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Transcript of Stressors and the Stress Response · post traumatic stress disorder ... calcium and oxygen contents...
Stressors and the Stress
Response
HOW OVER-ACTIVATION OF THE BODY AND BRAIN
STRESS SYSTEMS CAN PREDICTABLY LEAD TO
MENTAL HEALTH AND SUBSTANCE ABUSE PROBLEMS
STEPHEN G. HOLLIDAY, PHD
Copyright © 2017 by Sea Courses Inc
.
All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means – graphic,
electronic, or mechanical, including photocopying, recording, or
information storage and retrieval systems without prior written
permission of Sea Courses Inc. except where permitted by law.
Sea Courses is not responsible for any speaker or participant’s
statements, materials, acts or omissions.
WHO IDENTIFIES STRESS AS THE
HEALTH CARE EPIDEMIC OF THE 21ST
CENTURY• 50% OF PEOPLE IN THE WORKFORCE STATE THAT STRESS NEGATIVELY EFFECTS
PRODUCTIVITY
• JOB STRESS IS ASSOCIATED WITH OBESITY, ADDICTION, ANXIETY AND HEART
DISEASE
• WARS AND DISASTERS HAVE LED TO UNPRECEDENTED NUMBERS OF CASES OF
POST TRAUMATIC STRESS DISORDER (PTSD)
• STRESS IS ASSOCIATED WITH INCREASED INCIDENCE RATES OF DEPRESSION
AND ANXIETY
• ROCKETING RATES OF SUBSTANCE ABUSE ARE THOUGHT TO BE RELATED TO
INCREASED LEVELS OF STRESS
Pioneers in the Study of Stress
Walter Cannon (1871-1945)
Homeostasis
Fight or Flight Response
Hans Selye (1907 – 1982)
Stress Response (HPA)
General Adaptation Syndrome
Homeostasis
THE PROCESS(ES) THAT LIVING ORGANISMS USE TO ACTIVELY MAINTAIN THE STABLE PHYSIOLOGICAL CONDITIONS NECESSARY FOR SURVIVAL
THE NORMAL VALUE OF A PHYSIOLOGICAL VARIABLE IS CALLED ITS SET POINT
THE HUMAN BODY MAINTAINS STEADY LEVELS OF TEMPERATURE AND OTHER VITAL CONDITIONS SUCH AS THE WATER, SALT, SUGAR, PROTEIN, FAT, CALCIUM AND OXYGEN CONTENTS OF THE BLOOD
PFC-HC-AM-HP
ANS HPA Axis
Increased Resp.
PNS - CRH+AVPSNS +
EPI+NE
Cortisol
Immune + Inflam. Regulation
Corticosterone
ACTH
Growth Inhibition
Inc. Energy Release
Dec. Energy Storage
Increased Cardio
Reproduction –Inhib. Repair Inhibition
STRESSOR
SAM
(RAPID
RESPONSE)
HPA
(ONGOING
RESPONSE)
Three Types or
Levels of Stress
and Their
Differential Effects
on Physical and
Mental Health
Augments
Function
Requires
Compensation
Leads to
Pathology
A SIMPLE MODEL OF STRESS
• STRESSORS ACTIVATE PHYSIOLOGICAL SYSTEMS IN PREDICTABLE AND
CHARACTERISTIC WAYS (THE STRESS RESPONSE)
• ACTIVATION DISRUPTS/AUGMENTS NORMAL PHYSIOLOGICAL FUNCTION
(HOMEOSTATIC DYSREGULATION)
• ACTIVATION HAS PREDICTABLE IMMEDIATE ADAPTIVE CONSEQUENCES (FIGHT
OR FLIGHT RESPONSE)
• SHORT-TERM ACTIVATION IS FOLLOWED BY A RETURN TO THE NORMAL RANGE OF
FUNCTION (HOMEOSTASIS
• LONG TERM ACTIVATION HAS DETRIMENTAL PHYSIOLOGICAL CONSEQUENCES
(GENERAL ADAPTATION SYNDROME)
AUGMENTING THE SIMPLE MODEL
OF STRESS – FOUR ADDITIONS
• ALLOSTASIS
• NEUROENDOCRINOLOGY
• INDIVIDUAL DIFFERENCES IN SHORT AND
LONG-TERM RESPONSES TO STRESSORS
• EPIGENETICS
ALLOSTASIS
• AN ADAPTIVE PHYSIOLOGICAL RESPONSE THAT ORGANISMS
ACTIVATE WHEN HOMEOSTASIS IS DISRUPTED
• ALLOSTATIC PROCESSES ALTER METABOLIC FUNCTION VIA
COMPENSATORY/ANTICIPATORY MECHANISMS IN RESPONSE TO
INTERNAL OR EXTERNAL CUES/STIMULI (STRESSORS)
• ALLOSTATIC PROCESSES ALLOW THE BODY SYSTEMS TO ADAPTIVELY
ADJUST TO CONSTANTLY CHANGING ENVIRONMENTS
FEATURES OF ALLOSTASIS
• CHANGING SET POINT
• COMPENSATED EQUILIBRIUM
• EXTENSIVE ANTICIPATION OF DEMAND
• ADJUSTMENT BASED ON HISTORY
Allostatic Load
The Physiological Price of Adaptation that Organisms Pay
When Allostatic Process are Repeatedly Activated or When
Activation is Maintained Over Extended Periods of Time
BRAIN SYSTEMS UNDER STRESS
BRAIN SYSTEM LOW-MODERATE
INTENSITY STRESS
HIGH/EXTREME
INTENSITY STRESS
PFC and Hippocampus + Density of Dendrites and
Synapses
+Neurogenesis
- In Density of Dendrites and
Synapses
- Neurogenesis
Amygdala - In Density of Dendrites and
Synapses
- Neurogenesis
+ In Density of Dendrites
and Synapses
+ Neurogenesis
Nucleus Accumbens + Dopamine Release - Dopamine Release
A LESS SIMPLE MODEL OF STRESS
Stressors activate the body/brain stress systems
Specific responses are associated with particular types of stressors
Allostatic processes come into play when the stress system is activated
Long-term activation of the stress systems leads to allostatic overload
The response to CONTINUED allostatic overload is organ/system
dysfunction/failure
Individual differences play a role in stress response and adaptation
Exposure to stressors can lead to phenotype changes that have long-
term effects on the stress systems
STRESS AND MENTAL HEALTH
EXPOSURE TO STRESSORS CAN HAVE PROFOUND
EFFECTS ON MENTAL HEALTH
• MOOD DISORDERS
• ANXIETY DISORDERS
• POST TRAUMATIC STRESS DISORDERS
• TRAUMA-BASED DISORDERS
TWO DISTINCT SITUATIONS & OUTCMES
1. BRIEF OR PROLONGED EXPOSURE TO HIGH-INTENSITY STRESSORS
Post Traumatic Stress Disorders
Acute Trauma Disorders
Complex Trauma Disorders
2. PROLONGED EXPOSURE TO LOW/MODERATE-INTENSITY STRESSORS
Anxiety Disorders
Depression/Mood Disorders
VARIABLES THAT DETERMINE OUTCOME
• INDIVIDUAL DIFFERENCES AND VULNERABILITIES
• INTENSITY OF THE STRESSOR
• DURATION OF EXPOSURE TO THE STRESSOR
THE TWO DIMENSIONS OF ROBUSTNESS
1. RESISTANCE
ENDURANCE IN THE FACE OF BOTH GREATER INTENSITY
STRESSORS AND LONGER DURATION OF EXPOSURE TO STRESSORS
2. RESILIENCE
FASTER AND MORE EFFICIENT RECOVERY OF FUNCTION OR FASTER
AND MORE EFFICIENT RETURN TO NORMAL SET POINTS FOLLOWING
EXPOSURE TO STRESSORS
Low Robustness
High IntensityLow Intensity
Extended.
Moderate Risk
High Robustness
Brief
Moderate Risk
Low Risk
High Risk
Low to Moderate Risk
Factor 1. Physiological & Psychological Robustness (Low vs. High)Factor 2. Intensity of the Stressor (Low vs. High)
Factor 3. Duration of Exposure to the Stressor (Brief vs. Extended)
A THREE FACTOR MODEL FOR ESTIMATING LIKELIHOOD OF MENTAL HEALTH PROBLEMS SUBSEQUENT TO EXPOSURE TO STRESSORS
Low Intensity High Intensity
BriefBriefBrief Extended.Extended.Extended.
High Risk
Moderate to HighRisk
Moderate to HighRisk
Depression/Anxiety Depression/AnxietyTrauma/PTSD Trauma/PTSD
DSM V - PTSD
THERE ARE NOW FOUR SYMPTOM CLUSTERS
1. RE-EXPERIENCING THE EVENT
1. Spontaneous memories, flashbacks, dreams
2. HEIGHTENED AROUSAL
1. Hyper-vigilance, reckless behaviour, sleep disturbance
3. AVOIDANCE
1. Distressing memories, thoughts or feelings of the event
4. NEGATIVE THOUGHTS/MOOD/FEELINGS
1. Distorted sense of blame, diminished activities, estrangement
PTSD: A SIMPLE STRESS-FOCUSED MODEL
• EXPOSURE TO A HIGH INTENSITY STIMULI EVOKES A STRONG STRESS RESPONSE (AMYGDALA/HIPPOCAMPUS ETC.)
• INITIAL MEMORIES/RESPONSES OCCUR VIA CLASSICAL CONDITIONING (FLASH MEMORIES OF HIGH INTENSITY)
• SUBSEQUENT RESPONSES OCCUR VIA COGNITIVE/EMOTIONAL EVALUATIVE PROCESSES (TRADITIONAL LEARNING)
• RE-EXPOSURE TO INTERNALLY OR EXTERNALLY GENERATED STIMULI STRENGTHENS BOTH TYPES OF LEARNING
• THE TWO SOURCES OF MEMORY PLAY OFF OF EACH OTHER LEADING TO STRENGTHENING OF THE VARIOUS RESPONSES LEADING TO ONGOING TRIGGERING OF A) THE STRESS RESPONSE AND B) THE COGNITIVE/EMOTIONAL RESPONSE
Symptom Overlap
Depression
Feeling Sad, Empty, Hopeless
Decreased Pleasure or Interest
Loss of appetite/Weight Loss
Sense of Worthlessness or Guilt
Thoughts of Death
Agitation or Retardation
Fatigue / Loss of Energy
Poor Concentration
Problems with Cognition
Insomnia or Hypersomnia
Generalized Anxiety
Increased Anxiety or Worry
Irritability
Muscle Tension
Restlessness
Fatigue
Poor Concentration
Problems with Cognition
Sleep Disturbance
Stress
THE NON-SPECIFIC SYMPTOMS THAT ARE A PART OF THE DIAGNOSTIC CRITERIA OF THE VARIOUS VERSIONS OF THE DSM ARE REMARKABLY SIMILAR TO THE PHYSIOLOGICAL RESPONSES THAT OCCUR WHEN PEOPLE ARE EXPOSED TO MODERATE INTENSITY STRESSORS FOR LONG PERIODS OF TIME
DEPRESSION AND ANXIETY – STRESS
EXPOSURE END-STATES?
• LONG TERM EXPOSURE TO LOW/MODERATE INTENSITY STRESSORS LEADS TO ALLOSTATIC OVERLOAD IN VULNERABLE INDIVIDUALS
• PHYSIOLOGICAL OVER-AROUSAL LEADS TO EMOTIONAL AND PHYSICAL DESTABILILZATION
• OVER-ACTIVATION OF THE EMOTIONAL NETWORKS LEADS TO ANXIETY SYMPTOMS
• UNDER-ACTIVATION OF THE EMOTIONAL/BEHAVIOURAL NETWORKS LEADS TO DEPRESSIVE SYMPTOMS
• INDIVIDUAL VARIATION AND VULNERABILITIES DETERMINE SPECIFIC OUTCOMES
FEATURES OF THE ADDICTION CYCLE
1. A PATHOLOGICAL CHANGE IN THE HOMEOSTATIC MECHANISMS THAT REGULATE EMOTIONAL STATES
2. CHRONIC ELEVATION OF THE REWARD SET-POINTS LEADING TO EMOTIONAL AND COGNITIVE DISREGULATION
3. LOSS OF EXECUTIVE CONTROL LEADING TO IMPULSIVITY AND POOR BEHAVIOURAL REGULATION
4. COMPROMISE OF THE BRAIN ANTI-STRESS SYSTEMS WHICH CONTRIBUTED TO COGNITIVE AND EMOTIONAL DYSFUNCTION
SPECIFIC WAYS THE STRESS RESPONSE
CONTRIBUTES TO SUBSTANCE ABUSE
INITIAL STAGES/ACQUISITION
• ALL ADDICTIVE SUBSTANCES ARE ACUTE PHYSICAL STRESSORS/NEUROTOXINS
• ACUTE STRESSORS TRIGGER AUGMENTED LEARNING (CLASSICAL CONDITIONING)
• STRESS IS ASOCIATED WITH DISREGULATION OF DOPAMINE FUNCTION
• INCREASED ALLOSTATIC LOAD LEADS TO DISRUPTION OF COGNITIVE AND EMOTIONAL STATES
LATER STAGES/MAINTENANCE
• CHRONIC HPA ELEVATION LEADS TO CHRONICALLY DE-REGULATED COGNITIVE, EMOTIONAL
PROCESSES (BRAIN EFFECT)
• CHRONIC ALLOSTATIC LOAD LEADS TO EMERGENT HEALTH PROBLEMS (BODY EFFECT)
• CLASSICALLY CONDITIONED CUES TRIGGER CRAVINGS AND RELAPSE
IMPLICATIONS FOR TREATMENT
1. WITHDRAWAL MANAGEMENT MUST INCLUDE SPECIFIC EMPHASIS ON
DECREASING ALLOSTATIC OVERLOAD AND ASSOCIATED
PHYSICAL/EMOTIONAL/COGNITIVE PROBLEMS
2. TREATMENT MUST CONSIDER THE LEARNING PROCESSES THAT
UNDERLIE ADDICTIVE BEHAVIOUR
3. SELF-MANAGEMENT STRATEGIES MUST INCLUDE BOTH SIMPLE AND
COMPLEX STRESS MANAGEMENT TECHNIQUES
THE CASE FOR ROUTINE MONITORING
OF STRESSORS AND STRESS LEVELS
• OVERACTIVE BODY AND BRAIN STRESS SYSTEMS ARE
ASSOCIATED WITH NEGATIVE CLINICAL OUTCOMES
• REGULAR MONITORING CAN ALERT CLINICIANS TO RISKS
INCLUDING ALLOSTATIC LOAD
• FOLLOW-UP WITH STRESS-MANAGEMENT TECHNIQUES CAN
REDUCE ALLOSTATIC LOAD AND ASSOCIATED HEALTH RISKS
MONITORING PART 1
IDENTIFYING STRESSORS AND PERCEIVED STRESS
1. PTSD/ACUTE TRAUMA DISORDER RISK
2. COMMON STRESSORS
3. PERCEIVED STRESS
4. WORKPLACE STRESS
MONITORING PART 2
USING BIOMARKERS/ ALLOSTATIC LOAD INDICES
Primary Mediators: Cortisol, Epinephrine, Norepinephrine, DHEAS
Secondary Outcomes: Systolic and Diastolic BP, Waist-Hip Ratio,
High-Density Lipoprotein and Total Cholesterol Ratio, Glycosylated
Haemoglobin
USING COMPOSITE INDICES AND
SUMMARY SCORES
A SUMMARY SCORE IS MORE PREDICTIVE OF HEALTH SCORES THAN IS A
SINGLE VALUE OR VARIABLE
THERE IS NO AGREEMENT ON WHICH BIOMARKERS SHOULD BE USED TO
CREATE COMPOSITE SCORES.
THERE IS NOT YET A STANDARD FOR EVALUATING RISK (SIMPLE COUNT
VS CUTOFF VS QUARTILE VS Z-SCORES ETC.)
FIVE COMPONENTS OF STRESS
MANAGEMENT
1. EDUCATION
2. IDENTIFICATION OF STRESSORS
3. PHYSIOLOGICAL STABILIZATION
4. SIMPLE SELF-REGULATION TECHNIQUES
5. LIFESTYLE MANAGEMENT
1. EDUCATION
1. OVERVIEW OF THE MODERN MODEL OF STRESS
2. DISTINGUISH BETWEEN STRESSORS AND THE STRESS RESPONSE
3. APPRECIATE THE SHORT AND LONG-TERM EFFECTS OF STRESS
4. UNDERSTAND DIFFERENT TYPES OF STRESS CONTROL
3. PHYSIOLOGICAL STABILIZATION
REDUCE ALLOSTATIC LOAD
1. TREATMENT OF EXISTING CONDITIONS
2. TREATMENT OF INFECTIONS
3. SLEEP AND PAIN MANAGEMENT
4. DIETARY MANAGEMENT
4. SIMPLE SELF-REGULATION TECHNIQUES
CONTROLLED BREATHING
SIMPLE STRETCHING/TENSION REDUCING EXERCISES
COGNITIVE RE-SETS