in heart attacks and death over the following two weeks in the losing team’s city (Kloner et al.,  2011 ). And watching a stressful soccer match more than doubles the risk of having acute cardiovascular problems (Wilbert-Lampen et al.,  2008 ). How are you affected by stress? Does it make you anxious? Does it give you migraines?

The field of  health psychology  is concerned with the effects of stress and other psychological factors in the development and maintenance of physical problems. Health psychology is a subspecialty within  behavioral medicine . A behavioral medicine approach to physical illness is concerned with psychological factors that may predispose an individual to medical problems. These may include such factors as stressful life events, certain personality traits, particular coping styles, and lack of social support. Within behavioral medicine there is also a focus on the effects of stress on the body, including the immune, endocrine, gastrointestinal, and cardiovascular systems.

But stress affects the mind as well as the body. As we discussed in  Chapter 3 , the role that stress can play in triggering the onset of mental disorders in vulnerable people is explicitly acknowledged in the diathesis-stress model. Moreover, exposure to extreme and traumatic stress may overwhelm the coping resources of otherwise apparently healthy people, leading to mental disorders such as  posttraumatic stress disorder (PTSD) , as in the following example.

Posttraumatic Stress in a Military Nurse Jennifer developed PTSD after she served as a nurse in Iraq. During her deployment she worked 12- to 14-hour shifts in 120-degree temperatures. Sleep was hard to come by and disaster was routine. Day in and day out there was a never-ending flow of mangled bodies of young soldiers. Jennifer recalled one especially traumatic event:

·  I was working one evening. We received information that a vehicle, on a routine convoy mission, had been hit by an improvised explosive device (IED). Three wounded men and one dead soldier were on their way to our hospital. Two medics in the back room were processing the dead soldier for Mortuary Affairs. The dead soldier was lying on a cot. The air was strong with the smell of burned flesh. I was staring at the body and trying to grasp what was different about this particular body. After a while I realized. The upper chest and head of the dead soldier was completely missing. We received his head about an hour later. (Based on Feczer & Bjorklund,  2009 ).

In this chapter we consider the role that stress plays in the development of physical and mental disorders. We discuss both physical and mental problems because the mind and the body are powerfully connected and because stress takes its toll on both. Although the problems that are linked to stress are many, we limit our discussion to the most severe stress-related physical and mental disorders. In the physical realm, we focus on heart disease. For mental disorders, we concern ourselves primarily with PTSD.

After a Superbowl loss, heart attacks and death increase in the losing team’s city.

What is Stress?

Life would be very simple if all of our needs were automatically satisfied. In reality, however, many obstacles, both personal and environmental, get in the way. A promising athletic career may be brought to an end by injury; we may have less money than we need; we may be rejected by the person we love. The demands of life require that we adjust. When we experience or perceive challenges to our physical or emotional well-being that exceed our coping resources and abilities, the psychological condition that results is typically referred to as stress (see Shalev,  2009 ). To avoid confusion, we will refer to external demands as  stressors , to the effects they create within the organism as  stress , and to efforts to deal with stress as  coping strategies . It is also important to note that stress is fundamentally an interactive and dynamic construct because it reflects the interaction between the organism and the environment over time (Monroe,  2008 ).

All situations that require adjustment can be regarded as potentially stressful. Prior to the influential work of Canadian physician and endocrinologist Hans Selye ( 1956 ,  1976 ), stress was a term used by engineers. Selye took the word and used it to describe the difficulties and strains experienced by living organisms as they struggled to cope with and adapt to changing environmental conditions. His work provided the foundation for current stress research. Selye also noted that stress could occur not only in negative situations (such as taking an examination) but also in positive situations (such as a wedding). Both kinds of stress can tax a person’s resources and coping skills, although bad stress ( distress ) typically has the potential to do more damage. Stress can also occur in more than one form—not just as a simple catastrophe but also as a continuous force that exceeds the person’s capability of managing it.

Stress and the DSM

The relationship between stress and psychopathology is considered so important that the role of stress is recognized in diagnostic formulations. Nowhere is this more apparent than in the diagnosis of PTSD—a severe disorder that we will discuss later. PTSD was classified as an anxiety disorder in DSM-IV. However, DSM-5 introduced a new diagnostic category called trauma- and stressor related disorders. PTSD is now included there. Other disorders in this new category are adjustment disorder and acute stress disorder. These disorders involve patterns of psychological and behavioral disturbances that occur in response to identifiable stressors. The key differences among them lie not only in the severity of the disturbances but also in the nature of the stressors and the time frame during which the disorders occur (Cardeña et al.,  2003 ).

Factors Predisposing a Person To Stress

 SHAPE * MERGEFORMAT 

Stress can result from both negative and positive events. Both types of stress can tax a person’s resources and coping skills, although distress (negative stress) typically has the potential to do more damage.

Everyone faces a unique pattern of demands to which he or she must adjust. This is because people perceive and interpret similar situations differently and also because, objectively, no two people are faced with exactly the same pattern of stressors. Some individuals are also more likely to develop long-term problems under stress than others. This may be linked, in part, to coping skills and the presence of particular resources. Children, for example, are particularly vulnerable to severe stressors such as war and terrorism (Petrovic,  2004 ). Research also suggests that adolescents with depressed parents are more sensitive to stressful events; these adolescents are also more likely to have problems with depression themselves after experiencing stressful life events than those who do not have depressed parents (Bouma et al.,  2008 ).

Individual characteristics that have been identified as improving a person’s ability to handle life stress include higher levels of optimism, greater psychological control or mastery, increased self-esteem, and better social support (Declercq et al.,  2007 ; Taylor & Stanton,  2007 ). These stable factors are linked to reduced levels of distress in the face of life events as well as more favorable health outcomes. There is also some evidence from twin studies that differences in coping styles may be linked to underlying genetic differences (Jang et al.,  2007 ).

A major development in stress research was the discovery that a particular form of a particular gene (the 5HTTLPR gene) was linked to how likely it was that people would become depressed in the face of life stress. Caspi and colleagues ( 2003 ) found that people who had two “short” forms of this gene (the s/s genotype) were more likely to develop depression when they experienced four or more stressful life events than were people who had two “long” forms of this gene (the l/l geneotype). Although this specific finding was controversial for a while a recent meta-analysis has provided clear support for the original finding (Karg et al.,  2011 ). More generally, it is now widely accepted that our genetic makeup can render us more or less “stress-sensitive.” Researchers are exploring genes that may play a role in determining how reactive to stress we are (Alexander et al.,  2009 ; Armbruster et al.,  2012 ).

The amount of stress we experience early in life may also make us more sensitive to stress later on (Gillespie & Nemeroff,  2007 ; Lupien et al.,  2009 ). The effects of stress may be cumulative, with each stressful experience serving to make the system more reactive. Evidence from animal studies shows that being exposed to a single stressful experience can enhance responsiveness to stressful events that occur later (Johnson, O’Connor et al.,  2002 ). Rats that were exposed to stressful tail shocks produced more of the stress hormone cortisol when they were later exposed to another stressful experience (being placed on a platform). Other biological changes associated with stress were also more pronounced in these rats. These results suggest that prior stressful experiences may sensitize us biologically, making us more reactive to later stressful experiences. The term  stress tolerance  refers to a person’s ability to withstand stress without becoming seriously impaired.

Stressful experiences may also create a self-perpetuating cycle by changing how we think about, or appraise, the things that happen to us. Studies have shown that stressful situations may be related to or intensified by a person’s cognitions (Nixon & Bryant,  2005 ). This may explain why people with a history of depression tend to experience negative events as more stressful than other people do (Havermans et al.,  2007 ). For example, if you’re feeling depressed or anxious already, you may perceive a friend’s canceling a movie date as an indication that she doesn’t want to spend time with you. Even though the reality may be that a demand in her own life has kept her from keeping your date, when you feel bad you will be much more inclined to come to a negative conclusion about what just happened rather than see the situation in a more balanced or more optimistic way. Can you think of an example in your own life when something like this has happened to you?

Characteristics of Stressors

Why is misplacing our keys so much less stressful than being in an unhappy marriage or being fired from a job? At some level we all intuitively understand what makes one stressor more serious than another. The key factors involve (1) the severity of the stressor, (2) its chronicity (i.e., how long it lasts), (3) its timing, (4) how closely it affects our own lives, (5) how expected it is, and (6) how controllable it is.

Stressors that involve the more important aspects of a person’s life—such as the death of a loved one, a divorce, a job loss, a serious illness, or negative social exchanges—tend to be highly stressful for most people (Aldwin,  2007 ; Newsom et al.,  2008 ). Furthermore, the longer a stressor operates, the more severe its effects. A person may be frustrated in a boring and unrewarding job from which there is seemingly no escape, suffer for years in an unhappy and conflict-filled marriage, or be severely frustrated by a physical limitation or a long-term health problem. As we have already noted, stressors also often have cumulative effects (Miller,  2007 ). A married couple may endure a long series of difficulties and frustrations, only to divorce after experiencing what might seem to be a minor precipitating stressor. Encountering a number of stressors at the same time also makes a difference. If a man loses his job, learns that his wife is seriously ill, and receives news that his son has been arrested for selling drugs, all at the same time, the resulting stress will be more severe than if these events occurred separately and over an extended period. Symptoms of stress also intensify when a person is more closely involved in an immediately traumatic situation. Learning that the uncle of a close friend was injured in a car accident is not as stressful as being in an accident oneself.

A devastating house fire is not an event we can anticipate. It is almost impossible to be psychologically prepared to experience a stressor such as this.

Extensive research has shown that events that are unpredictable and unanticipated (and for which no previously developed coping strategies are available) are likely to place a person under severe stress. A devastating house fire and the damage it brings are not occurrences with which anyone has learned to cope. Likewise, recovery from the stress created by major surgery can be improved when a patient is given realistic expectations beforehand; knowing what to expect adds predictability to the situation. In one study, patients who were about to undergo hip replacement surgery watched a 12-minute film the evening before they had the operation. The film described the entire procedure from the patient’s perspective. Compared to controls who did not see the film, patients who saw the video were less anxious on the morning of the surgery, were less anxious after the surgery, and needed less pain medication (Doering et al.,  2000 ).

Unpredictable and uncontrollable events cause the greatest stress. These people are reacting to the collapse of the World Trade Center towers.

Finally, with an uncontrollable stressor, there is no way to reduce its impact, such as by escape or avoidance. In general, both people and animals are more stressed by unpredictable and uncontrollable stressors than by stressors that are of equal physical magnitude but are either predictable or controllable or both (e.g., Evans & Stecker,  2004 ; Maier & Watkins,  1998 ).

THE EXPERIENCE OF CRISIS

Most of us experience occasional periods of especially acute (sudden and intense) stress. The term  crisis  is used to refer to times when a stressful situation threatens to exceed or exceeds the adaptive capacities of a person or a group. Crises are often especially stressful, because the stressors are so potent that the coping techniques we typically use do not work. Stress can be distinguished from crisis in this way: A traumatic situation or crisis overwhelms a person’s ability to cope, whereas stress does not necessarily overwhelm the person.

Measuring Life Stress

Life changes, even positive ones such as being promoted or getting married, place new demands on us and may therefore be stressful. The stress from life changes can trigger problems, even in disorders, such as bipolar disorder, that have strong biological underpinnings (see Johnson & Miller,  1997 ). The faster life changes occur, the greater the stress that is experienced.

A major focus of research on life changes has concerned the measurement of life stress. Years ago, Holmes and Rahe ( 1967 ) developed the Social Readjustment Rating Scale. This is a self-report checklist of fairly common, stressful life experiences (see also Chung et al.,  2010 ; Cooper & Dewe,  2007 ). Although easy to use, limitations of the checklist method later led to the development of interview-based approaches such as the Life Events and Difficulties Schedule (LEDS; Brown & Harris,  1978 ). One advantage of the LEDS is that it includes an extensive manual that provides rules for rating both acute and chronic forms of stress. The LEDS system also allows raters to consider a person’s unique circumstances when rating each life event. For example, if a woman who is happily married and in good financial circumstances learns that she is going to have a baby, she may experience this news in a way that is quite different from that of an unmarried teenager who is faced with the prospect of having to tell her parents that she is pregnant. Although interview-based approaches are more time consuming and costly to administer, they are considered more reliable and are preferred for research in this area (see Monroe,  2008 ).

Resilience

After experiencing a potentially traumatic event, some people function well and experience very few symptoms in the following weeks and months. This kind of healthy psychological and physical functioning after a potentially traumatic event is called  resilience . You might be surprised to learn that resilience is not rare. In fact, resilience is the most common reaction following loss or trauma (Bonnano et al.,  2011 ; Quale & Schanke,  2010 ).

But why are some people more resilient than others? Research suggests that there is no single factor that predicts resilience. Rather, resilience is linked to a variety of different characteristics and resources. Factors that increase resilience include being male, being older, and being well educated. Having more economic resources is also beneficial. Some earlier studies suggested that, after the 9/11 attacks in New York, African Americans and members of some Latino groups fared more poorly and showed lower levels of resilience compared to whites. However, race and ethnicity are often confounded with social class. Importantly, when social class is controlled for, statistics show that race and ethnicity are no longer predictive of reduced resiliency.

It also helps to be a positive person. Research shows that people who can still show genuine positive emotions when talking about their recent loss also tend to adjust better after bereavement (see Bonnano et al.,  2011 ). In contrast, having more negative affect, being more inclined to ruminate, and trying to find meaning in what has happened is associated with people doing less well after a traumatic event.

The importance of positive and negative emotions is nicely illustrated in a study of 80 people who were being treated in a specialized rehabilitation hospital (Quale & Schanke,  2010 ). All had multiple traumatic injuries or severe spinal cord injuries, usually caused by accidents. The people who showed most resilience in the months after their injuries were those who, when interviewed shortly after arriving in the hospital, reported that they generally had an optimistic approach to life. In addition to optimism, being generally high on positive affect and low on negative affect also predicted having a more resilient trajectory (as opposed to a distress trajectory) over the period of rehabilitation treatment.

Resilience is the most common response to a potentially traumatic event. Optimism, positive emotions, and having more economic resources are all predictive of resilience.

Finally, it is interesting to note that people who are very self-confident and who view themselves in an overly positive light also tend to cope remarkably well in the face of trauma. Although people with this kind of self-enhancing style are sometimes unpleasant to interact with, such a style may serve them well in times of crisis. For example, in a recent prospective study, Gupta and Bonanno ( 2010 ) showed that college students with this self-enhancing style coped much better over a four-year period than people who did not.

in review

·  • What factors play a role in determining a person’s stress tolerance?

·  • What characteristics of stressors make them more serious and more difficult to adapt to?

·  • Describe two methods that can be used to measure life stress.

·  • What is resilience? Describe three factors that increase resilience and three factors that are associated with reduced resilience.

Stress and the Stress Response

To understand why stress can lead to physical and psychological problems, we need to know what happens to our bodies when we experience stress. Faced with the threat of a perceived stressor, the body undergoes a cascade of biological changes. Two distinct systems are involved here. The  sympathetic-adrenomedullary (SAM) system  (see Gunnar & Quevedo,  2007 ) is designed to mobilize resources and prepare for a fight-or-flight response. The stress response begins in the hypothalamus, which stimulates the sympathetic nervous system (SNS). This, in turn, causes the inner portion of the adrenal glands (the adrenal medulla) to secrete adrenaline (epinephrine) and noradrenaline (norepinephrine). As these circulate through the blood, they cause an increase in heart rate (familiar to all of us). They also get the body to metabolize glucose more rapidly.

The second system involved in the stress response is called the  hypothalamus-pituitary-adrenal (HPA) system  (which we introduced in  Chapter 3 ; also see  Figure 5.1 ). In addition to stimulating the SNS, the hypothalamus releases a hormone called “corticotrophin-releasing hormone” (or CRH). Traveling in the blood, this hormone stimulates the pituitary gland. The pituitary then secretes adrenocorticotrophic hormone (ACTH). This induces the adrenal cortex (the outer portion of the adrenal gland) to produce the stress hormones called glucocorticoids. In humans, the stress glucocorticoid that is produced is called  cortisol .  Figure 5.1  illustrates this sequence of events.

Cortisol is a good hormone to have around in an emergency. It prepares the body for fight or flight. It also inhibits the innate immune response. This means that if an injury does occur, the body’s inflammatory response to it is delayed. In other words, escape has priority over healing, and tissue repair is secondary to staying alive. This obviously has survival value if you need to run away from a lion that has just mauled you. It also explains why cortisone injections are sometimes used to reduce inflammation in damaged joints.

FIGURE 5.1 The Hypothalamic-Pituitary-Adrenal (HPA) Axis. Prolonged stress leads to secretion of the adrenal hormone cortisol, which elevates blood sugar and increases metabolism. These changes help the body sustain prolonged activity but at the expense of decreased immune system activity.

 Explore the simulation LivePsych! Stress and Immune System on MyPsychLab .

But there is also a downside to cortisol. If the cortisol response is not shut off, cortisol can damage brain cells, especially in the hippocampus (see Sapolsky,  2000 ). At a very fundamental level, stress is bad for your brain. It may even stunt growth (babies who are stressed don’t gain weight in the normal way and “fail to thrive”). Accordingly, the brain has receptors to detect cortisol. When these are activated, they send a feedback message that is designed to dampen the activity of the glands involved in the stress response. But if the stressor remains, the HPA axis stays active and cortisol release continues. Although short-term cortisol production is highly adaptive, a chronically overactive HPA axis, with high levels of circulating cortisol, may be problematic.

Biological Costs of Stress

The biological cost of adapting to stress is called the  allostatic load  (McEwan,  1998 ). When we are relaxed and not experiencing stress, our allostatic load is low. When we are stressed and feeling pressured, our allostatic load will be higher. Although efforts to relate specific stressors to specific medical problems have not generally been successful, stress is becoming a key underlying theme in our understanding of the development and course of virtually all physical illness. Moreover, the focus now is not just on major stressors such as job loss or the death of a loved one, but also on daily stressors such as commuting, unexpected work deadlines, or even computer problems (Almeida,  2005 ). For example, a person with allergies may find his or her resistance further lowered by emotional tension. Similarly, when a virus has already entered a person’s body—as is thought to be the case in multiple sclerosis—emotional stress may interfere with the body’s normal defensive forces or immune system. In like manner, any stress may tend to aggravate and maintain certain disorders, such as migraine headaches (Levor et al.,  1986 ) and rheumatoid arthritis (Affleck et al.,  1994 ; Keefe et al.,  2002 ).

The Mind–Body Connection

The link between stress and physical illness involves diseases (like colds) that are not directly related to nervous system activity. This suggests that stress may cause an overall vulnerability to disease by compromising immune functioning.  Psychoneuroimmunology  is the study of the interaction between the nervous system and the immune system. Although it was once thought that the immune system was essentially “closed” and responsive only to challenges from foreign substances, we now realize that this is not the case. The nervous system and the immune system communicate in ways that we are now beginning to understand.

Evidence continues to grow that the brain influences the immune system and that the immune system influences the brain. In other words, a person’s behavior and psychological states do indeed affect immune functioning, but the status of the immune system also influences current mental states and behavioral dispositions by affecting the blood levels of circulating neurochemicals; these, in turn, modify brain states. For example, we have already seen that glucocorticoids can cause stress-induced  immunosuppression . In the short term, this can be adaptive (escape first, heal later). However, it makes sense that longer-term stress might create problems for the immune system. To appreciate why this might be, we need to describe briefly the basics of immune functioning.

When we are relaxed and calm, our allostatic load is low.

When our allostatic load is high, we experience the biological signs of stress including high heart rate and increased levels of cortisol.

Understanding the Immune System

The word immune comes from the Latin immunis, which means “exempt.” The  immune system  protects the body from such things as viruses and bacteria. It has been likened to a police force (Kalat,  2001 ). If it is too weak, it cannot function effectively, and the body succumbs to damage from invading viruses and bacteria. Conversely, if the immune system is too strong and unselective, it can turn on the body’s own healthy cells. This is what may happen in the case of autoimmune diseases such as rheumatoid arthritis and lupus.

The front line of defense in the immune system is the white blood cells. These  leukocytes  (or  lymphocytes ) are produced in the bone marrow and then stored in various places throughout the body, such as the spleen and the lymph nodes. There are two important types of leukocytes. One type, called a  B-cell (because it matures in the bone marrow) produces specific antibodies that are designed to respond to specific antigens.  Antigens  (the word is a contraction of antibody generator) are foreign bodies such as viruses and bacteria, as well as internal invaders such as tumors and cancer cells. The second important type of leukocyte is the  T-cell  (so named because it matures in the thymus, which is an important endocrine gland). When the immune system is stimulated, B-cells and T-cells become activated and multiply rapidly, mounting various forms of counterattack (see  Figure 5.2 ).

FIGURE 5.2 Immune System Responses to a Bacterial Infection .

Source: J. W. Kalat.  2001 . Biological Psychology, 7th ed. Belmont, CA: Wadsworth.

T-cells circulate through the blood and lymph systems in an inactive form. Each T-cell has receptors on its surface that recognize one specific type of antigen. However, the T-cells are unable to recognize antigens by themselves. They become activated when immune cells called macrophages (the word means “big eater”) detect antigens and start to engulf and digest them. To activate the T-cells, the macrophages release a chemical known as interleukin-1. With the help of the macrophages, the T-cells become activated and are able to begin to destroy antigens (Maier et al.,  1994 ).

B-cells are different in structure from T-cells. When a B-cell recognizes an antigen, it begins to divide and to produce antibodies that circulate in the blood. This process is facilitated by cytokines that are released by the T-cells. Production of antibodies takes 5 days or more (Maier et al.,  1994 ). However, the response of the immune system will be much more rapid if the antigen ever appears in the future because the immune system has a “memory” of the invader.

The protective activity of the B- and T-cells is supported and reinforced by other specialized components of the system, most notably natural killer cells, macrophages (which we have already mentioned), and granulocytes. The immune system’s response to antigen invasion is intricately orchestrated, requiring the intact functioning of numerous components.

An important component of the immune system response involves  cytokines . Cytokines are small protein molecules that serve as chemical messengers and allow immune cells to communicate with each other. Interleukin-1, which we have just discussed, is a cytokine. Another cytokine that you may have heard about is interferon, which is given to patients with cancer, multiple sclerosis, and hepatitis C.

Cytokines play an important role in mediating the inflammatory and immune response (see Kronfol & Remick,  2000 , for a review). They can be divided into two main categories: proinflammatory cytokines and anti-inflammatory cytokines. Proinflammatory cytokines such as interleukin-1 (IL-1), IL-6, or tumor necrosis factor help us deal with challenges to our immune system by augmenting the immune response. In contrast, anti-inflammatory cytokines such as IL-4, IL-10, and IL-13 decrease or dampen the response that the immune system makes. Sometimes they accomplish this by blocking the synthesis of other cytokines.

What makes cytokines especially interesting is that in addition to communicating with the immune system, they also send signals to the brain. Because the brain and the immune system can communicate via the cytokines, we can regard the immune system almost as another sensory organ. Far from being a self-contained system, the immune system can monitor our internal state and send the brain information about infection and injury. The brain can then respond. What this means is that the brain is capable of influencing immune processes. With this in mind, some of the findings discussed in this chapter (the link between depression and heart disease, for example, and the health benefits of optimism and social support) make much more sense. In a very tangible way, what is going on at the level of the brain can affect what is going on with the body, and vice versa.

We also know that IL-1 and other cytokines can stimulate the HPA axis (refer back to  Figure 5.1 ). The resulting increase in cortisol sets off a negative feedback loop that is designed to prevent an excessive or exaggerated immune or inflammatory response. However, if this feedback system fails and is either too sensitive or not sensitive enough, serious disorders such as cancer, infection, or autoimmune diseases can develop. Because the brain is also involved in this feedback loop, emotional factors and psychosocial stresses may tilt the balance in the feedback loop in either a helpful or a detrimental way.

One implication of developments in cytokine research is that disorders of the brain could potentially have “downstream” effects on the immune system. In the opposite direction, problems with the immune system may also lead to some behavioral changes or even to psychiatric problems. For example, when you are ill you sleep more, have a diminished appetite, and have little sexual interest. This is classic sickness behavior. It may also result, at least in part, from the effects of specific cytokines on the brain. When cytokines such as IL-1 or interferon are injected, subjects become lethargic, lose their appetites, and have trouble concentrating, among other problems (Reichenberg et al.,  2001 ). In other words, they have some of the symptoms of depression. And when cancer patients are treated with cytokines such as interferon, they experience both flu-like symptoms and depression, the latter of which is typically treated with paroxetine (Paxil), an antidepressant (Musselman et al.,  2001 ). In short, cytokines may have great potential for helping us understand the links between physical and mental well-being that are at the heart of behavioral medicine.

Stress, Depression, and the Immune System

Did you know that stress slows the healing of wounds by as much as 24 to 40 percent (Kiecolt-Glaser et al.,  2002 )? This is because stress is linked to suppression of the immune system (Segerstrom & Miller,  2004 ). The list of stressors that have been linked to immunosuppression is varied and includes sleep deprivation, marathon running, space flight, being the caregiver for a patient with dementia, and death of a spouse (Cacioppo et al.,  1998 ; Schleifer et al.,  1985 ; Schleifer et al.,  1989 ; Vasiljeva et al.,  1989 ). On the positive side, there is evidence that laughter is associated with enhanced immune functioning (Berk et al.,  1988 ; Lefcourt,  2002 ).

Although short-term stress (such as occurs when we take an examination) compromises the immune system (Glaser et al.,  1985 ; Glaser et al.,  1987 ), it is the more enduring stressors such as unemployment or loss of a spouse that are associated with the most global immunosuppression. This is of particular concern in today’s difficult economic times. People who are unemployed have lower levels of immune functioning than people who are employed. The good news, however, is that immune functioning returns to normal again once people find another job (Cohen et al.,  2007 ).

Stress causes our immune system to function less efficiently.

Depression is also associated with compromised immune function (Kiecolt-Glaser et al.,  2002 ). Moreover, the relationship between depression and suppression of the immune system is at least partially independent of specific situations or events that may have provoked depressed feelings. In other words, the state of being depressed adds something beyond any negative effects of the stressors precipitating the depressed mood.

research CLOSE-UP: Correlational Research

In contrast to experimental research (which involves manipulating variables in some way and seeing what happens), in correlational research the researcher observes or assesses the characteristics of different groups, learning much about them without manipulating the conditions to which they are exposed.

Although there is a great deal of evidence linking stress to suppression of the immune system, researchers are becoming aware that both chronic stress and depression may also enhance certain immune system responses, although not in a good way (Robles et al.,  2005 ). Chronic stress and depression may trigger the production of proinflammatory cytokines such as interleukin-6 (IL-6). One  correlational research  study showed that women who were caring for a family member with Alzheimer’s disease had higher levels of IL-6 than women who were either anticipating the stress of relocation or who were experiencing neither of these stressors (Lutgendorf et al.,  1999 ). This difference was found even though the women who were caregivers were 6 to 9 years younger than the women in the other two groups and even though IL-6 levels are known to increase with age. Major depression has also been linked to enhanced production of proinflammatory cytokines, including IL-6, but treatment with antidepressant medications can reduce this elevation (Kenis & Maes,  2002 ).

These findings are especially interesting in light of research showing a relationship between IL-6 and aging, as well as to chronic diseases including certain cancers and cardiovascular disease (Papanicolaou et al.,  1998 ). Further evidence that higher levels of IL-6 are bad for health is suggested by their association with being overweight, smoking, and having a sedentary lifestyle (Ferrucci et al.,  1999 ).

One group of investigators has reported that older adults (average age 71 years) who regularly attended church had lower levels of IL-6 and were less likely to die during the course of a 12-year follow-up than those who did not go to church regularly (Lutgendorf et al.,  2004 ). These findings also held when other potential confounding variables such as age, social support, being overweight, having medical problems, and being depressed were also considered. Given all of the findings, it is not hard to see why researchers are becoming excited about the possibility that proinflammatory cytokines like IL-6 could be key mediators in the link between psychosocial factors and disease. Overall, what the research findings suggest is that chronic stress and depression can result in the immune system going out of balance in ways that may compromise health (see Robles et al.,  2005 ). In short, the potential for psychological factors to influence our health and for our health to affect our psychological well-being is becoming ever more apparent.

in review

·  • Describe the biological changes that occur when we are under stress.

·  • What is cortisol? Is cortisol beneficial or harmful?

·  • What is meant by the term allostatic load?

·  • Describe the relationship between stress and the immune system.

Stress and Physical Health

This chapter concerns the role of stress in physical and mental disorders. In this section we concern ourselves with medical conditions that are linked to stress. Because the brain influences the immune system, psychological factors are of great importance to our health and well-being. How you view problems and cope with challenges, and even your temperament, may directly affect your underlying physical health.

Negative emotions such as depression, anxiety, and anger may be especially important to avoid because they are associated with poor health (Kiecolt-Glaser et al.,  2002 ). On the other hand, an optimistic outlook on life, as well as an absence of negative emotions, may have some beneficial health consequences (see Rasmussen et al.,  2009 ). Indeed, there is now a growing interest in  positive psychology  (Snyder & Lopez,  2002 ). This school of psychology focuses on human traits and resources such as humor, gratitude, and compassion that might have direct implications for our physical and mental well-being.

An illustration of this comes from a study by Witvliet and colleagues ( 2001 ). These researchers asked college students to select a real-life interpersonal offense (such rejection, betrayals of trust, and personal insults) that they had experienced in the past. The researchers then collected self-reports as well as heart rate, blood pressure, and facial muscle tension data from the students while they were imagining responding to the real-life transgression in a way that was either forgiving or unforgiving. In the forgiving condition, the students were asked to think about granting forgiveness or developing feelings of empathy for the perpetrator. In the unforgiving condition, they were asked to stay in the victim role, to go over the hurt in their minds, and to nurse a grudge.

Forgiving those who have wronged us may lower our stress levels and enhance overall well-being.

The findings showed that when they were asked to be forgiving, participants did indeed report more feelings of empathy and forgiveness. And, when asked to ruminate and be unforgiving, participants reported that they felt more negative, angry, sad, aroused, and out of control. They also showed greater tension in their brows. Importantly, their heart rates went up, their blood pressures increased, and their skin conductance (a measure of SNS arousal) revealed more arousal. Even more striking was the finding that even after the grudge-harboring imagery was over and the subjects were told to relax, they were unable to do so. In other words, the high state of physiological arousal that had been triggered by dwelling on the past hurt could not easily be turned off.

What are the implications of these findings? Although fleeting feelings of anger probably do us no real harm, people who have a tendency to brood about the wrongs that other people have done to them may be doing themselves a major disservice. To the extent that perpetuating feelings of anger and increasing cardiovascular reactivity have consequences for heart disease and immune system functioning, harboring grudges may be hazardous to our health. Although it is not always easy, forgiving those who have offended us may lower our stress levels and enhance our well-being.

in review

·  • What individual characteristics are associated with better or worse health?

·  • What is positive psychology?

·  • What are the physiological consequences of being unforgiving?

Cardiovascular Disease

Because cardiovascular disease is the leading cause of death in the United States (American Heart Association,  2001 ), and because the impact of stress on the heart has been well researched, we use this disease to illustrate the many links between psychological factors and physical disease. Some of these are illustrated in the following case study. As you read the case of Dr. M., consider the role that negative emotions play. Also consider Dr. M’s personality. Do you consider him an optimist or a pessimist?

The Angry Physician Dr. M was a 44-year-old physician. The middle son of parents who had emigrated from Italy, he was ambitious and determined to make a successful life for himself and his family. He worked long hours helping patients with cancer, and he was caring and compassionate. His patients loved him. But his job was also very stressful. Added to the many demands of maintaining a busy medical practice was the great sadness that he felt when (inevitably) many of his terminally ill patients died.

At home Dr. M was a loyal husband and devoted father to his three children. But he was not an easy person to live with. He found it hard to relax, and he had a very volatile disposition. He was frequently angry and would shout at everyone whenever he had had a bad day. Often his moods were caused by his feeling that he was not fully appreciated by the other doctors with whom he worked. Although his wife realized that he “just needed to vent,” his moods took a toll on the family. His children distanced themselves from him much of the time, and his wife became less and less happy in the marriage.

One day at work, Dr. M started to feel unwell. He began to sweat and experienced a heavy pressure in his chest. It was difficult for him to breathe. Dr. M recognized the severity of his symptoms and called out for medical help. He had a sudden and severe heart attack and survived only because he was working in a hospital at the time of the attack. If he had not received prompt medical attention, he almost certainly would have died.

After his heart attack Dr. M became very depressed. It was almost as though he could not accept that he, a physician, had a severe medical problem. Although he lived in fear of having another heart attack, his efforts to lose weight (which his doctor had told him to do) were sabotaged by his unwillingness to follow any diet. He would try and then give up, coming back from the Italian bakery with bags of pastries. Making the problem worse was the fact that because he was a doctor, his own doctors were somewhat reticent about telling him what he had to do to manage his illness. He went back to work, and his family walked on eggshells, afraid to do or say anything that might stress him. His wife tried to encourage him to follow the doctors’ recommendations. However, Dr. M’s attitude was that if he was going to die anyway, he might as well enjoy himself until he did.

Hypertension

When we are stressed the blood vessels supplying our internal organs constrict (become more narrow) and blood flows in greater quantity to the muscles of the trunk and limbs. When this happens the heart must work harder. As it beats faster and with greater force, our pulse quickens and blood pressure increases. When the period of stress is over, blood pressure returns to normal. If the emotional strain is more enduring, however, high blood pressure may become a chronic problem.

Ideally, blood pressure should be below 120/80. (By convention, the first number given is the systolic pressure when the heart contracts; the second is the diastolic or between-beat pressure; see  Figure 5.3  on p. 139.) The unit of measurement is millimeters of mercury (Hg). The definition of  hypertension  is having a persisting systolic blood pressure of 140 or more and a diastolic blood pressure of 90 or higher. Blood pressure is simple and painless to measure by means of the familiar inflated arm cuff.

In general, blood pressure increases as we age. In younger adults, more men than women suffer from high blood pressure. After about age 50, however, the prevalence of hypertension is greater in women (Burt et al.,  1995 ), probably because meno-pause amplifies the stiffness in the arteries that naturally occurs with increasing age (Takahashi et al.,  2005 ). Current estimates suggest that sustained hypertension afflicts around 28 percent of Americans (Friedewald et al., 2010).

A small percentage of cases of hypertension are caused by distinct medical problems. However, in the majority of cases there is no specific physical cause. This is referred to as  essential hypertension . Hypertension is an insidious and dangerous disorder. The person who has it may have no symptoms until its consequences show up as medical complications. Hypertension increases the risk of coronary heart disease and stroke. It is also often a causal factor in occlusive (blocking) disease of the peripheral arteries, congestive heart failure (due to the heart’s inability to overcome the resistance of constricted arteries), kidney failure, blindness, and a number of other serious physical ailments.

Many clinicians and investigators think that hypertension begins when a person has a biological tendency toward high cardiovascular reactivity to stress (e.g., Tuomisto,  1997 ; Turner,  1994 ). This might be considered to represent a diathesis, or vulnerability factor. Over time, and in the face of chronic and difficult life circumstances, which create stress, the vulnerable person will go from having borderline hypertension to having a serious clinical problem. Not being able to express anger in a constructive way (e.g., by expressing why one feels angry and trying to reach an understanding by engaging in open communication with the person one is angry with) may also increase a person’s risk for hypertension (Davidson et al.,  2000 ).

FIGURE 5.3 Defining Hypertension. Blood pressure levels once thought normal are now considered high enough to signal prehypertension.

HYPERTENSION AND AFRICAN AMERICANS

African Americans have much higher rates of hypertension than European Americans (40% versus 27%; see Fox et al.,  2011 ). Their death rate from hypertension is also three times higher. Interestingly, the higher prevalence of hypertension in African Americans is not just found in the United States but seems to be the case for blacks worldwide. Rates of hypertension in young people are also alarmingly high. Ten percent of African American men aged 18 to 21 have hypertension compared with prevalence rates of 1 to 2 percent in other groups (see Friedewald et al., 2010).

Higher levels of stress from such factors as inner-city living, economic disadvantage, exposure to violence, and race-based discrimination may play a key role in this (Din-Dzietham et al.,  2004 ; Wilson et al.,  2004 ). Lifestyle may also be a factor. African American women in particular are more likely to be overweight than Caucasian women (see Whitfield et al.,  2002 ). African Americans are also less likely to exercise than Caucasians are (Bassett et al.,  2002 ; Whitfield et al.,  2002 ), perhaps because many live in places where health clubs are scarce and it is not safe to walk outside.

Biological factors likely also play a role. Like most Americans, African Americans consume a lot of fast food, which is loaded with salt. There is evidence that, as a group, African Americans are more likely to retain sodium, which results in fluid retention and endocrine changes that in turn elevate blood pressure (Anderson & McNeilly,  1993 ). Renin, an enzyme produced by the kidneys that is linked to blood pressure, is also processed differently by African Americans. Finally, studies suggest that nitric oxide (a dissolved gas that is crucial for the proper functioning of blood vessels and blood cells) is produced in lower levels in the blood vessels of African Americans and may also be destroyed more quickly too. All of these biological differences, as well as the presence of some specific genes (see Fox et al.,  2011 ), may increase the risk that African Americans have of developing hypertension.

Coronary Heart Disease

The heart is a pump, made of muscle. Coronary heart disease (CHD) is a potentially lethal blockage of the arteries that supply blood to the heart muscle, or myocardium. If the muscles of the heart are not getting enough oxygenated blood, the person may experience severe chest pain (angina pectoris). This is a signal that the delivery of oxygenated blood to the affected area of the heart is insufficient for its current workload. An even more severe problem is myocardial infarction. This results from a blockage in a section of the coronary arterial system. Because the heart muscle is being deprived of oxygen, tissue may die, permanently damaging the heart. If the myocardial infarction is extensive enough the person may not survive. Many instances of sudden cardiac death, in which victims have no prior history of CHD symptoms, are attributed to silent CHD. This often occurs when a piece of the atherosclerotic material adhering to the arterial walls (a “plaque”) breaks loose and lodges in a smaller vessel, blocking it. Every year, more than 900,000 people in the United States experience a myocardial infarction (Schwartz et al.,  2010 ).

Risk and Causal Factors in Cardiovascular Disease

CHRONIC AND ACUTE STRESS

Stress increases the risk of having a heart attack. Several researchers have documented that deaths from CHD rise in the days and weeks following a severe earthquake (see Leor et al.,  1996 ). As  Figure 5.4  shows, after the Northridge earthquake in Los Angeles in 1994, the number of sudden deaths due to CHD rose from an average of 4.6 (in the days preceding the earthquake) to 24 on the day of the earthquake (Kloner et al.,  1997 ). There was also an increase in sudden death from cardiac events after the Hanshin-Awaji earthquake in Japan (Kario & Ohashi,  1997 ).

Everyday forms of stress can also elevate risk for CHD and death (Matthews & Gump,  2002 ; Smith & Ruiz,  2002 ). A good example is work-related stress. Here the key factors appear to be having a highly demanding job and having little control over decision making. Both of these types of job stress increase risk for future CHD. Moreover, this association still holds when other negative health behaviors (such as smoking) are controlled (see Peter & Siegrist,  2000 ). It is also interesting to note that, in people who work, most heart attacks occur on a Monday. The stress of returning to work after the weekend is thought to play a role in this (Kloner et al., 2006).

Finally, simply being asked to give a 5-minute speech about an assigned topic to a small (but evaluative) audience was enough to produce detectable changes in cardiac function in about 20 percent of patients with existing coronary artery disease (see Sheps et al.,  2002 ). Furthermore, those patients who were most reactive to this form of mental stress were almost three times more likely (compared to the less reactive patients) to die in the next 5 to 6 years. Mental stress is known to raise systolic blood pressure and also to cause an elevation in epinephrine. Mental stress may also reduce the oxygen supply to the heart muscle (Yeung et al.,  1991 ). What the results of the Sheps study illustrate, however, is that stress does not have to be extreme or severe to be associated with lethal consequences later.

FIGURE 5.4 Cardiac Deaths and Earthquakes. On the day of the Northridge earthquake in California (January 17, 1994), cardiac deaths showed a sharp increase.

Source: Leor et al.,  1996 . The New England Journal of Medicine, 334(7), February 15, 1996, p. 415.

research CLOSE-UP: Risk Factor

A risk factor is a variable that increases the likelihood of a specific (and usually negative) outcome occurring at a later time. For example, obesity is a risk factor for heart disease; perfectionism is a risk factor for eating disorders.

PERSONALITY

Attempts to explore the psychological contribution to the development of CHD date back to the identification of the  Type A behavior pattern  (Friedman & Rosenman,  1959 ). Type A behavior is characterized by excessive competitive drive, extreme commitment to work, impatience or time urgency, and hostility. Many of us know people who are like this, and the term Type A is now quite commonly used in everyday language.

Interest in Type A behavior escalated after the results of the Western Collaborative Group Study began to be published. This investigation involved some 3,150 healthy men between the ages of 35 and 59 who, on entry, were typed as A or B status. (Type B personalities do not have Type A traits and tend to be more relaxed, more laid-back, and less time-pressured people.) All the men were then carefully followed for eight and a half years. Compared to Type B personality, Type A personality was associated with a twofold increase in coronary artery disease and an eightfold increased risk of recurrent myocardial infarction over the course of the follow-up (Rosenman et al.,  1975 ).

The second major study of Type A behavior and CHD was the Framingham Heart Study. This began in 1948 and involved the long-term follow-up of a large sample of men and women from Framingham, Massachusetts (see Kannel et al.,  1987 ). Approximately 1,700 CHD-free subjects were typed as A or B in the mid-1960s. Analysis of the data for CHD occurrence during an 8-year follow-up period not only confirmed the major findings of the earlier Western Collaborative Group Study but extended them to women as well.

Not all studies reported positive associations between Type A behavior and risk of coronary artery disease, however (Case et al.,  1985 ; Shekelle et al.,  1985 ). Moreover, as research with the construct has continued, it has become clear that it is the hostility component of the Type A construct (including anger, contempt, scorn, cynicism, and mistrust) that is most closely correlated with coronary artery deterioration (see Rozanski et al.,  1999 , for a summary of studies).

A more recent development is the identification of the “distressed” or  Type D personality  type (Denollet et al.,  2000 ). People with Type D personality have a tendency to experience negative emotions and also to feel insecure and anxious. Men with CHD who scored high on measures of chronic emotional distress were more likely to have fatal and nonfatal heart attacks over the 5-year follow-up period than were men who did not have these Type D personality traits (Denollet et al.,  2000 ). People with higher scores on the negative affectivity component of Type D personality (see  Figure 5.5 ) are also at increased risk of having more problems after cardiac surgery (Tully et al.,  2011 ). Overall, the Type D personality construct also provides a way to tie in some of the other findings linking negative emotions and CHD, which we discuss more below.

FIGURE 5.5 Characteristics of the Type D Personality .

Source: Based on Johan Denollet. 1998 Personality and coronary heart disease: The type-D Scale-16 (DS16). Annals of Behavioral Medicine, 20 (3) 209–215, and N. Kupper and J. Denollet ( 2007 ). Type D Personality as a prognostic factor in heart disease: Assessment and mediating mechanisms. Journal of Personality Assessment, 89 (3) 265–276.

DEPRESSION

People with heart disease are approximately three times more likely than healthy people to be depressed (Chesney,  1996 ; Shapiro,  1996 ). This may not strike you as especially surprising. If you had heart disease, perhaps you would be depressed too. However, depression is much more commonly found in people who have heart disease than it is in people who have other serious medical problems, like cancer (Miller & Blackwell,  2006 ). Furthermore, heart attack patients with high levels of depressive symptoms after having a heart attack are three times more likely to die over the next 5 years than patients who do not show high levels of depression (Glassman,  2007 ; Lesperance et al.,  2002 ). The most recent research in this area suggests that anhedonia (which is a symptom of depression characterized by profound loss of interest or pleasure) may be especially predictive of increased mortality after a heart attack (Davidson et al.,  2010 ).

Depression also appears to be a risk factor for the development of CHD. Pratt and her colleagues ( 1996 ), for 14 years, followed over 1,500 men and women with no prior history of heart disease. They found that 8 percent of those who had experienced major depression at some point and 6 percent of those who had experienced mild depression at some point had a heart attack during the 14-year follow-up interval. By contrast, only 3 percent of those without a history of depression suffered heart attacks. When medical history and other variables were taken into account, those who had experienced major depression were found to be four times more likely to have had a heart attack. Similar findings have also been reported in other studies (Ferketich et al.,  2000 ; Ford et al.,  1998 ).

Why are depression and heart disease so closely linked? Current thinking is that this is another example of the mind–body connection. Stress is thought to activate the immune system, triggering the production of proinflammatory cytokines such as IL-1, IL-6, and tumor necrosis factor by the white blood cells. Long-term exposure to these proinflammatory cytokines is thought to lead to changes in the brain that manifest themselves as symptoms of depression. Proinflammatory cytokines also trigger the growth of plaques in the blood vessels as well as making it more likely that those plaques will rupture and cause a heart attack. In other words, as illustrated in  Figure 5.6 , the link between heart disease and depression is due to inflammation and the presence of inflammatory cytokines (see Miller & Blackwell,  2006 ; Robles et al.,  2005 ). This is why doctors now test for the presence of C-reactive protein (CRP)—a molecule produced by the liver in response to IL-6—when they want to assess a person’s risk for heart disease. New research is also linking discrimination to elevated levels of CRP in African Americans (see The World Around Us box on p. 142).

FIGURE 5.6 Model of how inflammatory processes mediate the relations among chronic stressors, depressive symptoms, and cardiac disease. Stressors activate the immune system in a way that leads to persistent inflammation. With long-term exposure to the molecular products of inflammation, people are expected to develop symptoms of depression and experience progression of cardiac disease.

Source: Miller & Blackwell.  2006 , Dec. Turning Up the Heat: Inflammation as a Mechanism Linking Chronic Stress, Depression and Heart Disease. Current Directions in Psychological Science, 15, (6): 269–272(4). Copyright © 2006. Reproduced with permission of Blackwell Publishing Ltd.

ANXIETY

Depression is not the only form of negative affect that is linked to CHD. Research has also demonstrated a relationship between phobic anxiety and increased risk for sudden cardiac death. In a classic early study, Kawachi, Colditz, and colleagues ( 1994 ) studied nearly 34,000 male professionals who had been assessed for panic disorder, agoraphobia, and generalized anxiety. Over the course of the 2-year follow-up study, sudden cardiac death was six times higher in the men with the highest levels of anxiety. The findings were replicated in a second study of nearly 2,300 men who were participating in a normative aging study (Kawachi, Sparrow, et al.,  1994 ,  1995 ). Prospective studies of women (who were free of cardiac disease at the start of the study) have also linked phobic anxiety with a higher risk of sudden cardiac death (Albert et al.,  2005 ).

SOCIAL ISOLATION AND LACK OF SOCIAL SUPPORT

the WORLD around us: Racial Discrimination and Cardiovascular Health in African Americans

Experiences of discrimination have been linked to a number of bad health outcomes, including increased blood pressure and signs of cardiovascular disease. But how might this association arise? New research suggests that an important mediator in this relationship could be C-reactive protein, or CRP.

CRP is a protein synthesized in the liver. High levels of CRP signal widespread inflammation in the body. In an interesting study, Lewis and colleagues ( 2010 ) measured levels of CRP in blood samples taken from 296 older African Americans, whose average age was 73. These research participants also completed a questionnaire that asked about their experiences of everyday discrimination. Items on the questionnaire included being treated with disrespect, getting poorer service in restaurants or stores, as well as experiences of being insulted or harassed.

The findings revealed a significant correlation between everyday discrimination and CRP, where more experiences of discrimination were associated with higher levels of CRP. The association also remained even after factors such as smoking, high blood pressure, depression, and other health problems were considered. Although much more remains to be learned, these preliminary findings are very exciting. They provide a clue about a potential pathway through which experiences of racial bias might ultimately play a role in the poor cardiovascular health of older African Americans.

Studies point to the strong link between social factors and the development of CHD. Monkeys housed alone have four times more atherosclerosis (fatty deposits in blood vessels that eventually create a blockage) than monkeys housed in social groups (Shively et al.,  1989 ). Similarly, people who have a relatively small social network or who consider themselves to have little emotional support are more likely to develop CHD over time (see Rozanski et al.,  1999 , for a review).

For people who already have CHD, there is a similar association. In one study of people who had already suffered a heart attack, those who reported that they had low levels of emotional support were almost three times more likely to experience another cardiac event (Berkman et al.,  1992 ). In another study, death in CHD patients was three times more likely over the next 5 years if they were unmarried or had no one that they could confide in (Williams et al.,  1992 ). Echoing these findings, Coyne and colleagues ( 2001 ) have shown that the quality of the marital relationship predicts 4-year survival rates in patients with congestive heart failure. Although uncertain at this time, it may be that the stress that comes from marital tension or from a lack of social support triggers an inflammatory response in the immune system, causing depression and heart problems as a result. It may also be that depression, which is linked to relationship problems, could trigger an inflammatory response in its own right.

THE IMPORTANCE OF EMOTION REGULATION

If hostility, depression, and anxiety are all predictive of developing coronary heart disease, is it beneficial to be able to regulate one’s emotions? New research suggests that it is. In one study of men and women without a history of heart disease, it was found that it was the people who were least able to control their anger who developed more heart problems over the next 10 to 15 years (Haukkala et al.,  2010 ). In another study of 1,122 men who were followed for an average of 13 years, it was again those with the best emotion regulation skills who were the least likely to develop cardiac disease (Kubzansky et al.,  2011 ). Taken together these findings suggest that self-regulation skills may be very important—not only for our psychological well being but for our physical health as well.

in review

·  • What is essential hypertension, and what are some of the factors that contribute to its development?

·  • What risk factors are associated with coronary heart disease?

·  • What is Type A personality?

·  • What is Type D personality?

·  • How might racial bias play a role in the development of cardiovascular disease?

Treatment of Stress-Related Physical Disorders

As you have learned, environmental stressors are often closely linked to the development of a physical illness. Unfortunately, once an illness has developed and physical changes have taken place, removal of the stressor may not be enough to bring about recovery and restore health. This emphasizes the value of prevention and highlights the importance of stress management.

Biological Interventions

People who have serious physical diseases obviously require medical treatment for their problems. For patients with CHD, such treatments might include surgical procedures as well as medications to lower cholesterol or reduce the risk of blood clots. However, in light of the strong associations between depression and risk for CHD, treating depression is also of the utmost importance. Unfortunately, most people with clinical depression go untreated, resulting in an unnecessary added risk for CHD. Moreover, even though there is no medical risk factor that is more important in predicting mortality for patients who have already had a heart attack (Welin et al.,  2000 ), physicians often fail to treat depression in their cardiac patients. Instead, they dismiss it as an understandable consequence of having had a life-threatening medical scare (Glassman,  2005 ). Of those with major depression at the time of a heart attack, approximately one-half of those who have gone without treatment remain depressed or else have relapsed again 1 year later (Hance et al.,  1996 ). However, research shows that thousands of lives can be saved each year by giving antidepressant medications to patients who have suffered a myocardial infarction and who are depressed. In one study, patients treated with selective serotonin reuptake inhibitors (SSRIs) were much less likely to die or have another heart attack than patients who were not taking antidepressant medications (Taylor et al.,  2005 ). It is also worth noting that, in this study, treatment with cognitive-behavior therapy (CBT; see  Chapter 16  for more about this approach) was not associated with reduced mortality in the patients, although CBT treatment did help alleviate depression (see Berkman et al.,  2003 ; Glassman,  2005 ).

Psychological Interventions

How can we help ourselves stay healthy in the face of stress? As we have already mentioned, developing effective emotion regulation skills is probably beneficial. Evidence suggests that the following approaches are also helpful.

EMOTIONAL DISCLOSURE

“Opening up” and writing expressively about life problems in a systematic way does seem to be an effective therapy for many people with illnesses (Pennebaker,  1997 ). In the first study of emotional disclosure in people with rheumatoid arthritis, Kelley, Lumley, and Leisen ( 1997 ) found that people who had written about their emotions had significantly less physical dysfunction than those assigned to a control condition. In another study, people with either rheumatoid arthritis or asthma were asked to write about either their most traumatically stressful life experience or (in the case of the control group) their plans for the day. Subjects wrote for 20 minutes for 3 consecutive days. When they were assessed 4 months later, the participants with rheumatoid arthritis who were assigned to the emotional disclosure condition were doing significantly better than the participants with rheumatoid arthritis assigned to the control group.

In studies that involve emotional disclosure, patients often experience initial increases in emotional distress during the writing phase but then show improvement in their medical status over follow-up. Why emotional disclosure provides clinical benefits for patients is still not clear, however. One reason could be that patients are given an opportunity for emotional catharsis, or “blowing off steam.” Another possibility is that writing gives people an opportunity to rethink their problems. Given what we know about the link between emotional and physical well-being, it is not unreasonable to speculate that both emotional catharsis and rethinking problems could help improve immune function or perhaps decrease levels of circulating stress hormones.

BIOFEEDBACK

Biofeedback procedures aim to make patients more aware of such things as their heart rate, level of muscle tension, or blood pressure. This is done by connecting the patient to monitoring equipment and then providing a cue (for example, an audible tone) to the patient when he or she is successful at making a desired response (e.g., lowering blood pressure or decreasing tension in a facial muscle). Over time, patients become more consciously aware of their internal responses and able to modify them when necessary.

Biofeedback seems to be helpful in treating some conditions, such as headaches (Nestoriuc et al.,  2008 ). After an average of 11 sessions, patients report improvement in their symptoms and a decrease in the frequency of their headaches. Moreover, these treatment effects tend to be stable over time. Although it is especially helpful for children and adolescents, adults who have experienced headaches for a long time are also helped by biofeedback.

RELAXATION AND MEDITATION

Researchers have examined the effects of various behavioral relaxation techniques on selected stress-related illnesses. The results have been variable, though generally encouraging. For example, there is evidence that relaxation techniques can help patients with essential hypertension (see Blumenthal et al.,  2002 ). Relaxation training can also help patients who suffer from tension headaches (Holroyd,  2002 ). However, in general, headache sufferers treated with biofeedback appear to do better than those treated only with relaxation, and the best clinical results occur when these two treatments are combined (Nestoriuc et al.,  2008 ).

A growing topic of interest is meditation. Schneider and colleagues ( 2005 ) have shown that the daily practice of Transcendental Meditation may be helpful in reducing blood pressure. In this study, 194 African American patients with chronic hypertension were randomly assigned to receive training in either Transcendental Meditation or progressive muscle relaxation (which involves tensing and relaxing various muscle groups in a systematic way) or else to receive general information about lifestyle changes that would be helpful to them. Patients who practiced Transcendental Meditation for 20 minutes twice a day reduced their diastolic blood pressure significantly more than did patients who practiced muscle relaxation or who received sound health care advice.

Making an effort to slow down and relax may provide many health benefits.

COGNITIVE-BEHAVIOR THERAPY

CBT has been shown to be an effective intervention for headache (Martin, Forsyth et al.,  2007 ) as well as for other types of pain. CBT-oriented family therapy was markedly more successful than routine pediatric care in alleviating children’s complaints of recurrent abdominal pain (Robins et al.,  2005 ). Some CBT techniques have also been used for patients suffering from rheumatoid arthritis. Compared to those receiving standard medical care, patients who received CBT showed better physical, social, and psychological functioning (Evers et al.,  2002 ).

Finally, we note that making a conscious effort to slow down and enjoy life seems to be a prescription for better health. Meyer Friedman, who was the codiscoverer of the link between Type A behavior and heart disease, had a heart attack at age 55. A self-described Type-A personality, he made a conscious choice to change his ways in accordance with his own discoveries. To get more in touch with his slow, patient, and creative side, he read Proust’s languid seven-volume opus Remembrance of Things Past three times. In short, he trained himself to relax and to enjoy life. He had the last laugh at stress by living to the ripe old age of 90 (Wargo,  2007 ).

in review

·  • Why is it so important to screen people with heart disease for depression?

·  • What clinical approaches have been used to help people?

Stress and Mental Health

Our focus thus far has been to describe the nature of stress, highlighting the role it plays in physical disorders. But, as we have noted repeatedly throughout this chapter, when we experience stress, we pay a price not only in our bodies but also in our minds. In the sections below, we discuss the psychological consequences of experiencing the kind of stress that overwhelms our abilities to adjust and to cope. More specifically, we focus on two DSM disorders,  adjustment disorder  and PTSD. Both of these are triggered by exposure to stress. There is an important difference between them, however. In adjustment disorder, the stressor is something that is commonly experienced, and the nature of the psychological reaction is much less severe. In the case of PTSD, there is exposure to a traumatic stressor that is accompanied by fear, helplessness, or horror. Not surprisingly, the stress disorder that results from this can be intense and debilitating.

Adjustment Disorder

An adjustment disorder is a psychological response to a common stressor (e.g., divorce, death of a loved one, loss of a job) that results in clinically significant behavioral or emotional symptoms. The stressor can be a single event, such as going away to college, or involve multiple stressors, such as a business failure and marital problems. People undergoing severe stress that exceeds their coping resources may warrant the diagnosis of adjustment disorder (Strain & Newcorn,  2007 ). For the diagnosis to be given, symptoms must begin within 3 months of the onset of the stressor. In addition, the person must experience more distress than would be expected given the circumstances or be unable to function as usual.

In adjustment disorder, the person’s symptoms lessen or disappear when the stressor ends or when the person learns to adapt to the stressor. In cases where the symptoms continue beyond 6 months, the diagnosis is usually changed to some other mental disorder. Adjustment disorder is probably the least stigmatizing and mildest diagnosis a therapist can assign to a client. Next we discuss two situations that frequently lead to adjustment disorder.

Adjustment Disorder Caused By Unemployment

Work-related problems can produce great stress in employees (Lennon & Limonic,  2010 ). But being unemployed can be even more stressful. As a result of the recent recession millions of Americans have been coping with chronic unemployment. Tony is one of them.

Maybe Today Will Be the Day Tony wakes up at 5:30 every morning and makes coffee. He arranges his laptop, phone, and notepad on the kitchen table. And then he waits for the phone to ring. Unemployed for the last 16 months after losing his job as a transportation sales manager, Tony spends the day sending out resumes and cover letters. But most days nothing happens. “The worst moment is at the end of the day when it’s 4:30 and you did everything you could, and the phone hasn’t rung, the emails haven’t come through,” says Tony. He asks himself what he is doing wrong. Tony misses his old routine of getting dressed in the morning and going out to work. But he tries to stay optimistic. “You always have to hope that that morning when you get up, it’s going to be the day.” (Based on Kwoh,  2010 )

Unemployment reached a peak of 10.6 percent of the labor force in January 2010. It is now around 7.6 percent (Bureau of Labor Statistics,  2013 ). In almost every community, one can find workers who have been laid off from jobs they had held for many years and who are facing the end of their unemployment compensation. Unemployment is an especially severe problem for young minority males, many of whom live in a permanent economic depression with few job prospects. Rates of unemployment for blacks are twice as high as they are for whites (Bureau of Labor Statistics,  2013 ).

Managing the stress associated with unemployment requires great coping strength, especially for people who have previously earned an adequate living. Some people (like Tony in the case example above) find ways to stay focused and motivated, even though this can be very difficult at times. For others, however, unemployment can have serious long-term effects. One of the most disturbing findings is that unemployment, especially if it is prolonged, increases the risk of suicide (Borges et al,  2010 ; Classen & Dunn,  2011 ). Unemployment also takes its toll on other family members, especially children. When children live in families where a parent has lost a job, they are 15 percent more likely to have to repeat a grade at school (Stevens & Schaller,  2009 ).

in review

·  • What is an adjustment disorder?

·  • What kinds of stressors are potential triggers for the development of an adjustment disorder?

Posttraumatic Stress Disorder

In DSM-5 post-traumatic stress disorder is now grouped with other disorders in a new diagnostic category called trauma- and stressor-related disorders. Adjustment disorder, which we have just discussed, and acute stress disorder (see next section) are also part of this new diagnostic category. This is because the experience of major stress is central to the development of all of these conditions.  Watch the Video Bonnie: Posttraumatic Stress Disorder on MyPsychLab

DSM-5 criteria for: Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

·  A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

·  1. Directly experiencing the traumatic event(s).

·  2. Witnessing, in person, the event(s) as it occurred to others.

·  3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

·  4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

·  B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

·  1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

·  2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

·  3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

·  4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

·  5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

·  C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

·  1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

·  2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

·  D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

·  1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

·  2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

·  3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

·  4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

·  5. Markedly diminished interest or participation in significant activities.

·  6. Feelings of detachment or estrangement from others.

·  7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

·  E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

·  1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

·  2. Reckless or self-destructive behavior.

·  3. Hypervigilance.

·  4. Exaggerated startle response.

·  5. Problems with concentration.

·  6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

·  F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

·  G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

·  H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

The diagnosis of PTSD first entered the DSM in 1980 (see the DSM table for current clinical criteria). At this time, psychiatry began to realize that many veterans were emotionally scarred and unable to return to normal civilian life after their military service in Vietnam. The proposal to include PTSD in the diagnostic system was initially opposed, not least because including a disorder that had a clear and explicit cause (trauma) was inconsistent with the atheoretical nature of the DSM. Nonetheless, a consensus emerged that any extreme, terrifying, and stressful event that was life-threatening and outside the ordinary bounds of everyday experience could lead to psychological symptoms similar to those experienced by the Vietnam veterans. In other words, at the time of its entry into the DSM (which is after all a manual of mental disorders), PTSD was viewed as a normal response to an abnormal stressor (see McNally,  2008 ). In the Thinking Critically About DSM-5 below we describe how changes to the diagnostic criteria for PTSD have changed over time.

However, in keeping with the diathesis-stress model, research over the past two decades has made it clear that certain preexisting vulnerabilities also play an important role. Traumatic stressors include combat, rape, being confined in a concentration camp, and experiencing a natural disaster such as a tsunami, earthquake, or tornado.

Stress symptoms are very common in the immediate aftermath of a traumatic event. However, for most people, these symptoms decrease with time. Rothbaum and Foa ( 1993 ) reported that 95 percent of women who had been raped met the symptom criteria for PTSD within 2 weeks of the assault. One month after the rape, this figure had declined to 63.3 percent of women, and after 3 months, 45.9 percent of the women were diagnosed with the PTSD. Natural recovery with time is therefore a common pattern.

DSM-5 THINKING CRITICALLY about DSM-5: Changes to the Diagnostic Criteria for PTSD

When PTSD was first introduced into the DSM, the diagnostic criteria required exposure to a traumatic event that was “outside the range of usual human experience” and that would cause “significant symptoms of distress in almost anyone.” The exemplars provided included rape, earthquakes, torture, and military combat. In other words, the emphasis was on the nature of the stressor itself and not on the emotional response of the victim (Breslau & Kessler,  2001 ; McNally,  2008 ; Shalev,  2009 ).

A major change occurred with DSM-IV-TR. Not only was there a broadening of the range of experiences that could now be used to diagnose PTSD, but it was also required that the person’s response involve “intense fear, helplessness or horror.” Qualifying events could now include learning about the death of a close friend or relative (as long as the death was sudden and unexpected), being diagnosed with a life-threatening illness, or learning about traumatic events experienced by others. In short, there was a change in emphasis from the characteristics of the stressor to the experience of the victim. Rather than conceptualizing PTSD as a normal response to an abnormal stressor, in DSM-IV, PTSD was viewed as a pathological response to an extreme form of stress (McNally,  2008 ).

The implications of these changes were not trivial. Using the wider variety of stressors permitted in DSM-IV, a survey of community residents revealed that the vast majority (89.6%) reported that they had been exposed to a traumatic event that (given also the required level of emotional response and presence of other symptoms) would potentially qualify them for PTSD diagnosis (Breslau & Kessler,  2001 ). In most cases, the traumatic event was learning of the sudden and unexpected death of a loved one.

Moreover, females who reported traumatic events were much more likely than males to also report that they had had an emotional reaction that was severe enough for them to qualify for the PTSD diagnosis. So not only was the definition of a traumatic event broadened, but the kind of emotional response that qualifies for PTSD was much more likely to be reported by women than by men (Pratchett et al.,  2010 ).

In DSM-5, the diagnostic criteria for PTSD have been tightened. The traumatic event must now be experienced by the person directly, either because the event happens to you or because you witness, in person, something traumatic happening to someone else. No longer is it possible to experience trauma indirectly through electronic media (which could occur when someone watches television footage of a terrible event). As before, there is also a provision for experiencing trauma by learning of the death of another person. However, the person must be a close friend or relative and their death must have been violent or accidental. Yet another change is the removal of the requirement that the person respond in a particular way (i.e., with fear, helplessness, or horror) because this confounds the response with the event itself (Mc-Nally,  2009 ) and also makes it more likely that women will receive the diagnosis. Defining trauma exposure is difficult to do. Nonetheless, we believe that the modifications that have been made to the DSM criteria are good overall. Tightening the diagnostic criteria in these ways means that PTSD is more likely to remain a distinct diagnosis reserved for people who have experienced devastating life events. No longer will it be possible to diagnose PTSD in people who merely watch traumatic events on their computer or television screens and are very distressed by what they see.

Acute Stress Disorder

The diagnosis of PTSD requires that symptoms must last for at least 1 month. What this means is that, in the study just described, the women who had symptoms within 2 weeks of the assault would not be diagnosed with PTSD. Instead, the diagnosis would be  acute stress disorder . Acute stress disorder is a diagnostic category that can be used when symptoms develop shortly after experiencing a traumatic event and last for at least 2 days. The existence of this diagnosis means that people with symptoms do not have to wait a whole month to be diagnosed with PTSD. Instead they can receive treatment as soon as they experience symptoms (Cardeña & Carlson,  2011 ). Moreover, if symptoms persist beyond 4 weeks, the diagnosis can be changed from acute stress disorder to posttraumatic stress disorder. Studies show that people who develop an acute stress disorder shortly after traumatic event are indeed at increased risk of developing PTSD (Kleim et al.,  2007 ). This highlights the importance of early intervention.

Of course, PTSD is not the only disorder that can develop after a traumatic experience. Bryant and colleagues ( 2010 ) conducted a prospective study of a large sample of people who were injured in accidents. They were assessed at the time of their injury and then followed up 3 and 12 months later. The investigators found that, 12 months after injury, 31 percent of patients reported a psychiatric disorder, and 22 percent of them had a disorder they had never experienced before. The most common disorders were depression (9%), generalized anxiety disorder (9%), and PTSD (6%).

Clinical Description

In PTSD a traumatic event is thought to cause a pathological memory that is at the center of the characteristic clinical symptoms associated with the disorder (McNally,  2013 ). These memories are often brief fragments of the experience and often concern events that happened just before the moment with the largest emotional impact (e.g., “Perpetrator standing at the window with the knife,” Hackman et al.,  2004 ). In DSM-5, the clinical symptoms of PTSD are grouped into four main areas. These concern the following:

·  1. Intrusion: Recurrent reexperiencing of the traumatic event through nightmares, intrusive images, and physiological reactivity to reminders of the trauma. (In DSM-IV ruminative thoughts about the trauma were also considered to reflect intrusion. This is not the case in DSM-5).

·  2. Avoidance: Avoidance of thoughts, feelings or reminders of the trauma.

·  3. Negative cognitions and mood: This includes such symptoms as feelings of detachment as well as negative emotional states such as shame or anger, or distorted blame of oneself or others.

·  4. Arousal and reactivity: Hypervigilance, excessive response when startled, aggression, and reckless behavior.

These are illustrated in the following case.

Abducted and Terrorized Mr. A. was a married accountant, the father of two, in his early 30s. One night, while out running an errand, he was attacked by a group of young men. They forced him into their car and took him to a deserted country road. There they pulled him from the car and began beating and kicking him. They took his wallet, began taunting him about its contents (they had learned his name, his occupation, and the names of his wife and children), and threatened to go to his home and harm his family. Finally, after brutalizing him for several hours, they tied him to a tree. One man held a gun to his head. Mr. A. begged and pleaded for his life; then the armed assailant pulled the trigger. The gun was empty, but at the moment the trigger was pulled, Mr. A. defecated and urinated in his pants. Then the men untied him and left him on the road.

Mr. A. slowly made his way to a gas station and called the police. [One of the authors] was called to examine him and did so at intervals for the next 2 years. The diagnosis was PTSD. Mr. A. had clearly experienced an event outside the range of normal human experience and was reexperiencing the event in various ways: intrusive recollections, nightmares, flashbacks, and extreme fear upon seeing groups of tough-looking young men. He was initially remarkably numb in other respects: He felt estranged and detached. He withdrew from his family, lost interest in his job, and expected to die in the near future. Mr. A. also showed symptoms of increased physiological arousal. His sleep was poor, he had difficulty concentrating, and he was easily startled. When Mr. A. first spoke about his abduction in detail he actually soiled himself at the moment he described doing so during the original traumatic experience.

Mr. A. received treatment from a psychiatrist for the next 2 years. This consisted of twice-weekly individual psychotherapy as well as antidepressant medications. A focus of the therapy was the sense of shame and guilt Mr. A. felt over his behavior during his abduction. He wished he had been more stoic and had not pleaded for his life. With the help of his therapist, Mr. A. came to see that his murderous rage at his abductors was understandable, as was his desire for revenge. He was also able to accept that his response to his experience was likely similar to how others might have responded if faced with the same circumstances. By the end of treatment Mr. A. was almost without symptoms, although he still became somewhat anxious when he saw some groups of young men. Most important, his relationship with his wife and children was warm and close, and he was again interested in his work.

Prevalence of PTSD in the General Population

Estimates from the National Comorbidity Survey-Replication (NCS-R) suggest that the lifetime prevalence of PTSD in the United States is 6.8 percent (Kessler, Berglund, Demler, et al.,  2005b ). However, this figure obscures the sex difference in the prevalence of PTSD. The NCS-R data show that the lifetime prevalence of PTSD is higher in women. Over the course of their lives, 9.7 percent of women and 3.6 percent of men will develop this disorder.

The difference in the prevalence of PTSD in men and women is interesting, not least because studies show that men are much more likely to be exposed to traumatic events (Tolin & Foa,  2006 ). Some have suggested that the sex difference reflects the fact that women are more likely to be exposed to certain kinds of traumatic experiences, such as rape, that may be inherently more traumatic (Cortina & Kubiak,  2006 ). However, even when the type of traumatic event is controlled for, women still show higher rates of PTSD and tend to have more severe symptoms (Tolin & Foa,  2006 ). This suggests that there are differences between men and women that may determine their risk of developing PTSD after experiencing trauma.

Rates of PTSD After Traumatic Experiences

Disasters, both naturally occurring and human-caused, are far from rare occurrences. In a typical year countless people are exposed to the kinds of traumatic events that can cause PTSD. For example, more than 900 earthquakes with a magnitude between 5 and 8 on the Richter scale occur annually throughout the world (Naeem et al.,  2011 ). Tsunamis also devastate coastal villages, and hurricanes, tornadoes, and floods destroy lives and livelihoods. Of course, some places are safer than others. Not surprisingly, rates of PTSD throughout the world tend to be lower in areas where people experience fewer natural disasters and where wars and organized violence are less common.

Traumatic stressors include combat, rape, and experiencing a natural disaster such as an earthquake, flood, tornado, or hurricane.

Estimates of the prevalence of PTSD vary widely across different studies (Sundin et al.,  2010 ). One reason for this is that rates of PTSD seem to vary according to the type of trauma that is experienced. More specifically, traumatic events that result from human intent (such as rape) are more likely to cause PTSD than are traumatic events (such as accidents and natural disasters) that are not personal in nature (see Charuvastra & Cloitre,  2008 ). For example, Shalev and Freedman ( 2005 ) compared rates of PTSD after car accidents and after terrorist attacks in the same community in Israel. Interviews were conducted 1 week and 4 months after the traumatic event had occurred. Although there were no differences in the symptoms that people reported at the 1-week interview, at 4 months, rates of PTSD were much higher in the terrorist attack survivors than in those who had survived the car accidents. Traumatic events involving humans who do terrible things are perhaps even more difficult to come to terms with because they can destroy the sense of safety we often assume comes from being a member of a rule-abiding and lawful social group.

Another factor that is crucially important with respect to the development of PTSD is the degree of direct exposure to the traumatic event. After reviewing all published disaster research over a 25 year period, Neria, Nandi, and Galea ( 2008 ) have estimated that rates of PTSD range between 30 and 40 percent for adults who are directly exposed to disasters. The prevalence of PTSD in rescue workers, on the other hand, tends to be lower (5–10%), probably because they are not directly exposed to the traumatic event when it is happening. Nonetheless, these figures highlight the risk of PTSD in rescue workers. They also show that disasters leave large numbers of traumatized people in their wakes.

Finally, we should point out that difference in rates of PTSD across different studies may sometimes be linked to the way that PTSD is defined and the manner in which it is assessed. Estimates based on questionnaires tend to be higher than those based on clinical interviews. For example, in a study of Dutch veterans of the Iraq War, questionnaire assessments yielded rates of PTSD of 21 percent. However, when structured diagnostic interviews were used, only 4 percent of veterans met criteria for PTSD (Engelhard et al.,  2007 ). Reasons for the overestimates when questionnaire measures are used include misunderstanding the meaning of items on the questionnaire, presence of symptoms that cause little impairment in functioning, as well as inclusion of symptoms that began at times other than during or after a traumatic event.

THE TRAUMA OF MILITARY COMBAT

In a combat situation, with the continual threat of injury or death and repeated narrow escapes, a person’s ordinary coping methods are relatively useless. The adequacy and security the person has known in the relatively safe and dependable civilian world are completely undermined. Combat brings with it constant fear, unpredictability, many uncontrollable circumstances, and the necessity of killing. Other factors may further contribute to the overall stress experienced by soldiers. These include separations from loved ones, reductions in personal freedom, sleep deprivation, extreme and harsh climate conditions, and increased risk for disease.

Many people who have been involved in the turmoil of war experience devastating psychological problems for months or even years afterward (Garakani et al.,  2004 ). During World War I, traumatic reactions to combat conditions were called “shell shock,” a term coined by a British pathologist, Col. Frederick Mott ( 1919 ), who regarded these reactions as organic conditions produced by minute brain hemorrhages. It was gradually realized, however, that only a small percentage of such cases represented physical injury. Most victims were suffering instead from the general combat situation, with its physical fatigue, ever-present threat of death or mutilation, and severe psychological shocks. During World War II, traumatic reactions to combat were known as operational fatigue and war neuroses, before finally being termed combat fatigue or combat exhaustion in the Korean and Vietnam Wars. Even the latter terms were none too aptly chosen because they implied that physical exhaustion played a more important role than was usually the case.

It has been estimated that in World War II, 10 percent of Americans in combat developed combat exhaustion. However, the actual incidence is not known because many soldiers received supportive therapy at their battalion aid stations and were returned to combat within a few hours. Recent evaluations of World War II psychiatric casualty files concluded that this practice of “forward psychiatry” was not effective at returning soldiers with shell shock to combat, but their improved mood and adjustment allowed them to be reassigned to noncombat roles, resulting in reduced manpower losses overall (Jones et al.,  2007 ). In World War II, combat exhaustion was the greatest single cause of loss of personnel (Bloch,  1969 ).

MENTAL HEALTH CONSEQUENCES OF DEPLOYMENT TO IRAQ AND AFGHANISTAN

Almost 2 million members of the Armed Forces have deployed for operations in Iraq and Afghanistan (Department of Defense,  2010 ). During these deployments they are exposed to many traumatic experiences and have to function under conditions of sustained threat. The overwhelming majority (92%) of Army soldiers and Marines in Iraq report that they have been attacked or ambushed, and 86 percent report knowing someone who has been killed or seriously injured (Hoge et al.,  2004 ). Not surprisingly, this takes its toll on their mental health.

The high prevalence of postdeployment mental disorders in these military personnel is now a major source of concern. One recent survey of over 289,328 Iraq and Afghanistan war veterans reported that 21.8 percent received diagnoses of PTSD and 17.4 percent were diagnosed with depression (Seal et al.,  2009 ). Another study by Booth-Kewley and colleagues ( 2010 ) found that 17.1 percent of Marines reported symptoms of PTSD after deployment in Iraq or Afghanistan. These figures are higher than the rates of PTSD reported for veterans of the Vietnam War (12–16%; Thompson et al.,  2006 ) and Gulf War (12%; Kang et al.,  2003 ). They are also higher than rates of PTSD in UK military personnel following deployment to Iraq or Afghanistan (4.8%; see Iversen et al.,  2009 ). In addition to PTSD and depression, postdeployment rates of alcohol misuse and problems with aggression are also elevated (Thomas et al.,  2010 ).

The high prevalence of mental disorders in men and women returning from Iraq and Afghanistan may be a consequence of longer and more frequent deployments. Some brigade combat teams have been deployed three or four times (Thomas et al.,  2010 ). But other factors may also be involved. In 2006 concerns were raised in the media that military psychiatrists had been sending mentally unfit service members into combat. Later that same year, minimal mental health standards for deployment were developed by the Department of Defense (Warner et al.,  2011 ). A prospective longitudinal study has now confirmed that psychiatric problems measured predeployment significantly increase the risk of developing PTSD postdeployment (Sandweiss et al.,  2011 ). This highlights the importance of mental health screening prior to deployment and the need to provide additional resources and support for soldiers who may be most vulnerable.

The most methodologically rigorous study of PTSD in members of the armed forces who served in Iraq or Afghanistan was conducted by Smith et al. ( 2008 ). This large longitudinal study excluded people who had PTSD prior to their deployment. Overall, the rate of PTSD in the military personnel who were studied was 4.3 percent. As one might expect, the rate was higher (7.8%) for those exposed to combat and lower (1.4%) in those who did not have combat exposure.

There is also evidence that theater-specific duties may be shaping some of the symptoms that veterans have. In addition to PTSD, clinicians are now seeing veterans with compulsive checking behaviors, as in the following case example.

Still Checking for Bombs A 38-year-old married black army veteran of two deployments to Iraq came to the VA medical center stating, “My commanding officer suggested that I get help.” The patient’s primary duties during both of his tours included providing security for truck convoys by patrolling alongside them in an armed Humvee. In the course of his duties he was exposed to multiple life-threatening situations, witnessed an improvised explosive device detonate during a convoy, witnessed dead and mutilated bodies, witnessed a motor vehicle run over a little girl, and was responsible for checking the convoy trucks and accompanying vehicles for bombs. At the time of his contact with the clinic he was experiencing more than 10 direct intrusive memories. He engaged in avoidance through attempted thought suppression, doing his errands late at night to avoid people, and staying home as much as possible while not at work. The patient also checked under the hood of his car for bombs every time he needed to drive. Although he knew that his checking was not normal and was embarrassed by it, he felt that the danger of someone placing a bomb under his car was too great not to check.

Source: Adapted from Tuerk et al.,  2009 .

The military is also now trying to cope with another serious problem—soldier suicide. In the 5-year period from 2005 through 2009, more than 1,100 members of the Armed Forces took their own lives—a rate equivalent to one suicide every 36 hours (Department of Defense,  2010 ). Most of these suicides result from self-inflicted gunshot wounds. Suicide rates in the U.S. Army are especially high. Clay’s story serves as a tragic reminder of how destructive and invisible some of the wounds of war can be.

A Warrior Takes His Own Life Clay was a handsome and friendly 28-year-old. A former Marine corporal, he received a Purple Heart after taking a bullet in Iraq and later returned to combat in Afghanistan. After his deployment was over Clay became involved in humanitarian work in Chile and Haiti. He lobbied in Washington to improve the disability claims process for veterans and was chosen to appear in a public service announcement to remind veterans that they were not alone. But Clay’s smiles and boundless energy were masks covering the emotional pain he lived with every day. Clay suffered from PTSD and depression. He also experienced survivor guilt, asking himself why he had survived when many people he had served with had died. One day in the early spring, Clay locked the door of his apartment and shot himself. His death leaves a void in the lives of his family and friends. It also highlights the need for renewed efforts within the military to address the growing problem of suicide by members of the armed forces. (Based on Helfling,  2011 ).

PRISONERS OF WAR AND HOLOCAUST SURVIVORS

Among the most stressful and persistently troubling wartime experiences is that of being a prisoner of war (Beal,  1995 ; Page et al.,  1997 ). Although some people have been able to adjust to the stress (especially when part of a supportive group), the toll on most prisoners is great. About 40 percent of the American prisoners in Japanese POW camps during World War II died during their imprisonment; an even higher proportion of prisoners of Nazi concentration camps died. Many survivors of Nazi concentration camps sustained residual organic and psychological damage, along with a lowered tolerance to stress of any kind. Symptoms were often extensive and commonly included anxiety, insomnia, headaches, irritability, depression, nightmares, impaired sexual potency, and diarrhea (which may accompany even relatively mild stress). Such symptoms were attributed not only to the psychological stressors but also to biological stressors such as head injuries, prolonged malnutrition, and serious infectious diseases (Sigal et al.,  1973 ; Warnes,  1973 ).

Among returning POWs, the effects of the psychological trauma they had experienced were often masked by the feelings of relief and jubilation that accompanied release from confinement. Even when there was little evidence of residual physical pathology, however, survivors of prisoner-of-war camps commonly showed impaired resistance to physical illness, low frustration tolerance, dependence on alcohol and drugs, irritability, and other indications of emotional instability (Chambers,  1952 ; Goldsmith & Cretekos,  1969 ; Hunter,  1978 ; Strange & Brown,  1970 ; Wilbur,  1973 ).

In a retrospective study of psychological maladjustment symptoms following repatriation, Engdahl and colleagues ( 1993 ) interviewed a large sample of former POWs and found that half of them reported symptoms that met standard criteria for PTSD in the year following their releases from captivity; nearly a third met PTSD criteria 40 to 50 years after their wartime experiences.

Another measure of the toll taken by the prolonged stress of being in a POW or concentration camp is the higher death rate after return to civilian life. Among returning World War II POWs from the Pacific area, Wolff ( 1960 ) found that within the first 6 years, nine times as many died from tuberculosis as would have been expected in civilian life; four times as many from gastrointestinal disorders; over twice as many from cancer, heart disease, and suicide; and three times as many from accidents. Many problems of adjustment and posttraumatic symptoms can be found in POWs years after their release (Sutker & Allain,  1995 ).

PSYCHOLOGICAL TRAUMA AMONG VICTIMS OF TORTURE

Among the most highly stressful experiences human beings have reported are those inhuman acts perpetrated upon them by other human beings in the form of systematic torture. From the beginning of human history to the present, some people have subjected others to pain, humiliation, and degradation for political or inexplicable personal reasons (Jaranson & Popkin,  1998 ). History and literature are full of personal accounts of intense suffering and lifelong dread resulting from maltreatment by ruthless captors. In addition, several empirical studies have reported on the prevalence of torture in the modern world: Allden and colleagues ( 1996 ) reported that 38 percent of Burmese political dissidents who escaped to Thailand had been tortured before their escape. Shrestha and colleagues ( 1998 ) compared Bhutanese survivors of torture in a Nepalese refugee camp with matched controls and found that torture survivors had more PTSD, anxiety, and depressive symptoms than the controls. Similar findings were reported by van Ommeren and colleagues ( 2001 ), who compared tortured and nontortured Bhutanese refugees and reported that those acknowledging being tortured had more PTSD and higher rates of lifetime mood and generalized anxiety disorders. Silove and colleagues ( 2002 ) also found higher PTSD scores in a sample of Tamil torture victims living in Australia compared with refugees who had not been tortured. The case of Muhammad B. illustrates many of the symptoms that can follow systematic torture.

Muhammad B.’s Captivity Muhammad B., a 21-year-old Ethiopian refugee, lives with his mother, father, two younger brothers, and two younger sisters in a small center-city apartment building in a large Midwestern city. He works part time as a parking lot attendant and attends night school, majoring in business. Muhammad has been in the United States for 5 years after a very tumultuous period in his home country. He was held for interrogation, along with several other young people from his village, in a government prison compound for several months when he was 15 years old. The treatment the captives received was severe, including starvation and frequent physical punishment. During a 7-month period of confinement, he was interrogated, usually after a severe beating or after being shown the bodies of other prisoners, in an effort by his captors to obtain information about the whereabouts of antigovernment guerilla fighters. On one occasion he was questioned while one of the guards held a rifle barrel in his mouth, and on another occasion he was subjected to a “staged execution” in order to get him to talk. After the captors determined that he had no relevant information, he was released. His family was able to escape the country shortly afterward.

Since his release from imprisonment, Muhammad has experienced severe PTSD symptoms including night terrors, sleeping disturbances, attacks of intense anxiety, and depression. He reports almost constant headaches and pains in the hand that was broken by his captors.

Although Muhammad has been able to complete high school successfully in the United States and has accumulated a year of college credit going to school part time, his day-to-day functioning is characterized by disabling intrusive thoughts, anxiety, nightmares, and recurring depression.

Other symptoms experienced after torture have been well documented (Başoĝlu & Mineka,  1992 ; Carlsson et al.,  2006 ). They include physical symptoms (such as pain, nervousness, insomnia, tremors, weakness, fainting, sweating, and diarrhea), psychological symptoms (such as night terrors and nightmares, depression, suspiciousness, social withdrawal and alienation, irritability, and aggressiveness), cognitive impairments (such as trouble concentrating, disorientation, confusion, and memory deficits), and disturbed behaviors (such as aggressiveness, impulsivity, and suicidal attempts).

Başoĝlu and colleagues ( 1994 ) reported the results of a unique empirical study in which 55 former Turkish prisoners who were political activists and had been tortured were compared with 55 political activists who had not been tortured. The torture victims and control subjects were matched on demographic variables including age, gender, education level, ethnic status, and occupation. Standard assessment techniques, including a psychiatric interview and psychological tests, were also used.

One of the most interesting findings from this study was the relatively low rate of PTSD (33 percent) in the political activists who had been tortured. This is especially remarkable because they had been imprisoned for an average of almost 4 years, endured nearly 300 episodes of torture, and been tortured in many different ways. Victims who were able to assert some element of cognitive control over the circumstances (for example, those who were able to predict and ready themselves for the pain they were about to experience) tended to be less affected over the long term (see Başoĝlu & Mineka,  1992 ; Başoĝlu et al.,  1997 ). These investigators concluded that prior knowledge of and preparedness for torture, strong commitment to a cause, immunization against traumatic stress as a result of repeated exposure, and strong social supports have protective value against PTSD in survivors of torture.

Causal Factors in Posttraumatic Stress Disorder

The study of causal risk factors that might be involved in the development of PTSD has been a controversial area (McNally,  2008 ). There are two major reasons for this. First, the very notion of PTSD makes it explicit that PTSD is caused by experiencing trauma. So why should we look any further if we wish to know what causes PTSD? The second concern is that, if some people are more likely to develop PTSD in the face of severe stress than other people are, might this not lead to double victimization, with victims of trauma also being stigmatized and being blamed for the troubles that they have?

On the other side of the issue, we know that not everyone who is exposed to a traumatic event will develop PTSD. This suggests that some people may be more vulnerable to developing PTSD than others. In order to prevent and better treat this disorder, we therefore need to understand more about the factors that are involved in its development.

As we have already noted, the nature of the traumatic stressor and how directly it was experienced can account for much of the differences in stress response. For example, there is a close relationship between the total number of people killed and wounded and the number of psychiatric casualties in war (Jones & Wessely,  2002 ). Soldiers who report killing or being responsible for killing during their deployment are also more vulnerable to developing PTSD (Maguen, Lucenko et al.,  2010b ).

If the level of stress is high enough, then, the average person can be expected to develop some psychological difficulties (which may be either short-lived or long term) following a traumatic event. But why is the breaking point of one person different from the breaking point of another? Some of the answers may lie in factors that we have discussed earlier in this chapter. In the sections below, we highlight some areas that appear to be important.

Individual Risk Factors

When it comes to risk for PTSD, we need to keep two things in mind: As has been noted by researchers in this field, there is risk for experiencing trauma and there is also risk for PTSD given that there has been exposure to trauma (see McNally,  2013 ). Not everyone is at equal risk when it comes to the likelihood that she or he will experience a traumatic event. Certain occupations, such as being a soldier or a firefighter, carry more risk than others, such as being a librarian. Risk factors that increase the likelihood of being exposed to trauma include being male, having less than a college education, having had conduct problems in childhood, having a family history of psychiatric disorder, and scoring high on measures of extraversion and neuroticism (Breslau et al.,  1991 ,  1995 ). Rates of exposure to traumatic events are also higher for black Americans than they are for white Americans.

Given that someone has been exposed to a traumatic event, what factors increase risk for developingPTSD? As we have already noted, being female is a risk factor. Other individual risk factors that have been identified by researchers include lower levels of social support, neuroticism (having a tendency to experience negative affect), having preexisting problems with depression and anxiety, as well as having a family history of depression, anxiety, and also substance abuse (see McNally,  2013 ; Wilk, Bliese, et al.  2010 ). Also relevant are the appraisals people make of their own stress symptoms shortly after the trauma. If people believe that their symptoms are a sign of personal weakness or if they believe that others will be ashamed of them because they are experiencing symptoms, they are at increased risk for developing PTSD, even when the level of initial symptoms is statistically controlled (Dunmore et al.,  2001 ).

Certain occupations place people at higher risk of experiencing a traumatic event.

On the other side of the coin, are there factors that may be protective and buffer against PTSD? Good cognitive ability seems to be important here. Breslau et al., ( 2006 ) collected IQ data from 6-year-old children who lived in and around Detroit. When these children reached the age of 17, they were interviewed and assessed both for exposure to trauma and for PTSD. The children who at age 6 had IQ scores above 115 were less likely to have experienced a traumatic event by age 17; furthermore, if they had been exposed to trauma, they were at lower risk for developing PTSD. These findings suggest that having a higher IQ may be protective against experiencing trauma and developing PTSD because children who had average or below-average IQ scores were at similar risk for PTSD.

Similar findings have also been reported for Vietnam veterans. Kremen and colleagues ( 2007 ) collected information from a large sample of twins and also obtained information about their cognitive ability scores before they went to serve in Vietnam. All of the men involved in the study were subsequently exposed to traumatic events during their military service. Compared with men who had scored in the lowest quartile on the Armed Forces Qualification Test (a measure of cognitive ability), men who had scored in the highest quartile had a 48 percent lower risk of developing PTSD.

Why might higher pretrauma cognitive abilities provide protection against PTSD? One possibility is that individuals with more intellectual resources might be better able to create some meaning from their traumatic experiences and translate them into a personal narrative of some kind. Earlier in this chapter, we discussed the therapeutic benefits of systematically writing about distressing events (Pennebaker,  1997 ). Perhaps people with higher cognitive abilities are more naturally able to incorporate their traumatic experiences into their life narratives in ways that are ultimately adaptive and emotionally protective.

BIOLOGICAL FACTORS

Given that PTSD is a stress disorder, it might be expected that people with this disorder would have high levels of stress hormones such as cortisol. However, this does not generally seem to be the case (Young & Breslau,  2004 ). Under conditions of imposed experimental stress (trauma reminders, cognitive challenges), people with PTSD do seem to show an exaggerated cortisol response (de Kloet et al.,  2006 ). However, baseline levels of cortisol are often very similar in people with PTSD compared to those of healthy controls (Meewisse et al.,  2007 ).

Gender may be an important factor here, however. Women with PTSD do seem to have higher levels of baseline cortisol than women without PTSD. This is not so for men with and without PTSD. Another interesting finding is that levels of cortisol tend to be lower in people with PTSD who have experienced physical or sexual abuse. In other words, the type of trauma may be an important factor (Meewisse et al.,  2007 ). Although many of the findings in this area are confusing, researchers are still exploring biological dysregulations in PTSD.

Another focus of research interest is gene–environment interactions. Earlier we discussed how people with a particular form of a particular gene (the 5HTTLPR, or serotonin transporter gene) seem to be more at risk for developing depression in the face of four or more life events. Data now suggest that this gene may also be a risk factor for the development of PTSD. Kilpatrick and colleagues ( 2007 ) collected DNA data and interviewed 589 adults from Florida 6 to 9 months after the 2004 hurricane season. The prevalence of post-hurricane PTSD in the sample overall was 3.2 percent. Risk factors for developing PTSD were a high level of exposure to the hurricanes and low levels of social support. However, people who had the high-risk (s/s) genotype of the serotonin-transporter gene were at especially high risk for the development of PTSD if they also had high hurricane exposure and low social support. For those in this group, the rate of PTSD was 14.8 percent—4.5 times higher. People with the s/s genotype were also more likely to develop depression if they had high hurricane exposure and low social support. These findings suggest that having the s/s form of the serotonin-transporter gene makes a bad situation worse. People with this genotype may be especially susceptible to the effects of traumatic stress, particularly if they also have low levels of social support.

What do we know about the brains of people with PTSD? Studies show that a brain area called the hippocampus seems to be reduced in size in people with PTSD. The hippocampus is a brain area known to be involved in memory. It is also a brain area known to be responsive to stress. In a landmark study, Gilbertson and colleagues ( 2002 ) measured the volume of the hippocampus in combat veterans with and without PTSD. The results showed that the veterans with PTSD had smaller hippocampal volumes than did the veterans without PTSD. The reason this study is so important, however, is that all the men were MZ (identical) twins. And when Gilbertson and colleagues looked at the volume of the hippocampus in the healthy co-twins of the combat veterans with PTSD, they found that these men also had small hippocampal volumes, just like their brothers. In contrast, the combat veterans who did not have PTSD, as well as their twins (who had not been involved in combat), had similar (and larger) hippocampal volumes. What these findings suggest, then, is that for reasons we do not yet understand, small hippocampal volume may be a vulnerability factor for developing PTSD in people who are exposed to trauma.

A major problem with research in this area is that many of the brain abnormalities associated with PTSD (including reduced hippocampal size) are also found in people who are depressed. Because PTSD and depression are highly comorbid and co-occurring disorders, it is therefore hard for researchers to be sure which brain abnormalities are specific to PTSD and which might stem from depression (Kroes et al.,  2011 ). But perhaps it is a bit naïve to expect that PTSD would be associated with brain abnormalities that are completely unique and distinct and that are not shared with any other disorders. We know that stress plays a role in the development of depression and the development of PTSD. We also know that stress (via glucocorticoids) has a negative impact on brain areas (like hippocampus) that are important for healthy emotional functioning. Why then should we not expect to see some commonalities when we look at people who have disorders in which stress is implicated?

Sociocultural Factors

Being a member of a minority group seems to place people at higher risk for developing PTSD. DiGrande and colleagues ( 2011 ) studied 3,271 civilians who were evacuated from the World Trade Center towers on September 11, 2001. Two to three years after the attacks 15 percent of people were assessed as having PTSD. Compared with whites, African American and Hispanic survivors were more likely to have PTSD. Echoing the discussion of resilience earlier in this chapter, being more educated and having a higher annual income were also factors associated with lower rates of PTSD overall.

Returning to a negative and unsupportive social environment can also increase vulnerability to posttraumatic stress (Charuvastra & Cloitre,  2008 ). For example, in a 1-year follow-up of Israeli men who had been psychiatric war casualties during the Yom Kippur War, Merbaum (1977) found that not only did these men continue to show extreme anxiety, depression, and extensive physical complaints, but (in many instances) they also appeared to become more disturbed over time. Merbaum hypothesized that the men’s further psychological deterioration was due to the negative attitudes of the community. In a country so reliant on the strength of its army for its survival, considerable stigma is attached to psychological breakdown in combat. Because of this stigma, many of the men were experiencing not only isolation within their communities but also self-recrimination about what they perceived as their own failure. These feelings exacerbated the soldiers’ already stressful situations.

Sociocultural variables also appear to play a role in determining a person’s adjustment to combat. Important factors include justification for the combat and how clear and acceptable the war’s goals are to the person whose life is being put in harm’s way (Hoge et al.,  2004 ). Identification with the combat unit and quality of leadership also make a difference (Jones & Wessely,  2007 ).

Today, military psychiatrists apply techniques that have been learned over the past century to help reduce psychological casualties. Interventions that promote morale and encourage cohesion that were developed in World War II and the Korean and Vietnam Wars have proved effective at reducing psychological casualties occurring among U.S. troops during their deployments to the Afghanistan and Iraqi war zones (Ritchie,  2007 ). Strategically placed combat stress control teams deploy as soon as is practical after combat engagements to provide timely counseling to troops. To improve morale of troops, the military also made efforts to provide breaks from long engagements by having “safe” zones that include such improvements as air conditioning, regular mail delivery, and good food. One of the most effective morale builders among troops has been the availability of the Internet at most established facilities in both Iraq and Afghanistan.

Having access to the Internet improves the morale of soldiers during long deployments.

Long-Term Effects of Posttraumatic Stress

As we have already noted, soldiers who have experienced combat exhaustion may show symptoms of posttraumatic stress for sustained periods of time (Shalev,  2009 ; Solomon & Mikulincer,  2007 ). If it develops, PTSD can be a severe and chronic condition. Moreover, in some cases, soldiers who stood up exceptionally well during their deployments have experienced delayed PTSD upon their return home. The difficulties readjusting to life as a civilian after extended periods away from home cannot be underestimated. Feelings of responsibility associated with killing as well as feelings of guilt for having survived when friends and unit peers did not may also play a role here.

The nature and extent of PTSD is somewhat controversial, however (McNally,  2008 ). The delayed version of PTSD is less well defined and more difficult to diagnose than disorders that emerge shortly after the precipitating incident (Andrews et al.,  2007 ). Moreover, with the exception of Vietnam veterans, cases of delayed-onset PTSD are exceedingly rare, with only one case of delayed PTSD being reported in a civilian study (Breslau et al.,  1991 ). Reports of delayed stress syndrome among Vietnam combat veterans are often difficult to relate explicitly to combat stress because these people may also have other significant adjustment problems. Some authorities have questioned whether a delayed reaction should be diagnosed as PTSD at all; instead, some would categorize such a reaction as some other anxiety-based disorder. For example, people with adjustment difficulties may erroneously attribute their present problems to specific incidents from their past, such as experiences in combat.

Also troubling are findings that show that 7 percent of men seeking treatment for combat-related PTSD had either never served in Vietnam or had not been in the military at all (Frueh et al.,  2005 ). The wide publicity given to delayed PTSD and the potential for receiving service-connected disability payments may be relevant factors here. Based on their analysis of a large federal database, a group of labor economists has concluded that the enormous increase in PTSD disability claims made by Vietnam veterans results more from financial need than it does from psychiatric disorder (Agrist, Chen & Frandsen,  2010 ).

in review

·  • What is the main difference between acute stress disorder and PTSD?

·  • What risk factors are associated with experiencing trauma?

·  • What risk factors are implicated in the development of PTSD?

·  • Why might high IQ be protective against PTSD?

·  • How might genetic factors play a role in the development of PTSD?

·  • What is controversial about the diagnosis of delayed PTSD?

Prevention and Treatment of Stress Disorders

Prevention

One way to prevent PTSD is to reduce the frequency of traumatic events. Although natural disasters are inevitable, efforts could be made to reduce the access that adolescents have to firearms. This could reduce the frequency of school violence and shootings. Other changes in the law and in social policy might also yield beneficial effects.

It is also worth considering whether it is possible to prevent maladaptive responses to stress by preparing people in advance and providing them with information and coping skills. As we noted earlier, this approach has been found to be helpful for people experiencing the stress of major surgery. Other research further supports the idea that psychological preparedness can foster resilience in political activists who are arrested and tortured (Başoĝlu et al.,  1997 ). Adequate training and preparation for extreme stressors may also help soldiers, firefighters, and others for whom exposure to traumatic events is highly likely. Findings from a study that examined PTSD in rescue and recovery workers at the World Trade Center site are consistent with this (Perrin, DiGrande et al.,  2007 ). Rates of PTSD differed markedly across occupations, with lower rates being reported in police (6.2 percent) and the highest rates being found in volunteers (21.2 percent) who had occupations that were completely unrelated to rescue and recovery work (e.g., finance or real estate).

The use of cognitive-behavioral techniques to help people manage potentially stressful situations or difficult events has been widely explored (Brewin & Holmes,  2003 ). This preventive strategy, often referred to as  stress-inoculation training , prepares people to tolerate an anticipated threat by changing the things they say to themselves before or during a stressful event. As helpful as these approaches are, however, it is almost impossible to be prepared psychologically for most disasters or traumatic situations, which by their nature are often unpredictable and uncontrollable.

the WORLD around us: Does Playing Tetris After a Traumatic Event Reduce Flashbacks?

“Flashbacks,” or intrusive memories, are a hallmark feature of PTSD. They often involve visual experiences where the person reexperiences the traumatic event. Because of this flashbacks can be very frightening. But can flashbacks be prevented?

In a clever and creative study, Holmes and colleagues ( 2009 ) exposed a group of research participants to 12 minutes of graphic film footage depicting scenes of injury and death. Thirty minutes after seeing the footage, some participants played Tetris for 10 minutes while others (control condition) sat quietly for the same period of time. All participants then used a diary to record the number of flashbacks they experienced over the course of the following week. Compared to the participants in the control condition, those people who played Tetris after viewing the trauma film reported significantly fewer involuntary flashbacks (4.6 versus 12.8 for controls).

But why should this be? Forming a memory involves a neuro-biological process. But in the early stages of this process (within the first six hours) the memory consolidation process can be disrupted. The brain also has a limited capacity. Because Tetris is a visuospatial task, playing Tetris shortly after the traumatic experience may disrupt the consolidation of traumatic visual memories. In other words, the new images of Tetris compete with the earlier visual images from the film, making the visual memories of the film less strong.

In other work, this same group of researchers have shown that simply being distracted after viewing the traumatic film does not reduce the frequency of later flashbacks (Holmes et al.,  2010 ). In fact, participants who were assigned to a verbal task condition (playing Pub Quiz—a general knowledge, verbal computer game) showed an increased number of flashbacks compared to both the group that played Tetris and the group that did nothing.

Taken together, the results of these interesting studies support the possibility that simple visuospatial tasks such as Tetris might have promise as a “cognitive vaccine” if they can be administered early enough. Importantly, although they experienced fewer intrusive flashbacks, people who played Tetris were still able to recall as many details from the film as people in the control group. In other words, their factual memories of the film remained intact. This is obviously important from the perspective of legal proceedings, where victims of trauma might need to testify about the events that they had experienced.

People who played Tetris after viewing a traumatic film reported fewer involuntary flashbacks the following week.

Given this, what might be done to help people who have just experienced a traumatic event? How might we reduce risk for PTSD? Strange as it may seem, there is reason to believe that playing Tetris might have some benefits (see The World Around Us box above).

Treatment for Stress Disorders

As we have already discussed, many people who are exposed to a traumatic stressor will experience symptoms and then gradually begin to recover without any professional help. After the terrorist attacks at the World Trade Center, grief and crisis counselors flocked to New York City because it was expected that countless numbers of people would be seeking psychological assistance. Relatively few people sought professional help, however, and millions of dollars that had been allocated to cover the costs of providing free counseling went unspent (McNally et al.,  2003 ). With time, and with the help of friends and family, it is quite typical for traumatized people to recover naturally.

TELEPHONE HOTLINES

National and local telephone hotlines provide help for people under severe stress and for people who are suicidal. In addition, there are specific hotlines for victims of rape and sexual assault and for runaways who need help. Many of these hotlines are staffed by volunteers. How skilled and knowledgeable the volunteer is plays an important role in how satisfied users are with the hotline (Finn et al.,  2010 ). Studies also suggest that the most positive outcomes come when helpers show empathy and respect for callers (Mishara et al.,  2007 ).

CRISIS INTERVENTION

Crisis intervention  has emerged in response to especially stressful situations, be they disasters or family situations that have become intolerable (Brown, et al.,  2013 ; Callahan,  2009 ; Krippner et al.,  2012 ). Short-term crisis therapy is of brief duration and focuses on the immediate problem with which an individual or family is having difficulty (Scott & Stradling,  2006 ). Although medical problems may also require emergency treatment, therapists are concerned here with problems of an emotional nature. A central assumption in crisis-oriented therapy is that the individual was functioning well psychologically before the trauma. Thus therapy is focused only on helping the person through the immediate crisis, not on “remaking” her or his personality.

In such crisis situations, a therapist is usually very active, helping to clarify the problem, suggesting plans of action, providing reassurance, and otherwise providing needed information and support. A single-session behavioral treatment has been shown to lower fears and provide an increased sense of control among earthquake trauma victims (Başoĝlu et al.,  2007 ). Although people are far from better after this single session, they receive knowledge and learn skills that will help them gain better control over their lives in the ensuing weeks and months.

Psychological Debriefing

Psychological debriefing approaches are designed to help and speed up the healing process in people who have experienced disasters or been exposed to other traumatic situations (Day,  2007 ). As a central strategy, traumatized victims are provided with emotional support and encouraged to talk about their experiences during the crisis (Dattilio & Freeman,  2007 ). The discussion is usually quite structured, and common reactions to the trauma are normalized. Some believe that this form of counseling (much of which is conducted by people who are not mental health professionals) should be mandated for disaster victims in order to prevent PTSD (Conlon & Fahy,  2001 ). Indeed, a small industry has sprung up to provide debriefing services, and disaster scenes are often swarmed by well-intentioned service providers—many of whom have little or no mental health training.

In the immediate aftermath of a crisis, people need practical assistance as well as emotional support.

One form of psychological debriefing is Critical Incident Stress Debriefing (CISD; see McNally et al.,  2003 ). A single session of CISD lasts between 3 and 4 hours and is conducted in a group format, usually 2 to 10 days after a “critical incident” or trauma.

Psychological debriefing is currently quite controversial. Reviews of the literature have generally failed to support the clinical effectiveness of the approach (Bisson et al.,  2009 ; Devilly et al.,  2006 ; McNally et al.,  2003 ). Although those who experience the  debriefing sessions  often report satisfaction with the procedure and with the organization’s desire to provide assistance, no well-controlled study has shown that it reduces symptoms of PTSD or hastens recovery in civilians (see Adler et al.,  2008 ).

Clearly, trauma survivors should not be left alone to pick up the pieces of their lives. As we noted earlier, lack of social support is a risk factor for the development of PTSD. Moreover, providing the right kind of social support may facilitate recovery. The most appropriate crisis intervention methods may not be those that follow an explicit protocol and urge emotional expression even when the trauma survivor is not ready. Rather, the most beneficial interventions may be those that focus explicitly on the needs of the individual and time their approaches accordingly. As Foa (cited in McNally et al.,  2003 ) has wisely suggested, in the aftermath of a trauma, survivors should follow their own natural inclination and talk (or not talk) with the people they want to talk to. In a related vein, therapists should take their lead from the trauma survivor, engaging in active listening, being supportive, but not directing or pushing for more information than the survivor wishes to provide. Caring, kindness, and common sense can go a long way to helping trauma survivors along the path to healing.

MEDICATIONS

As we have seen, persons experiencing traumatic situations usually report intense feelings of anxiety or depression, numbing, intrusive thoughts, and sleep disturbance. Several medications can be used to provide relief for intense PTSD symptoms. Antidepressants, for example, are sometimes helpful in alleviating PTSD symptoms of depression, intrusion, and avoidance (Reinecke et al.,  2007 ). In some cases, antipsychotic medications, like those used to treat disorders such as schizophrenia, are used (Bartzokis et al.,  2005 ; David et al., 2004). However, there is still some doubt about the extent to which medications are effective in the treatment of PTSD symptoms (Ehlers,  2000 ; Jaranson et al.,  2001 ).

COGNITIVE-BEHAVIORAL TREATMENTS

If you watch a scary movie over and over again what happens? Over time, the fear decreases and the movie becomes less frightening to you. One behaviorally oriented treatment strategy that is now being used for PTSD is  prolonged exposure  (Cloitre,  2009 ). It operates on exactly the same principle. The patient is asked to vividly recount the traumatic event over and over until there is a decrease in his or her emotional responses. This procedure also involves repeated or extended exposure, either in vivo or in the imagination, to feared (but objectively harmless) stimuli that the patient is avoiding because of trauma-related fear (Foa & Rauch,  2004 ; Powers et al.,  2010 ). Prolonged exposure can also be supplemented by other behavioral techniques (Taylor,  2010 ). For example, relaxation training might also be used to help the person manage anxiety following a traumatic event.

Because prolonged exposure therapy involves persuading clients to confront the traumatic memories they fear, the therapeutic relationship may be of great importance in this kind of clinical intervention (Charuvastra & Cloitre,  2008 ). The client has to trust in the therapist enough to engage in the exposure treatment. In all clinical work, it is important that the therapist provides a safe, warm, and supportive environment that can facilitate clinical change. For those who have been traumatized, and who may have extreme issues with trust, having a capable, understanding, and caring therapist may be especially necessary.

the WORLD around us: Virtual Reality Exposure Treatment for PTSD in Military Personnel

Large numbers of military personnel begin showing signs of PTSD within 6 months of deploying (Milliken et al.,  2007 ). However, because of stigma, many soldiers are reluctant to seek help. As one Marine explained, “I didn’t want it put on my military record that I was crazy” (Halpern,  2008 ).

A much-needed development in this regard is the use of computer simulations and virtual reality to provide a form of exposure therapy. Although such approaches are not new, technological advances now allow for the virtual reality programs to be customized to reflect the individual soldier’s traumatic experience as closely as possible. With the click of a mouse, the therapist can add such trauma-related cues as vibrations of the ground, the smell of smoke, and the sound of AK-47 fire. Treatment is typically short term (4 weeks), consisting of four to six 90-minute individual sessions. The first session is devoted to obtaining sufficient details of the trauma (time of day, weather conditions, location, sounds, smells, etc.) to make the virtual reality experience as realistic as possible. As the therapy progresses, new cues may be added to the program to provide further exposure experiences.

Early reports suggest that virtual reality exposure treatment is associated with substantial decreases in PTSD symptoms and improvements in overall functioning (Gerardi et al.,  2008 ; Reger & Gahm,  2008 ). Importantly, virtual reality treatment approaches are also well received by soldiers and preferred over traditional talk therapy (Wilson et al.,  2008 ). As one soldier put it, virtual reality “sounded pretty cool” (see Halpern,  2008 ). Given the growing numbers of veterans now being diagnosed with PTSD, any form of treatment that is well received by soldiers and provides relief from debilitating symptoms cannot come a moment too soon.

Virtual reality treatment is well received by soldiers.

Prolonged exposure is an effective treatment for PTSD (Doane et al.,  2010 ; Powers et al.,  2010 ). In a recent study involving women who had served in the military, ten 90-minute treatment sessions led to a reduction of symptoms and a decrease in the number of women meeting diagnostic criteria for PTSD compared to a sample of women who had received a form of treatment that focused on their current life problems (Schnurr et al.,  2007 ). However, one problem with prolonged exposure therapy is that it tends to have a higher dropout rate than other approaches. This no doubt is because it is difficult for people with PTSD to be exposed to their traumatic memories. Another current issue of concern is how long the treatment effects last. In the study just described, the longer-term effects of the prolonged exposure treatment were less robust than expected.

Recognizing the need for improvements in the treatment of PTSD, other approaches are now being developed. Ehlers and colleagues ( 2005 ) have developed a treatment for PTSD that is based on a cognitive model of the disorder. More specifically, it is thought that PTSD becomes persistent when people who have experienced trauma make excessively negative and idiosyncratic appraisals of what has happened to them in a way that creates a sense of a serious, current threat. For example, a bus driver who was assaulted by one of his passengers believed he was a terrible father who had failed his children because he had asked the passenger to buy a ticket before the passenger attacked him (Ehlers & Clark,  2008 ). Cognitive therapy for PTSD is designed to modify excessively negative appraisals of the trauma or its consequences, decrease the threat that patients experience when they have memories of the traumatic event, and remove problematic cognitive and behavioral strategies.

Evidence suggests that this treatment approach is very effective. In three different studies comparing patients who received cognitive therapy with patients assigned to a waiting list control group, rates of recovery were significantly higher in the cognitive therapy group and ranged from 71 to 89 percent. The drop-out rate was also very low. In fact, the only patient who dropped out of the treatment was a woman who moved abroad (Ehlers & Clark,  2008 ). Moreover, these treatment gains appear to continue after treatment has ended. Another exciting new treatment development that seems to be well received by clients is virtual reality exposure therapy (see The World Around Us box above).

Challenges in Studying Disaster Victims

Conducting research into disasters is extremely difficult to implement for a number of reasons. It is virtually impossible to have an ideal, well-controlled, and well-funded experiment set up “awaiting a disaster.” One cannot easily predict natural disasters such as a tornado or fire, so it is difficult to have qualified staff ready to conduct the research immediately after the disaster strikes. Good research also requires careful definition of the variables concerned and meticulous attention to methodological detail. But in disaster situations the extraneous conditions are difficult if not impossible to control. Often in disaster situations (e.g., airplane crashes), therapy sessions are conducted in noisy, makeshift locations such as crew lounges, hallways, and gate areas. Moreover, federal disaster funds are typically only available for immediate intervention and cannot be used for long-term care or evaluation research (Pfefferbaum et al.,  1999 ).

All of these factors make it difficult to learn how best to help people who have been traumatized or who are in crisis. Nonetheless, a great deal of good research is now being conducted. The more we understand the mechanisms through which trauma can create pathological memories that will not abate, the more we will be able to help the large numbers of people who need help both now and in the future.

Trauma and Physical Health

If stress is linked to problems with physical health, what role does trauma play in our physical well-being? In asking this question we come full circle, recognizing the impor tance of the mind–body connection. Although questions like this are only now beginning to attract empirical attention, we end with an interesting finding: In a sample of HIV-positive men and women, previous trauma (occurring years before the study and usually during childhood) was highly predictive of death from HIV and also from other causes (Leserman et al.,  2007 ). In other words, traumatic events are not only bad for the mind. A history of trauma also predicts mortality. Although the mechanisms for this are far from clear, they again highlight the role that stress and trauma play in both physical health and psychological well-being.

in review

·  • What strategies are useful for preventing or reducing maladaptive responses to stress?

·  • Describe crisis intervention therapy. How is this treatment approach different from psychotherapy for other mental health conditions?

·  • In what ways are medications used in treating individuals in crisis?

·  • Describe the current controversy surrounding the use of “debriefing interventions.”

·  • What forms of cognitive-behavioral treatments are effective for patients with PTSD?

·  • Why is the therapeutic relationship so important in the treatment of chronic PTSD?

UNRESOLVED issues: Why Is the Study of Trauma so Contentious?

Unlike other research topics, the field of traumatic stress study is characterized by passionate and highly divisive argument. For example, although researchers routinely seek to identify risk factors for the development of various disorders such as depression or eating disorders, the idea that there could be individual risk factors for PTSD (apart from exposure to the traumatic event itself) was a taboo topic for many years. The reason it was unacceptable was because it was viewed as “blaming the victim.” There were also concerns that the study of vulnerability factors might provide the federal government with an excuse to deny treatment and benefits to Vietnam veterans. In other words, advocacy, rather than science was the priority.

Now, of course, the study of individual vulnerability factors for PTSD is an active area of research. Nonetheless, individual scientists in this area are still subjected to attacks when they present findings that some in the trauma field do not want to hear (Satel,  2007 ). A case in point is the reanalysis of data from the National Vietnam Veterans Readjustment Study. This suggested that the originally reported estimates of PTSD might have been too high. Rather than engage in discourse about the methodology of the study or the statistical analysis used, prominent members of the audience instead chose to attack the presenter, coming close to accusing him of lying (Satel,  2007 ).

This is not an isolated example. After scholars published a meta-analysis that revealed that there was only a weak association between childhood sexual abuse and later psychopathology (Rind, Tromovitch & Bauserman,  1998 ) there was a huge outcry from experts in the trauma field. The American Psychological Association made efforts to distance itself from the conclusions made by the authors and eventually Congress weighed in, issuing a formal condemnation of the article (see Lilienfield,  2002 ). In another case, some scholars were accused of “minimization or outright denial of human suffering” (Marshall,  2006 , p. 629) after they referred to the transient rise in stress reactions following the 9/11 terrorist attacks as normal emotional responses (see McNally,  2013 ).

Science searches for truth. And, as McNally ( 2013 ) notes, advocacy for victims of trauma is best served by scientific inquiry that is free of ideology. If certain assumptions are off-limits to investigation or critique, no one is well served. Advocates for trauma victims are no doubt well-intentioned. But when advocacy determines what scientific findings are or are not acceptable, do we not all lose?

5 summary

·  5.1 What is stress?

·  • When challenges to our physical or emotional well being exceed our coping abilities or resources, we experience stress. Stress can result from negative or positive situations. Key factors involved in making one situation more stressful than another include how severe the stressor is, how long it lasts, when it occurs, how much it impacts our lives, how expected it is and how much control we have over the situation.

·  • Stress takes its toll on our physical and psychological well-being.

·  5.2 How does the body respond to stress?

·  • When we are stressed, the autonomic nervous system responds in a variety of ways. One consequence of stress is increased production of cortisol. High levels of this stress hormone may be beneficial in the short term but problematic over the longer term.

·  • Stress compromises immune functioning. Psychoneuroimmunology is a developing field concerned with the interactions between the nervous system and the immune system

·  • In the immune system, specialized white blood cells called B-cells and T-cells respond to antigens such as viruses and bacteria. They are assisted by natural killer cells, granulocytes, and macrophages.

·  • Cytokines are chemical messengers that allow the brain and the immune system to communicate with each other. Some cytokines respond to a challenge to the immune system by causing an inflammatory response. Other cytokines, called anti-inflammatory cytokines, dampen the response that the immune system makes when it is challenged.

·  5.3 What role does our emotional state play in our physical health?

·  • Negative emotional states, such as being under a lot of stress or having low social support, can impair the functioning of the immune system and the cardiovascular system, leaving a person more vulnerable to disease, infection, and problems such as hypertension and cardiovascular disease.

·  • Many physical illnesses seem to be linked to chronic negative emotions such as anger, anxiety, and depression. Hostility is well established as an independent risk factor for CHD. The same is true of depression.

·  5.4 What mental disorders are explicitly recognized as being triggered by stress?

·  • The DSM-5 classifies people’s psychological problems in response to stressful situations under two general categories: adjustment disorders and posttraumatic stress disorder.

·  • Several relatively common stressors (prolonged unemployment, loss of a loved one through death, and marital separation or divorce) may produce a great deal of stress and psychological mal-adjustment, resulting in adjustment disorder.

·  • More intense psychological disorders in response to trauma or excessively stressful situations (such as military combat, being held hostage, or torture) may be categorized as posttraumatic stress disorder.

·  • A new diagnostic category called “Trauma- and stressor-related disorders has been added to DSM-5. Several disorders (including PTSD) that were formally in the Anxiety Disorders section of the DSM have been moved into this new category

·  5.5 What are the clinical features of posttraumatic stress disorder?

·  • PTSD can involve a variety of symptoms including intrusive memories or recurrent and distressing dreams about the event, avoidance of stimuli associated with the trauma, negative cognitions or impaired memory about aspects of the traumatic event, and increased arousal or reactivity.

·  • Many factors influence a person’s response to stressful situations. The impact of stress depends not only on its severity but also on the person’s preexisting vulnerabilities. Resilience is the most common long-term trajectory.

·  • Although it is very common to experience psychological symptoms after a traumatic event, these often fade with time. Most people exposed to traumatic events do not develop PTSD. The prevalence of PTSD in the general population is 6.8 percent.

·  • If symptoms begin 6 months or more after the traumatic event, the diagnosis is delayed posttraumatic stress disorder.

·  5.6 What are the risk factors for PTSD?

·  • Factors that increase a person’s risk of experiencing traumatic events include certain occupations (e.g., firefighter), being male, not having a college education, conduct problems in childhood, high levels of extraversion and neuroticism, as well as a family history of psychiatric problems.

·  • Factors that increase the risk of developing PTSD are being female and having low levels of social support; higher levels of neuroticism; a family history of depression, anxiety, and substance abuse; as well as preexisting problems with anxiety and depression.

·  • Women with PTSD have higher baseline cortisol levels than women who do not have PTSD. This is not the case for men with PTSD. Under conditions of stress, people with PTSD show an exaggerated cortisol response.

·  • Having the s/s genotype of the serotonin-transporter gene may increase vulnerabilty to PTSD in the face of trauma exposure. Smaller hippocampal volume is also a biological vulnerability factor.

·  5.7 What treatment approaches are used for PTSD?

·  • Medications are sometimes used in the treatment of PTSD. Psychological treatments include prolonged exposure therapy and cognitive therapy. A new approach that appears promising is the use of virtual reality exposure therapy.

key terms

·  acute stress disorder  148

·  adjustment disorder  145

·  allostatic load  134

·  antigens  134

·  B-cell  134

·  behavioral medicine  129

·   coping strategies   130  correlational research

·  study  136

·  cortisol  133

·  crisis  132

·  crisis intervention  157

·  cytokines  135

·  debriefing sessions  157

·  distress  130

·  essential hypertension  138

·  health psychology  129

·  hypertension  138

·   hypothalamic-pituitary-adrenal

·  (hPA) system  133

·  immune system  134

·  immunosuppression  134

·  leukocytes  134

·  lymphocytes  134

·  positive psychology  137

·   posttraumatic stress disorder

·  (PTSD)  129

·  prolonged exposure  158

·  psychoneuroimmunology  134

·  resilience  132

·  stress  130

·  stress-inoculation training  155

·  stress tolerance  131

·  stressors  130

·   sympathetic-adrenomedullary

·  (SAM) system  133

·  T-cell  134

·  Type A behavior pattern  140

·  Type D personality  141

The post Adjustment Disorders appeared first on Essay Mine.

Welcome to originalessaywriters.com, our friendly and experienced essay writers are available 24/7 to complete all your assignments. We offer high-quality academic essays written from scratch to guarantee top grades to all students. All our papers are 100% plagiarism-free and come with a plagiarism report, upon request

Tell Us “Write My Essay for Me” and Relax! You will get an original essay well before your submission deadline.