Coping and Stress (5 questions) Flashcards
Good stress
circuit activation –> return to normal at end of stress
Mild stress: what happen?
- desensitize circuits –> experience based resilience;
- 5HT ↑’s availability of BDNF, preventing or reversing neuron loss
- hippocampus vulnerable to these losses
Chronic stress: what happens?
- turns off BDNF genes –> ↓creation/maintenance of neurons & connections –> synapse loss or apoptosis (loss of the whole neuron)
- Stress and cortisol exposure decrease BDNF expression and can cause hippocampal atrophy, similar to atrophy that occurs in depression
What is BDNF?
- Brain Derived Neurotrophic Factor
- A protein; member of neurotrophins – r/t NGF or nerve growth factor
- Found in brain & periphery
- Supports neuron survival, encourages growth/differentiation of new neurons and synapses.
- Active in hippocampus, cortex, basal forebrain – r/t learning, memory, higher thinking
- Neurotrophins help to stimulate and control neurogenesis and BDNF is very active
- In animal models, exercise increases BDNF secretion in hippocampus
Cortisol vs corticosterone
Cortisol is the predominant glucocorticoid in humans (and is produced in the adrenal zona fasciculata), whereas corticosterone is less abundant in humans, but is the dominant glucocorticoid in rodents (in humans it is produced in the zonae fasciculata AND glomerulusa).
Defining stress
- Stress – response to pressures of daily life or threats to well being; adrenaline response (fight or flight)
- Motivates; increase productivity
- Minor interference with life
- Coping strategies used to resolve; able to problem solve
*
Defining fear
- Fear: response to a known threat –prepares us
*
Defining anxiety
- Anxiety: unknown, vague response; may be expressed physically; a negative outcome of stress
- Fear & Anxiety are part of the same circuit
Stress vs anxiety
- Reaction is greater than typical response
- Requires help to relieve
- Usual coping ineffective
- Unable to problem solve
- Anxiety can be: mild, moderate, severe or panic level
- Selye: General Adaptation Syndrome (GAS)
Levels of anxiety
Acute anxiety (severe), Panic, Chronic anxiety (moderate)
Physiological symptoms of acute anxiety (severe)
Tachycardia, palpitations, hyperventilation, fainting, dizzy, blurred vision, trembling, diarrhea, headaches, insomnia, nausea, freq urination
Emotional symptoms of acute anxiety
Irritability, anger, crying, withdrawal, clinging, critical of self/others, inadequacy, Insecurity, powerlessness,
Cognitive symptoms of acute anxiety (severe)
- Preoccupied
- Distracted
- Inattentive
- Attends only to a specific detail
Physiological symptoms of panic
All the symptoms of severe acute anxiety PLUS
- Aimless/random behavior (run, shout)
- Immobility
- Unable to speak
Emotional symptoms of panic
- Feelings of dread
- Like dying
- Terror
- Eeriness
- Feel unreal
Cognitive symptoms of Panic
- Delusions
- Hallucinations
- Poor reality testing
Physiological symptoms of chronic anxiety (moderate)
- Jumpy
- Daytime fatigue
- Sleep disturbance
- Heartburn, belching
- Muscle tension
- Sweaty palms
- Flushed, dry mouth
- Frequent sighing
Emotional symptoms of chronic anxiety (moderate)
- Nervousness
- Irritability
- Loneliness
Cognitive symptoms of chronic anxiety (moderate)
- Ruminating
- Worrying
- Attend only to details, immediate task
Fight or flight response
- Epinephrine & NE secretion from adrenal medulla and sympathetic nervous system enables mobilization
- Sympathetic nervous system triggered and within seconds effects: heart rate, bp, metabolism, respiration, decreased digestion enable successful mobilization to survive threats
Selye’s GAS
General Adaptation Syndrome (GAS)
-
Alarm: SAM & HPA activation:
- Mobilization!
- Resistance: Attempt to adapt to threat:Less than optimal function. If we cannot adapt…
- Exhaustion: Unable to adapt or function; Illness or death if threat not resolved
SAM: sympathetic adrenal medullary response
What is allostasis?
process of achieving stability (homeostasis) through adaptive physiologic or behavior change. Good in short term. Possibly damaging if not “shut off”
- e.g., adrenalin, glucocorticoids, cytokines act on organs/tissue
What is allostatic load?
cost of wear and tear from repeated activation of stress responses. Leads to physical and emotional disease (atrophy of neurons compromising hippocampus function)
3 types of allostatic load
- Frequent stressors (frequency of events determine amt of load)
- Failure to turn off physiologic responses (autonomic, neuroendocrine)
- Failure to respond adequately to a challenge (ex: increased inflammatory cytokine activity b/c HPA activity does not contain)
Axes involved in fight or flight
- Sympathetic-adrenal-medullary (SAM) axis activation
- Hypothalamic-pituitary-adrenal (HPA) axis activation
increase of sympathetic activity, cortisol, and proinflammatory cytokines
decline in parasympathetic activity
Stress response: what happens when we perceive a threat?
Thalamus → Amygdala. Lateral amygdala receives sensory input (ex: fear) → to central nucleus of amygdala → output activates HPA axis & sympathetic ns
-
Hypothalamus secretes:
- CRH → triggers ACTH release from anterior pituitary → triggers stress hormone release (glucocoritcoids, i.e. cortisol) from adrenal cortex
- β-endorphin (mitigates pain reduction) → stimulates epinephrine release from adrenal medulla;
- AVP also released from hypothalamus
-
Hippocampus has adrenal steroid receptors:
- Type I: mineralocorticoid; Type II: glucocorticoid
- Produces excitation, if prolonged can lead to excitotoxicity/damage
Which produces a faster reaction, HPA or SAM?
SAM
Describe the hormonal cascade involved in HPA activation
- Corticotrophin releasing hormone (CRH) secreted in hypothalamus →
- AP, which releases ACTH →
- Through bloodstream to adrenal cortex, which releases glucocorticoids (cortisol) →
- Cortisol feeds back, slowing release of ACTH & CRH
HPA: effect of cortisol
- mobilizes energy
- Increases CV tone
- Suppresses anabolic activity (reproduction, digestion, growth, immunity)
- Increased release in early AM hrs → prepare for day
- Acute/Chronic Stress
Role of hippocampus in HPA axis
inhibitory (turns HPA down)
HPA: feedback mechanisms image
SAM axis activation
- RAPID response to stress → prepares body to react
- Catecholamines (Epi, NE) released by adrenal medulla →
- ↑ heart rate, ↑ respiration, ↑ blood flow, ↑ BP, ↑ glucose
- ↓ digestive activity
- Counterbalanced with Parasympathetic activity
PNS: role
freeze/hide behaviors; direct innervation of organs – promote vegetative function and decreased physiologic arousal
PNS vs SNS
counteract one another - in most people - only small % have both high or both low
SNS: what are the two paths of the F or F response coordinated by the Locus Coeruleus?
- Fast: direct noradrenergic innervation of visceral organs
- Slow: hormonal path from adrenal medulla → epi & NE and Increased: heart rate, respiration, glucose, blood flow to muscle
HPA response: when does it occur in response to stress?
approx. 5 min after event
* from Hypothalamus (PVN) → CRH → Vasopressin (AVP) → pituitary → ACTH → Adrenal cortex → cortisol
* response: PNS –> SNS –> HPA*
balance between the sympathetic and parasympathetic nervous system: image
What happens in a normal stress response?
CRH is released from the hypothalamus → Pituitary which releases ACTH → Adrenal gland which releases glucocorticoids → hypothalamus (glucocorticoids inhibit CRH release)
What happens in a chronic stress response?
same flow as normal stress response, BUT excess glucocorticoid release can cause hippocampal atrophy and the disinhibition of the hypothalamus occurs. Causing greater risk of Psychiatric symptoms
Physiologic consequences of stress
(consistent HPA, SNS, PNS)
- Immune suppression
- inflammation and CVD
- Difficulty stabilizing and managing Dz
- Greater morbidity and mortality
- Chronic stress effects d/t excess cortisol exposure
What are some chronic stress effects d/t excess cortisol exposure?
- ↑BP, plaque formation, diabetes, ulcers
- ↓immune function, ↓memory (hippocampus ∆)
- Disrupted long term potentiation
- Cortisol → amygdala → potentiates hippocampus
Function of hippocampus
memory (declarative, spatial), learning
Effect of stress on the hippocampus
inhibits neurogenesis in the hippocampus (dentate gyrus)
Effect of cortisol on memory
increased glc-corticoids leads to decrease in declarative memory, hippocampal atrophy, decreased size of hippocampus, decreased neurogenesis
(increased memory is associated w/increased hippocampal volume)
Findings on relationships between inflammatory markers and Major Depression
- TNF-alpha: Increased HPA activity in acute depression leads to TNF-alpha activity. After remission, normal HPA activity, but increased TNF alpha.
- CRP: MDD associated w/increase (risk of CVD?)
- MPO: strongest inflammatory marker. Higher in dizygotic twin w/MDD
What are the core symptoms that suggest a vascular depression subtype?
Late onset depression, executive dysfunction, vascular disease
Effect of sleep on blood sugar
As little as a week of poor sleep (6 vs. 8hrs) raise evening blood sugar levels
How does stress affect arthritis and other autoimmune processes?
if body can’t mount adequate response to acute stress, they get worse
Physiologic effect of social isolation post cardiac arrest in mice
↑cell death & ↑TNF-α
association between sleep duration and obesity
Reduced sleep duration associated with ↑BMI and obesity in NHANES
Physiologic effect of restricting sleep to 4hrs/night
- ↑BP,
- ↓parasympathetic tone,
- ↑evening cortisol,
- ↑insulin,
- ↑appetite
Physiologic effect of restricting sleep to 6hrs/night
- ↑proinflammatory cytokine levels
- ↓performance in tests of psychomotor vigilance
‘Symptoms of Stress’ often seen in health settings…
- Headaches, stomachaches
- Diarrhea, constipation
- Frequent colds/’flu’
- Sleep problems (↑ or ↓)
- Muscle tension, muscle spasm
- Lowered libido
- General anxiety
- ‘overwhelmed’
- Irritability, anger
- Difficulty making decisions, thinking
Psychological effects of ‘stress’
- Anxiety
- Depression
- Irritability… anger… hostility… aggression
- Tension
- Sleep disturbances
- Poor concentration, forgetful, thought blocking, confusion
- Helplessness, powerlessness, frustration
- Fear of… losing control, loss, death
- Exacerbation of mental illness
Some ways to measure stress
- Social readjustment rating scale (SRRS, Holmes & Rahe)
- Trier social stress test (TSST)
- Hassles and uplifts scale
continuum of reactions to stress
Coping is Higher order: talking with friends, setting a goal, distraction
Defense mechanisms are ego function: denial, projection, acting out
Psychosis is psychotic level: paranoid delusion, hallucination
Coping modalities
- Active & Passive Coping: active coping mediates sympathetically controlled CV changes
- Resilience:
Coping strategies indicator: categorizes you as avoidant, problem solving, or support seaking
Disorders related to stress
Adjustment disorder; Acute stress disorder; PTSD
Attributes of individual, context that affect response to stress
- Gender
- SES
- Social support
- Exercise
- Optimism, self esteem, mastery
Stress: When do symptoms require intervention (i.e. mental health referral)?
Symptoms experienced cause clinically significant distress or impaired role function:
- Social, Occupational, Family, Other
- wide range of function: from in bed all day to normal
- degree of impairment compared to their ‘normal’?
- severity of symptoms or stressors (and how many)?
- safety issue? (Danger to self, others)
- How long have symptoms caused impairment? (a day, week, month, months?)
- Do others indicate there is a problem too? (family, coworkers, friends)
-
What efforts to manage symptoms have been tried, what were results?
- Rx’s (were they properly titrated and managed?)
- Self care?
Pharmaceutical agents for stress
- Sleep meds, anxiolytics, beta blockers, antidepressants
- help metabolic and neuro consequences (anti-inflamm, cholesterol, insulin resistance, chronic pain)
- SIDE EFFECTS
Areas benefited by physical activity
(stress)
- Brain
- ↑neurotrophin expression in cortex & hippocampus
- ↑neurgenesis in dentate gyrus (animal studies); similar to antidepressant effects
- Improves memory
- Cognitive flexibility
- ↑BDNF thought to r/t antidepressant action (hippocampal volume, memory, mood)
- Cardiovascular system
- Metabolic system
Why don’t interventions work sometimes?
- Need education
- Non-compliance
- Readiness : Health Belief Model (Rosenstock, later: Prochaska)
- Self Efficacy: (Bandura)
Summary of the health belief model
All kinds of stuff about your background and experience influences how likely you are to perceive something as a threat to your health and thus to take action
Mild anxiety: what happens to your perceptions?
↑awareness of all senses
Sensory field enlarged
Moderate anxiety: what happens to your perception?
↓ perception, can attend to more if directed
Sever anxiety: what happens to your perception?
Distorted perception, ↓ sensory input
Panic: what happens to your perception?
Major distortion, Lack of reality testing
Mild Anxiety: what happens to your cognition?
Conducive to learning, concentration, problem solving. Can see relationships between concepts
Moderate anxiety: what happens to your cognition?
Conducive to learning, concentration, problem solving. Can see relationships between concepts
Severe Anxiety: what happens to your cognition?
Unable to see relationships
Processing scattered and disorganized; difficult to function
Panic: what happens to your cognition?
Impossible to: Concentrate, learn, problem solve
Processing scattered and disorganized; difficult to function
Mild Anxiety: what happens to your Verbal & Non-verbal behaviors?
Logical-verbal, rate & volume approp, alert, secure
Moderate Anxiety: what happens to your Verbal & Non-verbal behaviors?
Freq topic change, joking, wordy, ↑rate, ↑ volume, thought blocking, gesturing, hesitate, procrastinate
Severe Anxiety: what happens to your Verbal & Non-verbal behaviors?
Reflect distorted perception & cognition; purposeless activity (pacing, hand wringing)
↑↑discomfort
Panic: what happens to your Verbal & Non-verbal behaviors?
↑emotional pain, helpless,
↑ disorganized
May appear psychotic, may run, scream, cling
Mild and Moderate anxiety: interventions
- Verbal empathic communication
- LISTEN!
- Deep breathing techniques,
- Express feelings
- Problem solve!
Severe anxiety and panic: interventions
- Directive, Concise, Respectful,
- Use person’s name, repeat phrases
- Stay with person,
- identify we will help them stay safe, breathing techniques,
- slow step by step directions,
- Needs protection and calming
Anxiety interventions: what to do in a crisis situation
- LISTEN!!! & Do NOT RUSH!
- Make contact, Identify problem behavior,
- Engage in problem solving
- Remove the stimulus
- Offer options (but not too many)
- Don’t make a show of it!
Mindfulness: where has it been found to be most effective?
Can be used in any setting, but especially good in social anxiety disorder d/t high degree of negative rumination
Types of “emotional first aid” crisis interventions for adults
- Psychotherapy:
- Brief dynamic therapy
- Supportive therapy
- CBT
- IPT
- EMDR
- Role playing
- Biofeedback
- Assertiveness training
- Support groups
- Activation
- Stress Reduction/Relaxation
- Pharmacotherapy:
- Sleep (benadryl, trazodone, ambien)
- Anxiety (ssri’s, benzo????)
- Depression (celexa, paxil, zoloft, effexor)
Types of “emotional first aid” crisis interventions for kids/ados
- PMT (parent mgmt training?? Restraints?? Thank you for the abbrev, JI.)
- Play therapy
- Role playing
- CBT
- Stress reduction
3 Cs associated with hardiness
control, commitment, challenge – characteristics of those able to manage well despite stress
Stress and anxiety: what advice can we take from ancient times?
- Living in bands (bonded with others)
- Hunting & gathering (physical exercise required)
- Mastery of skills
- Frequent rest periods
- Rituals (spirituality, traditions)
Important concepts when learning to be stress resistant
- hardiness
- honor our past/use ancestors’ methods
- be holistic
- recover from burnout
- Be strategic
- Social support
- Control what you can
- Time manage well
- Personal philosophy about your work/life
- Humor
Know when to change or move on
Signs and symptoms of burnout
- Exhaustion, fatigue
- Forgetfulness, losing things
- Emotional numbing
- Fear of loss of control of environment (work)
- ‘Stress symptoms’
- Compulsive & addictive behaviors
- Apathy
- Anger not matching trigger
- Loss of meaning in work, life
- Disillusioned with career or relationships
Traits that make stress worse
- Perfectionism
- Competition
- Self criticism
- Act on Unverified assumptions
- Hurrying
- Pessimism
- Unrealistic expectations
- Comparisons
- Self sacrificing martyrdom
- Avoidance of confrontation
- Dependence
Things we do that make stress worse
- Personalize things
- Negative self talk (‘no one appreciates me’, ‘I’m a failure’, etc)
- Complaining more than acting
- Focusing on others problems, needs vs. our own
- Dwelling on failures vs. successes
- Take on the victim role
- Too serious all the time
- Couch potato – not caring for self
- Trying to meet others expectations
- Isolating yourself
- Convincing yourself that you ‘can’t’
