1. RECENT
UNDERSTANDING
ABOUT STRESS
SATYAKAM MOHAPATRA
JUNIOR RESIDENT –II
DEPARTMENT OF PSYCHIATRY

2. INTRODUCTION
 Stress is a common problem that affects
almost all of us at some point in our lives.
Learning to identify when we are under
stress, what is stressing us and different
ways of coping with stress can greatly
improve both our mental and physical
well being.
 Stress is one of the central concepts in
Psychiatry.
 Stress has been invoked as a cause of
major psychopathology, a precipitator or
trigger of psychiatric illness and a
contributor to considerable mental

3. ORIGIN AND TERMINOLOGY
 Stress is a word derived from the Latin
word stringere, meaning to draw tight .
 The term stress was first employed in a
biological context by Hans Selye in the
1930s.
 He explained stress as an inappropriate
physiological response to any demand.
 In his usage stress refers to a condition
and stressor to the stimulus causing it.
 It covers a wide range of phenomena, from
mild irritation to drastic dysfunction that may
cause severe health breakdown.

4. DEFINITION
 A state of affair involving demand on physical
or mental energy-Oxford Dictionary.
 A physical or psychological stimulus that can
produce mental tension or physiological
reactions that may lead to illness.
 Now, the most commonly accepted definition
of stress (mainly attributed to Richard S
Lazarus) is that stress is a condition or
feeling experienced when a person
perceives that demands exceed the
personal and social resources the
individual is able to mobilize.

5. DIFFERENT MODELS OF STRESS
General adaptation model: By Selye
 Alarm is the first stage. When the stressor is identified the
body's stress response is a state of alarm. Adrenaline will be
produced in order to bring about the fight-or-flight response.
There is also some activation of the HPA
axis, producing cortisol.
 Resistance is the second stage. If the stressor persists, it
becomes necessary to attempt some means of coping with
the stress. Although the body begins to try to adapt to the
strains or demands of the environment, the body cannot keep
this up indefinitely, so its resources are gradually depleted.
 Exhaustion is the third. At this point all of the body's
resources are eventually depleted and the body is unable to
maintain normal function. The initial autonomic nervous
system symptoms may reappear. If stage three is
extended, long term damage may result as the body, and the
immune system is exhausted and function is impaired
resulting in decompensation.

6. DIFFERENT MODELS OF STRESS(CONDT.)
COGNITIVE APPRAISAL MODEL: LAZARUS
 Lazarus argued that in order for a psychosocial
situation to be stressful, it must be appraised as
such. He argued that cognitive processes of
appraisal are central in determining whether a
situation is potentially threatening or is benign.
 Both person and environmental factors influence
this primary appraisal, which then triggers the
selection of coping processes. Problem-focused
coping is directed at managing the problem, while
emotion-focused coping processes are directed at
managing the negative emotions. Secondary
appraisal refers to the evaluation of the resources
available to cope with the problem and may alter the
primary appraisal.

7. RECENT VIEWS
 There are renewed laboratory research into
the neuroendocrine, molecular and immunological bases of
stress.
 By the 1990s, "stress" had become an integral part of
modern scientific understanding in all areas of physiology and
human functioning.
 The confusion between STRESS as ‗cause‘ versus ‗trigger‘ of
illness has hindered progress.
 Views that a stressor caused an illness is difficult to
demonstrate in most human studies that impose a short-term
stressor and examine the resultant physiological changes.
 There is, however, an alternative hypothesis that provides
very strong evidence for a link between stressors and illness.
This argument emphasizes that stressors trigger illness in
individuals whose underlying illness is latent or subclinical.

8. CAUSES OF STRESS
 Common external causes of stress
 Major life changes
 Work
 Relationship difficulties
 Financial problems
 Children and family
 Personal Health and Safety
 Common internal causes of stress
 Inability to accept uncertainty
 Pessimism
 Negative self-talk
 Unrealistic expectations
 Perfectionism
 Lack of assertiveness

9. TYPES OF STRESS
(1)EUSTRESS
Also called "good stress" or "positive stress". They are able to exert a
healthy effect on us. It gives one a feeling of fulfilment or contentment and
also makes one excited about life. Unfortunately, it is a type of stress that
only occurs for a short period of time. Eustress is also often called the
curative stress because it gives a person the ability to generate the best
performance or maximum output.
(2)DISTRESS
Distress is a ―negative stress‖. It is a stress disorder that is caused
by adverse events and it often influences a person‘s ability to cope.
Distress can be classified further as acute stress or chronic stress..
(a) Acute Stress
 Acute stress is the type of stress that comes immediately with a change of
routine. It is an intense type of stress, but it passes quickly. Acute stress is
the body's way of getting a person to stand up and take inventory of what is
going on, to make sure that everything is OK.
(b)Chronic Stress
 Chronic stress will occur if there is a constant change of routine for week
after week. Chronic stress affects the body for a long period of time. This is
the type of stress experienced by someone who constantly faces moves or
job changes.

10. WARNING SIGNS AND SYMPTOMS OF STRESS

11. SIDE EFFECTS OF STRESS
 DEPRESSION : one of the side effects of
stress, caused actually by the excess of
stress
 WEIGHT GAIN :The calories intake
increases significantly during stressful
moments. When we are stressed, we try to
compensate the problems we are facing by
eating more than we need.
 WEAK IMMUNE SYSTEM: Stress has a big
role in weakening our immune System.
 INSOMNIA

12. PHYSIOLOGICAL RESPONSES TO STRESS
(A)NEUROTRANSMITTER RESPONSE TO STRESS
STRESS activates
 Noradrenergic system
 Serotonergic system
 Dopaminergic system
 Amino acid and peptinergic neurotransmitter system
(B)ENDOCRINE RESPONSE TO STRESS
STRESS activates HPA AXIS
 CRH acts at the anterior pituitary to trigger release of
adrenocorticotropic hormone (ACTH)which acts at the adrenal
cortex to stimulate the synthesis and release of glucocorticoids.
 Glucocorticoids themselves have myriad effects within the body, but
their actions can be summarized in the very short term as promoting
energy use, increasing cardiovascular activity (in the service of the
flight-or-fight response), and inhibiting functions such as
growth, reproduction, and immunity.

13. PSYCHONEUROIMMUNOLOGY
 Recent research has shown that
immune system is a key player in
stress physiology.
 Psychoneuroimmunology is the study
of the bidirectional interactions
between brain, behaviour, and the
immune system.

14. BIOLOGICAL CONNECTIONS BETWEEN THE
CENTRAL NERVOUS SYSTEM AND IMMUNE
SYSTEM:
Autonomic Nervous System
 Sympathetic nervous system activation can
reduce cellular immune response activation
by suppressing the activity of diverse
populations of immune cells, including natural
killer (NK) cells and T lymphocytes.
 Sympathetic nervous system activation
enhance the humoral immune response by
enhancing , the production of antibodies by B
cells and the ability of macrophages to
release cytokines .

15. BIOLOGICAL CONNECTIONS BETWEEN THE CENTRAL
NERVOUS SYSTEM AND IMMUNE SYSTEM (CONTD.)
NEUROENDOCRINE AXIS:
 The other way in which the brain can
communicate with the immune system is via the
HPA system.
 Cortisol exerts influence on the actions of various
cells involved in an immune response by
suppressing the cellular immune response.
 Cortisol can also prompt some immune cells to
move out from circulating blood into lymphoid
organs or peripheral tissues, such as the skin.
 Immune cells can produce neuroendocrine
peptides (e.g., endorphin, ACTH), which suggests
that the brain, neuroendocrine axis, and immune
system use the same molecular signals to
communicate with each other.

16. BEHAVIOURAL AND PSYCHOLOGICAL
INFLUENCES ON IMMUNITY
Behaviours and emotions are capable of altering immunity.
A) Acute Stress and Immunity in Humans:
 Acute stressors produce profound and rapid changes in the immune
system due to the redistribution of immunoregulatory cells from
lymphoid organs, such as the spleen, into the vascular space.
 Such acute stressor elicit decreases in cellular immune responses and
increases in the markers of inflammation (IL-6) which are thought to be
mediated by release of sympathetic neurotransmitters and beta-
adrenergic receptor activation.
 Individuals who are aged or are undergoing chronic stress show
exaggerated immune responses to acute stress and are likely to take
longer to recover from the exposure to stress, which may put them at
increased risk of infectious disease.

17. BEHAVIORAL AND PSYCHOLOGICAL
INFLUENCES ON IMMUNITY(CONTD.)
(B) CHRONIC STRESS, DEPRESSION, AND IMMUNITY:
 chronic or naturalistic stressors are associated with reliable
decreases of cellular and innate immunity.
 A similar pattern of immune alterations is reported in patients
with major depression. This latter observation is not
surprising, because individuals undergoing stress often report
negative emotions and depressive symptoms, and the presence
of such affective symptoms is associated with greater immune
alterations.
 Heterogeneity in the effects of stress and depression on
immunity can be accounted for by a number of factors, such as
age, gender, ethnicity, health behaviours (e.g., smoking, alcohol
consumption), and coping or personality

18. BEHAVIOURAL AND PSYCHOLOGICAL
INFLUENCES ON IMMUNITY(CONTD.)
(C)SLEEP, CYTOKINES, AND IMMUNITY:
 Disordered sleep and loss of sleep are thought to
adversely affect resistance to infectious disease
and alter inflammatory disease progression.
 Sleep deprivation suppresses NK activity and IL-2
production and induces decrease in specific
antibody production to infectious challenges.
 In contrast measures of innate immunity and
proinflammatory cytokine expression including
cellular and genomic markers of inflammation are
enhanced following sleep loss.

19. BEHAVIORAL AND PSYCHOLOGICAL
INFLUENCES ON IMMUNITY(CONTD.)
(D)Cytokine Influences on the Central Nervous
System and Behaviour:
 The immune system acts, in many ways, like a
sensory organ, conveying information to the brain that
ultimately regulates neuroendocrine and autonomic
outflow and the course of the immune response.
 IL-1 and, possibly, other inflammatory cytokines
communicate with the brain by stimulating
peripheral, afferent nerves, such as the vagus.
 Human studies have begun to reveal links between
peripheral cytokines and behavioural changes.
 physiological activation of the immune system with the
release of proinflammatory cytokines leads to
increases of depressed mood and anxiety and
decreases in verbal and nonverbal memory functions.

20. STRESS AND PSYCHIATRIC ILLNESS
BIOPSYCHOSOCIAL MODEL- proposed by
MEYER:
 This orientation held that an individual's
response to stress is modified by a number of
intrinsic and extrinsic factors.
 The model incorporated stressful life events
as initiating or exacerbating factors and a
variety of support networks as potentially
modifying factors for the occurrence of
mental illness.
 For the most part, this multideterminate
model of mental illness dominates modern
psychiatric thinking.

21. STRESS AND PSYCHIATRIC ILLNESS(CONTD.)
 DSM-IV-TR does not emphasize this
Biopsychosocial model of the nature and
genesis of psychiatric disorders.
 DSM-IV-TR continues to struggle with the
best way to classify and incorporate
stressful life events into diagnosis.
 In the face of this ongoing
turbulence, however, much research has
been conducted that serves to sharpen
thinking about the relationship between
stress and psychiatric illness.

22. STRESS AND PSYCHIATRIC ILLNESS(CONTD.)
(A)Stress and Psychotic Disorders
 There is little reason to suspect that stress
plays a role in the pathogenesis of
schizophrenia.
 There is, however, ample evidence that
adverse life events and stressful social
and familial milieu play an important role in
determining the course of illness in
general and episodes of relapse in
particular.

23. STRESS AND PSYCHIATRIC ILLNESS(CONTD.)
(B)Affective Disorders
 Recent advances in psychiatric epidemiology suggest that a simple
relationship between stressful life events and affective illness may
not exist.
 Most studies of stress and depression have a number of
methodological shortcomings.
 There is a tendency for depressed patients to selectively recall
negative life events and associate these events with their current
difficulties.
 Although these effects can be minimized by ascertaining life events
when patients are not in episodes of depression, there is additional
evidence that depressed patients really do experience more
negative life events than nondepressed patients.
 Genes and stressful life events operate in consert to elicit
depressive episodes.

24. STRESS AND PSYCHIATRIC ILLNESS(CONTD.)
(C)Anxiety Disorders (Other Than PTSD)
 In comparison to the voluminous literature on stress
and depression, there is less empirical research on the
relationship between stress and anxiety disorders.
 Nonetheless, it is apparent that panic disorder
frequently has its onset or recrudescence in the
context of stressful life events.
 In terms of the effects of early life stressors, there is
growing evidence that certain adverse early life
events, such as sexual or physical abuse, may be risk
factors for the later development of panic
disorder, particularly in women.

25. STRESS AND PSYCHIATRIC ILLNESS(CONTD.)
(D)POSTTRAUMATIC STRESS DISORDER
 The occurrence of PTSD after severe psychological trauma provides
the most persuasive evidence in favour of certain kinds of stress
causing psychiatric illness.
 It is important to note, however, that the neuroendocrine profile of
patients with PTSD is not what one might expect to see after chronic
stress, nor in major depression.
 Whereas the latter two conditions would be expected to be
associated with hypercortisolism, most (but not all) studies of
patients with PTSD have demonstrated rather subtle
hypocortisolism.
 Although the neurobiological implications of this finding remain to
be elucidated, the message for stress researchers is clear: There is
no longer hope that a uniform neuroendocrine stress response
can explain the heterogeneity of psychiatric disorders
encountered in the wake of psychological stress.

26. TREATMENT
PHARMACOLOGICAL APPROACHES TO STRESS
MANAGEMENT
 As discussed above, stressors worsen many different
psychiatric conditions.
 When major psychiatric conditions, such as depression or
psychosis, are present, the most appropriate medications are
those for the Axis I diagnosis.
 However, more typically, the picture is primarily one of
anxiety or insomnia, perhaps not of as great a magnitude as
that found typically in anxiety disorder, but still very distressing
to the patient. In such settings, pharmacological therapy with
anxiolytic medications or short-term hypnotics can be
extremely helpful.
 This intervention, in association with supportive
psychotherapy, is extremely effective in crisis intervention

27. COGNITIVE-BEHAVIORAL APPROACHES TO STRESS
MANAGEMENT
 Cognitive-behavioural therapy methods
are increasingly used to help individuals
better manage their responses to stressful
life events.
 These treatment methods are based on
the notion that cognitive appraisals about
stressful events and the coping efforts
related to these appraisals play a major
role in determining stress responding

28. COGNITIVE-BEHAVIORAL APPROACHES TO STRESS
MANAGEMENT(CONTD.)
Cognitive-behavioural therapy approaches to stress
management have three major aims:
(1)to help individuals become more aware of their own
cognitive appraisals of stressful events.
(2) to educate individuals about how their appraisals of stressful
events can influence negative emotional and behavioural
responses and to help them reconceptualise their abilities to
alter these appraisals
(3) to teach individuals how to develop and maintain the use of a
variety of effective cognitive and behavioural stress
management skills.

29. STRESS-MANAGEMENT TRAINING
 When cognitive-behavioural therapy is
used for stress management, training is
provided in a wide range of stress-
management skills.
 Five skills that form the core of almost all
stress-management programs: self-
observation, cognitive
restructuring, relaxation training, time
management, and problem solving.

30. SELF-OBSERVATION
 One of the most effective ways to help
individuals become more aware of how they
respond to problem situations is to have them
keep a daily record of their behaviour.
 A daily diary format is often used, with
patients being asked to keep a record of how
they responded to challenging or stressful
events that occurred each day.
 Individuals who keep daily diary records of
stress-related behaviours often make
changes in their own behaviour, even before
other stress-management methods are
introduced

31. COGNITIVE RESTRUCTURING
 A hallmark of cognitive-behavioural therapy is its
insistence that cognition plays a central role in the
stress and coping process.
 In cognitive-behavioural therapy, cognitive
appraisals about stressful events are considered
to be the key factor in determining stress-related
responding.
 Given this emphasis on cognition, it is not
surprising that a major thrust of
cognitive-behavioural therapy approaches to
stress management is on helping participants
become aware of and change their maladaptive
thoughts, beliefs, and expectations.

32. RELAXATION TRAINING
 Relaxation skills can be very helpful in
managing stress.
 DIFFERENT RELAXATION TECHNIQUES:
 DEEP BREATHING EXERCISE.
 PROGRESSIVE MUSCLE RELAXATION
(PMR) TECHNIQUE involves the progressive
or sequential, tensing and then relaxing of
specific muscle groups. When individuals
learn to relax, their overall muscle tension is
reduced, as is their overall level of autonomic
arousal.
 MUSIC THERAPY
 DANCE THERAPY

33. RELAXATION TRAINING(CONTD.)
 YOGA is a useful stress reducing exercise;
The harmony with which the body moves, in
sync with the breath has therapeutic and
calming effects.

34. RELAXATION TRAINING(CONTD.)
 PHYSICAL EXERCISE

35. RELAXATION TRAINING(CONTD.)
 AROMATHERAPY Essential oils work because of
their small molecular size which allows them to penetrate
bodily tissues easily. They also create a pleasant smell that
emotionally lifts the user. The neurochemical makeup of the
brain is altered through the olfactory sense.

36. RELAXATION TRAINING(CONTD.)
 Individuals who are able to relax are also
more likely to be able to think more
rationally and restructure negative
cognitions when faced with stressful
events.
 Finally, relaxation skills may be helpful in
reducing maladaptive behaviour patterns.

37. TIME MANAGEMENT
 Time-management methods are designed
to help individuals restore a sense of
balance to their lives.
 The first step in training in
time-management skills is designed to
enhance awareness of current patterns of
time use.
 The second step in time management is
designed to help individuals set their
priorities.

38. PROBLEM SOLVING
 Problem solving is a skill that is introduced in the later
stages of stress-management training.
 As trainees attempt to apply what they have learned
about stress management, they may find that some
problem situations are particularly challenging and
difficult to manage using only one or two stress-
management techniques.
 Steps of problem solving:
(a)problem identification.
(b)generating alternatives.
(c)evaluating the alternatives and selecting the best
solution.
(d)implementing the solution.

39. CONCLUSION
 Recent advances in the understanding of the many complex
connections between the human mind and body have
produced a variety of mainstream approaches to stress-
related illness.
 Complete prevention of stress is neither possible nor
desirable, because stress is an important stimulus of human
growth and creativity, as well as an inevitable part of life.
 In addition, specific strategies for stress prevention vary
widely from person to person, depending on the nature and
number of the stressors in an individual's life, and the amount
of control he or she has over these factors.
 In general, however, a combination of attitudinal and
behavioural changes works well for most patients. The best
form of prevention appears to be parental modeling of healthy
attitudes and behaviours within the family.

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41. THANK YOU