Stress Causes, Effects and Management. By Dr. Ali Garatli


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Presentation by Dr. Ali Garatli on Stress and its management for King Fahd Medical City staff in Riyadh, Saudi Arabia

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Stress Causes, Effects and Management. By Dr. Ali Garatli

  2. 2. Package
  3. 3. Stress Response Savior to Killer232.flv
  4. 4. The Stress Response System Cannon proposed that  the stress response  (fast) was a fight‐or‐ flight response marked  by the outpouring of  epinephrine and  norepinephrine from  the  inner adrenal  glands, increasing  heart and respiration  rates, mobilizing sugar  and fat, and dulling  pain.
  5. 5. Physiological Responses to Stress Endorphins are released Pupils dilate to admit more light for more sensitive vision Mucous membranes of nose & throat shrink while muscles force wider opening of passages to permit easier air flow Heart rate increases Liver releases sugar into blood stream – energy for muscles and brain Bone marrow throughout body produces more while blood cells Voluntary skeletal muscles contract throughout the body Hearing becomes more acute Secretion of saliva decreases Bronchi dilate Perspiration increases – evaporation cools body Spleen releases more red blood cells Pancreas decreases secretion Adrenal glands release adrenalin and noradrenalin resulting in increased blood pressure, increased heart rate, increased fatty acids in blood stream and increased blood sugar
  6. 6. CRF & Stress CRF plays an important role in stress response Stress exposure is associated with ↑ CRF Central CRF administration is associated with fear-related behaviors ↓ exploration ↑ startle ↓ grooming
  7. 7. Main biological pathways of chronic stress: - Dysregulation of the hypothalamushypophysis-adrenocortical (HPA) axis and the sympathetic-adrenal-medullary system (SAM) resulting in elevations in serum catecholamin and cortisol levels. Sympathoadrenal hyperactivity contributes to the development of CVD through effects of catecholamines upon the heart, blood vessels and platelets. Sympathoadrenal activation modifies the function of circulating platelets
  8. 8. Stress and Illness Leading causes of death in the US in 1900 and 2000
  9. 9. Stress and Disease Negative emotions and health-related consequences Heart disease Persistent stressors and negative emotions Unhealthy behaviors (smoking, drinking, poor nutrition and sleep) Release of stress hormones Immune suppression Autonomic nervous system effects (headaches, hypertension)
  10. 10. stress is the result of the perceived demands outweighing the perceived capability to cope This perception is influenced by a number of factors: personality, situational demands, previous experiences Resources any current stress state already existing
  11. 11. Good things about stress Sometimes it will save your life, or help you Fight Accident Test…
  12. 12. Stressful Life Events Chronic Stress by Age
  13. 13. Stress and Individual Differences Hardiness A characteristic of people who can tolerate stress well or even thrive on it Resilience Ability of a person to “bounce back” after a stressful event Self-imposed stress
  14. 14. Coping With Stress Direct coping Intentional efforts to change an uncomfortable situation Confrontation ⌧Acknowledging stress directly and initiating a solution Compromise ⌧Choosing a more realistic goal when an ideal goal cannot be met Withdrawal ⌧Avoiding a situation when other options are not practical
  15. 15. Compromise
  16. 16. Sources of Extreme Stress Unemployment Stages of relief, optimism, doubt, malaise, cynicism, Divorce and separation Ambivalence, feelings of failure, sadness, and fear Bereavement ‫اﺳﻬﻢ‬
  17. 17. Signs of stress Physical: headache, sleep disorders, racing heart, trembling, wt loss or gain Mental: constant worry, forgetfulness, mood swings, loss of sense of humor Emotional: anger, anxiety, negative thinking Behavioral: critical attitude of others, impulsive actions, withdrawal from relations, alcohol abuse
  18. 18. Gender differences There are no fundamental gender differences in physiological adaptation processes Although male and female hormones influence it in both respect Estrogenes decrease the stress reactivity According to animal studies, males appear to be more vulnerable to long-lasting stress-induced hippocampal damage than females (Uno et al, J. Neurosci,9,1705-1711,1989), the decline of circulating testosterone levels resulting from uncontrollable stress seems to play an additional role. Perinatal processes might result in dysregulation- postnatal depression
  19. 19. •Improper functioning of the subunit could impair the GABA system’s ability to adapt to hormone fluctuations during the highly 20 vulnerable post partum period
  20. 20. Package
  21. 21. Started before conception Stress in pregnant mother can have detrimental effect . Increased cortisol , fetus will shift to a protection mode , from growth mode Child will be vulnerable for later CAD, DM
  22. 22. Early life chronic stress: Phases of disruption of mother-infant or peer bonding: 1. "protest" behaviour (acute and resistance phases of stress). 2.“despair”: locomotor inactivity and a disinterst in motivationally salient external stimuli. 3."detachment""hardwired" in the brain of many social mammals and results in high stress vulnerability
  23. 23. Attachment theory (Bowlby, Imre Hermann) Physiological, psychological and developmental importance of the early childhood affective mother-child bond and the negative consequences of the disruption of this relationship. According to follow up studies, insecure attachment predicts later emotional instability and health deterioration. Maltreatment at an early age can have enduring negative effects on a child’s brain development and function, and on his or her vulnerability to stress.
  24. 24. Special gender roles, crucial effect of maternal care Maternal neglect behaviour results in attachment disturbances Naturally occuring variations in maternal care alter the expression of genes that regulate behavioral and endocrine responses to stress, as well as hippocampal synaptic development – related to oxytocin receptor gene expression (M.J.Meaney: Ann Rev Neurosci2001, 24,1161-1192)
  25. 25. Learned helplessness as result of chronic stress A condition of loss of control created by subjecting animals or humans to an unavoidable, emotionally negative life situation (such as unavoidable shocks, relative deprivation, role conflict, etc). Being unable to avoid or escape (flight or fight) an aversive situation for a long period of time produces a feeling of helplessness that generalises to subsequent situations.
  26. 26. Brain consequences of learned helplessness: The hippocampus is primarily affected by the long-lasting elevations of circulating corticosteroids resulting from uncontrollable stress. Severe stress for a prolonged period causes damage in hippocampal pyramidal neurons, especially in the CA 3 and CA4 region and reductions in the length and arborization of their dendrites.
  27. 27. Stress and Illness The body’s resistance to stress can last only so long before exhaustion sets in Stress resistance Stressor occurs Phase 1 Alarm reaction (mobilize resources) Phase 2 Resistance (cope with stressor) Phase 3 Exhaustion (reserves depleted) General Adaptation Syndrome Selye’s concept of the body’s adaptive response to stress in three stages
  28. 28. Stage 1: Alarm = stress response – stressor has been detected and a response made to alarm. Adrenaline is produced leading to fight or flight activity.
  29. 29. Stage 2: Resistance = Apparent coping, if stress continues it is necessary to find some means of coping and resist collapse. In this stage the body is adapting to the demands of the environment, but at the same time resources are being used up. Thus = apparent coping because in reality things are deteriorating
  30. 30. Stage 3: Exhaustion = breakdown, onset of stress-related illness. Eventually the body can no longer maintain normal functioning. Initial physiological changes may appear, e.g. sweating, increased heart rate. The adrenal gland (produces adrenaline) may be damaged due to over activity and the immune system may unable to cope due to the production of proteins being needed elsewhere = ulcers, depression, cardiovascular problems etc
  31. 31. More GAS 3) Exhaustion Defenses depleted at this point Very vulnerable Lots of this is bad Leads to destruction of hippocampal cells caused by cortisol release So, memory loss!
  32. 32. Hippocampal Volume Reduction In PTSD NORMAL PTSD MRI scan of the hippocampus in a normal control & patient with PTSD secondary to childhood abuse. The hippocampus, outlined in red, is visibly smaller in PTSD. Overall 12% reduction in volume in PTSD. (Bremner 1995; Bremner 1997)
  33. 33. Stress Antidepressants ↑ Cortisol ↑ Normal Serotonin & NE ↑ ↑ BDNF ↓BDNF Normal Survival & Growth Cortisol ↓ Atrophy & death Survival & Growth & Growth Other neuronal insults: Genetic Factors Factors Hypoxia-Ischemia Hypoxia-Ischemia Hypoglycemia Hypoglycemia Neurotoxins Neurotoxins Viruses Viruses ( Duman, Heninger & Nestler 1997)
  34. 34. Questions Can stress, anxiety, depression, social support, and optimistic view alter our ability to resist infection, autoimmune diseases or cancer? What are the biological pathways through which psychological state or characteristic will influence in disease susceptibility? Can we alter immunity and therefore disease susceptibility through psychological intervention?
  35. 35. 1981 David Felten: Discover a “hard-wire connection between the immune system and the CNS (trace nerves to bone marrow, lymph nodes, thymus and the spleen) Psychoneuroimmunology (PNI): study of interrelations between the CNS and the immune system (David Felten, 1981) Existence of neurologic terminations directly into lymphoid tissues in the spleen and release of neurochemicals in this location 2000 Bellinger: NA innervation of BM, thymus , spleen and nodes in animal models (immune system cells have adrenergic receptors receptors for NE ): Herbert, 1994; Bachen, 1995 Human research: establish the association between psychological states and immunity
  36. 36. Psychoneuroimmunology B lymphocytes fight bacterial infections, T  lymphocytes attack cancer cells and viruses, and  microphages ingest foreign substances. During  stress, energy is mobilized away from the  immune system making it vulnerable. Lennart Nilsson/ Boehringer Ingelhein International GmbH
  37. 37. Immunity and Disease How the immune system works
  38. 38. Stress and Colds People with the highest life stress scores were also  the most vulnerable when exposed to an  experimental cold virus.
  39. 39. Stress and Heart Disease Adrena l CORT EX Adrenal MEDUL LA Cortisol (associated with long-term effect of stress) – loss of control Adrenalin (associated with acute or short term response to stress. Increased FFA, increased Platelet numbers, increased Serum Cholesterol, decreased Potassium, direct injury producing effect of coronary artery walls.
  40. 40. Increased Platelet stickiness, direct injury producing effect on coronary artery walls, over contractibility of myocardium, increased FFA, shearing effect on plaques resulting in clotting system.
  41. 41. GP IIb/IIIa Receptor Final Pathway to Platelet Aggregation o Platelet activation and aggregation are early events in the development of coronary thrombosis o GP IIb/IIIa receptors on activated platelets undergo a conformational change allowing recognition and binding of fibrinogen o Fibrinogen”acts like glue”,bridging GP IIb/IIIa recptors on adjacent platelets, leading to platelet aggregation
  42. 42. Pathophysiology in Motion
  43. 43. y Increases the Risk of a Heart Attack 1. Stress Hormones (Cortisol & Adrenaline) elevate Blood Pressure. 2. Adrenalin increases blood platelet stickiness. 3. Cortisol increases blood platelet numbers. 4. Adrenalin & Cortisol have a direct injuryproducing effect on artery walls (contributes to atherosclerosis). 5. Adrenaline causes over-contractibility of heart muscle (rupture fibers?). 6. Cortisol increases cholesterol levels and lowers potassium levels.
  44. 44. INTERHEART: Measured Factors
  45. 45. Stress and the Heart Stress that leads to elevated blood pressure may  result in coronary heart disease, a clogging of the  vessels that nourish the heart muscle. Plaque in coronary artery Artery clogged
  46. 46. Stress and the Heart Hopelessness scores 3.5 3 Men who feel extreme hopelessness are at greater risk for heart attacks and early death 2.5 2 1.5 1 0.5 0 Heart attack Low risk Death Moderate risk High risk
  47. 47. Stress and type A’ person ,competitive, hostile /aggressive, timeconscious, ‘workaholic’ and easily frustrated with others. Respond to life events with impatience and hostility 70%of this sort of person died from heart attacks – Have two fold risk of CV disease and 5fold risk of MI 1970s, Friedman and Rosenman
  48. 48. Stress and the Heart
  49. 49. Stress, Depression and Heart Disease Managing Stress Learn to accept things you can’t change. You don’t have to solve all of life’s problems Count to 10 before answering or responding when you feel angry Don’t use smoking, drinking, overeating, drugs or caffeine to cope with stress . They make things worse
  50. 50. Coping with stress Assert yourself: honest and upfront Exercise regularly Control what you can and leave that you cant Examine your values and live by them Set realistic goals Sell yourself to yourself Get enough rest sleep in the dark, early night Eat and drink sensibly Stop smoking meditation Keep positive attitude
  51. 51. Negative Self Talk words our inner dialogue uses when we think can increase our stress levels by limiting our potential Can color our experience in a negative light When you tell yourself something is ‘difficult’ or ‘unfair’, it becomes more stressful to deal with than if you tell yourself it’s a ‘challenge’, or even a ‘test’ Patterns of negative self-talk typically begin in childhood the negative self-talk habit may have been coloring thinking for years CBT
  52. 52. Promoting Positive Self Talk 1. Notice your patterns: The first step toward change is to become more aware of the problem. You may not realize how often you say negative things in your head, or how much it affects you 2. Journal Writing: keeping a journal can be an effective tool for examining your inner process. 3. Thought-Stopping: As you notice yourself saying something negative in your mind, try to alter your thought mid-stream my saying to yourself “Stop”.
  53. 53. Methods of Reducing Stress Calm down Exercise Relaxation training Reach out Social support network Religion Studies have shown an association between religion and lower stress May be related to social support Altruism Giving to others because is gives you pleasure Shown to be a good way to reduce stress
  54. 54. Coping With Stress at College Plan ahead Prioritize Exercise Listen to music, watch TV, or go out as a study break Talk to others Meditate or use other relaxation techniques
  55. 55. The Key Word Is…. Balance
  56. 56. Sleep-Wake Cycle: Role of Endogenous Melatonin Circadian and Homeostatic Regulation of Sleep Sleep Drive Wake Wake Propensity Melatonin Circadian Alerting Signal 9 am Awake 3 pm 9 pm 3 am Asleep 9 am Sleep