Emotions, Stress and Anxiety PDF

Unit 4 Emotions, Stress and Anxiety Psychology and Communication Mercedes Hurtado Riquelme Bachelor in Dentistry INDEX CONTENTS 1. What is stress? 2. Vulnerability factors to stress 3. Protection factors to stress 4. Coping strategies 5. Anxiety 6. Anxiety & Stress & Dentistry 2 1. What is s...

Unit 4 Emotions, Stress and Anxiety Psychology and Communication Mercedes Hurtado Riquelme Bachelor in Dentistry INDEX CONTENTS 1. What is stress? 2. Vulnerability factors to stress 3. Protection factors to stress 4. Coping strategies 5. Anxiety 6. Anxiety & Stress & Dentistry 2 1. What is stress? 3 Studying for an exam can be stressful or not, depending on whether the situation controls you or you control the situation. Stress occurs when events seem uncontrollable and threatening. Taking control by keeping up with homework, planning each day, and preparing in a timely fashion can make studying less stressful. 4 Image 1 Stress at work 1. Stress Definition It is a negative emotional experience accompanied by predictable biochemical, physiological, cognitive, and behavioural changes that are directed either toward altering the stressful event or accommodating to its effects. Note. Adapted from Freepik 5 1. What is stress? • McGrath (1970): substantial unbalance (perceived) between the demands and response capacity uncertain conditions in which failure has important consequences. • Brengelmann (1987): Situations that require strong demands for the individual and can consume his/her coping resources. • Labrador (1995): Automatic response of the organism to any environmental change where it gets ready to face possible demands that will be generated as consequences of this new situation. • Seyle (1936): General response of the organism to any stressor stimulus or stressful situation. 6 1. What is stress? Psychophysiological changes in the organism as response to an over-demanding situation. Stress prepares the body to face emergency situations, mobilizing all the disponible resources for a specific goal. Stress response is eminently adaptative. 7 1. What is stress? Stress vs Distress • Stress (momentaneous physiological and psychological hyperactivation) is ESSENTIAL to survive. • However, when this hyperactivation turns into a chronic state → DISTRESS! • Distress alters and dysregulates the physiological basis of stress, leading to important organic and psychological disorders. 8 1. What is stress? Stress theories Stress theories Selye Lazarus Holmes and Rahe 9 1. What is stress? Hans Selye (1907-1982) • Physician and Physiologist. • First to use stress concept in physiology. • General adaptation syndrome (GAS): Model that explains how the body defends itself in stressful situations. • All stressors, regardless of type, produced essentially the same pattern of physiological changes. • Main critic: Less importance psychological variables. to 10 1. What is stress? Hans Selye (1907-1982) 11 General Adaptation System Hans Selye (1907-1982) 1. ALARM STAGE • Body mobilizes resources to fight against the stressor. • Adrenaline release provokes: blood pressure increase, muscles energy supply decreased gastrointestinal and sexual activation. • Short-term adaptive reactions. Image 2 Stress response: alarm Note. Adapted from Freepik 12 General Adaptation System Hans Selye (1907-1982) 2. RESISTANCE STAGE • Stress situation is taking longer than should be. • Continued exposure to a stressor, stress responses rise above normal. • Body tries to adapt. This will depend on the stressor intensity and duration. • Activation decrease but still being higher than normal. • This activation sustained in time is generally related with hormonal, physiological and immune alterations (infections). 13 General Adaptation System Hans Selye (1907-1982) 3. EXHAUSTION STAGE • If takes too much time, general reduction in energy and resources available. • Long-term exposure to the stressor → resistance will fall below normal. • Weakens individual’s capacity to resist / regulate stress. • Increased probability to get ill again. Image 3 Exhausted Note. Adapted from Freepik 14 1. What is stress? Richard Lazarus (1922-2002) • US Psychologist • Transactional model of stress: one of the most influential theories about stress. • Stress: product of the cognitive interpretation done by the person concerning the potentially stressful events. • It is not about the environmental situation or the people’s response to stress, but the subject’s perception about such situation or stimulus, as well as the perception/interpretation that the subject has about his/her capacity to manage it. • Interpretation and perception importance is what differs Lazarus’s from Selye’s model. 15 1. What is stress? Richard Lazarus (1922-2002) • Perceptions + Interpretations of the context, stimulus or event • Individual differences: people react differently to the same situation. • Regulated by emotion and cognition: emotional memory that will influence future evaluations. • Possible stressful event → Person’s appraisal → Person’s reaction • Three types of appraisals: 1. Primary 2. Secondary 3. Re-appraisal 16 Transactional model of stress Richard Lazarus (1922-2002) 1. PRIMARY APPRAISAL Amount of potential danger posed by the situation ➢ We analyse the quality and nature of the stressful event. Is that something related to me?; Is it relevant to me?; Is it something positive, negative, or neutral? ➢ Based on this appraisal, three different types of stressful events: Damage: Pain, failure Threat: expectation of a future damage Challenge: demand that raises an opportunity. 17 Transactional model of stress Richard Lazarus (1922-2002) 2. SECONDARY APPRAISAL Available resources to face and control the situation ➢ We analyse our own resources and capacities to face the stressful situation/stimulus. How can I solve this?; What can I use?; Whom can I call? ➢ Possible appraisals: Internal and external responsibility (fault/merit): attribution theory → Anger Potential problem- and/or emotion-focused coping → Fear/Anxiety Future expectations about situation change → Sadness 18 Transactional model of stress Richard Lazarus (1922-2002) 3. RE-APPRAISAL New information is incorporated to the situation ➢ The way we appraise some stressful event changes with our experience (time). ➢ Re-appraisal might take place due to an environmental factor. ➢ It does not always result in less stress → Sometimes we learn to develop a better relationship with stress (decreased distress), sometimes we develop worse behavioural patterns (increased distress). 19 Factors that influence stress appraisal 1. Imminent events: more stress when is imminent. E.g., the lecturer decides to put an exam tomorrow. 2. Events that occur unexpectedly or are unpredictable. E.g., to be fired when you are one of the most productive workers. 3. Ambiguous events concerning the role to be played. E.g., beginning a new course/work/ first time living abroad 4. High risky events. E.g., surgery 5. Unwished events. E.g., to move to another city because you were dismissed, not because you wanted 6. Uncontrolled events. E.g., diseases 7. Events that could be linked to an important vital change. E.g., you got a baby. 20 1. What is stress? Holmes and Rahe (1967) • Major life events: events that require people to make major adjustments in their lives. • Long list of events, positive or negative events: death of a family member, loss of a job, or being put in jail, retirement from work, vacation, etc. • Each event associated with stress “points”. • Subjects indicate whether these life events have happened to them and add up the stress points for all of those events. • A good estimate of the amount of stress experienced by that person. • They found that people with the most stress points were also the most likely to have a serious illness during that year. 21 1. What is stress? 22 1. What is stress? 23 1. What is stress? Holmes and Rahe (1967) Interpreting the scale • Less than 150 pts: relatively low amount of life change and low susceptibility to stress. No reason to expect a health related problem. • Between 150 and 300 points: 50% chance of a health breakdown. • More than 300 pts: 80% chance of a health breakdown 24 1. What is stress? Physiology of stress Two interrelated systems are heavily involved in the stress response: 1 2 The sympatheticadrenomedullary (SAM) system The hypothalamicpituitaryadrenocortical (HPA) axis 25 1. What is stress? Physiology of stress 1. THE SYMPATHETIC-ADRENOMEDULLARY (SAM) SYSTEM • When events are perceived as harmful or threatening → information from the cortex is transmitted to the hypothalamus: initiates one of the earliest responses to stress. • Sympathetic arousal stimulates the medulla of the adrenal glands, which, in turn, secrete the catecholamines (epinephrine and norepinephrine). • Flight-or-fight response. • These effects result in the cranked-up feeling we usually experience in response to stress: increased blood pressure, increased heart rate, increased sweating, and constriction of peripheral blood vessels, among other changes. 26 1. What is stress? Physiology of stress 2. THE HYPOTHALAMIC-PITUITARY-ADRENOCORTICAL (HPA) AXIS. • Hypothalamus releases corticotrophin-releasing hormone (CRH), which stimulates the pituitary gland to secrete adrenocorticotropic hormone (ACTH), which, in turn, stimulates the adrenal cortex to release glucocorticoids. • Of these, CORTISOL is especially significant → It acts to conserve stores of carbohydrates and helps reduce inflammation in the case of an injury. It also helps the body return to its steady state following stress. 27 STRESS Physiology of stress Hypothalamus SAM system HPA system CRH Activation of pituitary gland Activation of adrenal glands & peripheral SNS ACTH Stimulation of adrenal cortex Catecholamines Flight-or-fight response, increased alertness, heart rate, blood pressure, and blood flow to muscles. Cortisol Increase in plasma glucose level, immunosuppressive and anti-inflammatory activity 28 1. What is stress? Physiology of stress Video 1 How stress affects your brain Note. This video shows the effects of stress on our brain. Source: TED-Ed, 2015 29 1. What is stress? How does stress cause Illness? 30 2. Vulnerability factors to stress 31 2. Vulnerability factors to stress • Vulnerability is not only associated with resources deficit → but with the individual’s perception of the relationship between the importance of the consequences to the individual and the resources he has to avoid the threat of such circumstances (Lazarus & Folkmanm, 1986). • Vulnerability to stress: subjects’ susceptibility degree to suffer negative consequences in stressful situations • Higher exposure to stressful situations • Presence of inadequate stress-absorbers systems • Disproportionated reactivity to stress • Longer duration of the response to stress 32 3. Protection factors to stress 33 3. Protection factors to stress 1. Healthy life 2. Positive self-esteem 3. Self-control feeling 4. Constructive coping style 5. Extensive and intense social support network 6. Personal strengthens (compromise, challenge, control and optimism). 7. Values and beliefs systems that would let subject to face difficulties in life 34 4. Coping strategies 35 4. Coping strategies What is to cope with? • Lazarus (1966): Coping refers to the strategies for dealing with threats. • Lipowski (1970): Set of cognitive processes and behaviours used for organism preservation and illness recovery. • Weisman & Worder (1977): Behaviour that looks for alleviation, reinforcement and equilibrium when facing any problem. • Mechanic (1979): One person’s capacity, behaviours, techniques and knowledge used for problem resolution. • Pearlin & Schooler (1978): Any response to external tensions that is working to avoid or control stress. • Coping → “Thoughts and behaviours used to manage the internal and external demands of situations that are appraised as stressful”. 36 4. Coping strategies PHYSICAL → Physical context and subject’s biological features PSYCHOLOGICAL → Affective and cognitive states, action schemes and behavioral repertoires STRUCTURAL → Person’s development and implication concerning social roles SOCIAL → Social interaction with the environment CULTURAL → Person’s beliefs around disease 37 4. Coping strategies Coping style • Propensity to deal with stressful events in a particular way. Avoidant coping style Approach coping style Minimizing. Stress and anxiety reduction, gradual threat recognition Confrontative, vigilant. gathering information or taking direct action Short-term effectiveness Long-term effectiveness 38 4. Coping strategies Coping style • Propensity to deal with stressful events in a particular way. Problem-Focused coping Emotion-Focused coping Attempts to do something constructive about the stressful conditions that are harming, threatening, or challenging an individual. Efforts to regulate emotions experienced due to the stressful event. 39 4. Coping strategies Moorey & Greer (1989) 5 strategies Passive Survival scheme that determines five coping strategies or styles. Active Fatalism Anxious worry Fighting spirit Avoidance/negation Hopelessness 40 4. Coping strategies Moorey & Greer (1989) ACTIVE STRATEGIES 1. Fighting spirit = Active responses based on diagnosis acceptance with optimist attitude, ready to fight against the disease and taking active role in all decisions around treatment. Diagnosis as a challenge. Positive emotional tone and soft anxiety. 2. Avoidance/Negation = Patient rejects diagnosis, minimizes disease’s severity, avoid thinking about the disease. Calm emotional tone, optimist general sensations around the pathology evolution. 41 4. Coping strategies Moorey & Greer (1989) PASIVE STRATEGIES 1. Fatalism = Patient accepts diagnosis with resigned and fatalist attitude, perceiving it as a real threat. Control perception is absent and depends on others. Problemfocused strategies will be absent. Calm emotional tone. 2. Anxious worry = Patient feels constantly worried about disease. Any aversive sign is perceived as an essential part of disease. They are continuously looking for others’ approval of the severity of their illness. Generalized anxiety. 3. Hopelessness = Patient just sinks in disease’s diagnosis, adopting a pessimist attitude with feelings of hopelessness, perceiving diagnosis as huge threat. These patients generally give up, the absence of both problem- and emotional-focused coping strategies. Depressive emotional tone. 42 Coping interventions Mindfulness Meditation Mindfulness-based stress reduction (MBSR) • Systematic training in mindfulness to help people manage their reactions to stress and the negative emotions that may result (Brown & Ryan, 2003). • Help people approach stressful situations mindfully rather than reacting to them automatically. • 8-week MBSR program led to health and quality of life improvement (Roth & Robbins, 2004). • Mindfulness engages the prefrontal cortical regions of the brain, which regulate affect and downregulate activity in the limbic areas related to anxiety and other negative emotions (Creswell et al., 2007). 43 Coping interventions Acceptance/Commitment Theory Acceptance/Commitment Theory (ACT) • It is a Cognitive Behavioural Therapy (CBT) technique that incorporates acceptance of a problem, mindfulness regarding its occurrence and the conditions that elicit it, and commitment to behaviour change. • It does not challenge thoughts directly, but instead teaches people to notice their thoughts in a mindful manner and from a distance so as to be able to respond more flexibly to them. 44 Coping interventions Relaxation Training Relaxation Training • Affects the physiological experience of stress by reducing arousal. • Deep breathing, progressive muscle relaxation training, guided imagery, transcendental meditation, yoga, and self hypnosis. • Can reduce heart rate, muscle tension, blood pressure, inflammatory activity, lipid levels, anxiety, and tension, among other physical and psychological benefits. 45 A common pattern Stress Distress Anxiety Depression 46 5. Anxiety 47 5. Anxiety Definition • Anxiety is an emotion commonly associated with other emotions such as fear and anguish. • Characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. • It can appear in real or unreal situations, from people’s thoughts or emotional state. • Like most emotions, anxiety is inherently adaptive → Acts as a warning signal for impending danger or harm. 48 5. Anxiety Definition • Anxiety does not only appear at risky situations, as people get into this emotional states based on their thoughts and this is not a tangible reality. • There is important cognitive component: anxiety is emotional-cognitive function • Anxiety can “get attached” to specific stimulus that can reproduce the symptomatology. • Problem is in our thoughts; in the way we interpret stressful situations. • Those situations that can induce anxiety states are extremely variable. 49 5. Anxiety Symptoms Symptoms Cognitive Physiological Motor 50 5. Anxiety Cognitive symptoms Excessive preoccupation Insecurity feelings Fear Apprehension Negative thinking Threat anticipation Concentration difficulties Decisionmaking difficulties Lost of control sensation Memory related problems Familiar and social excessive preoccupation 51 5. Anxiety Physiological symptoms Cardiovascular • Fast pulse, palpitations, heat accesses Genitourinary • Frequent pee, enuresis, erective dysfunctions Respiratory • Suffocation sensation, lack of air, fast and superficial respiration, thoracic oppression Neuromuscular • Muscular tension, trembling, tingling Gastrointestinal • Nausea, vomits, diarrhea, digestives problems Neurovegetative • Dry mouth, excessive sweating, dizziness 52 5. Anxiety Motor symptoms Restlessness Motor inhibition Difficulties in verbal expression Clumsy and disorganized movements Rejection/avoidance behaviours 53 5. Anxiety State and trait anxiety State anxiety: • Unpleasant emotional arousal in face of threatening demands or dangers. • Transient feelings of anxiety at a given moment in time (i.e., “I feel anxious”). Trait anxiety: • An individual's predisposition to respond with state anxiety in the anticipation of threatening situations. • Tendency to appraise situations as threatening and to respond to those situations with state anxiety behaviours (i.e., “I am an anxious person”). 54 5. Anxiety A N X I E T Y LOW LEVEL Adaptive functions MODERATE LEVEL SEVERE LEVEL Anxiety disorders. Interferes with daily functioning and is highly maladaptive. 55 5. Anxiety Anxiety as a mental disorder • Generalized Anxiety Disorder • Panic Disorder • Phobias, Specific Phobia • Agoraphobia • Social Anxiety Disorder (previously called social phobia) • Separation Anxiety Disorder 56 5. Anxiety Anxiety as a mental disorder • Generalized Anxiety Disorder 57 5. Anxiety Anxiety as a mental disorder • Panic Disorder 58 5. Anxiety Anxiety as a mental disorder • Phobias, Specific Phobia 59 5. Anxiety Anxiety as a mental disorder • Agoraphobia 60 5. Anxiety Anxiety as a mental disorder • Social Anxiety Disorder (previously called social phobia) 61 5. Anxiety Anxiety as a mental disorder • Separation Anxiety Disorder 62 5. Anxiety How do we diagnose anxiety? • Clinical interview concerning signs and symptoms • Psychological tests, questionnaires and scales 1. State-Trait Anxiety Inventory (STAI; Spielberger et al., 1983). 2. Endler Multidimensional Anxiety Scales (EMAS; Endler et al., 1991) 3. Hamilton Rating Scale for Depression 4. Beck Depression Inventory (BDI; Beck et al., 1979). 5. Generalized Anxiety Disorder (GAD-7; Spitzer et al., 2006) 63 5. Anxiety State-Trait Anxiety Inventory (STAI) • It has 20 items for assessing trait anxiety and 20 for state anxiety. • State anxiety items: • • “I am tense; I am worried” • “I feel calm; I feel secure.” Trait anxiety items: • “I worry too much over something that really doesn’t matter” • “I am content; I am a steady person.” • All items are rated on a 4-point scale (e.g., from “Almost Never” to “Almost Always”). • Higher scores indicate greater anxiety. 64 5. Anxiety How de we treat anxiety? Intervention Psychological Behavioral therapy Cognitive therapy Reinforce/ punishment modulation Psychiatric Relaxation/Medit ation techniques Cognitive restructuring Mindfulness Pharmacological intervention Anxiolytics Barbituric Benzodiazepines 65 Concepts clarification Stress vs. Anxiety Stress is not the same as Anxiety Stress requires the presence of a stressful factor or event (external or internal). Anxiety continues once such stressful event or factor has disappeared 66 6. Anxiety and stress in dentistry 67 6. Anxiety and stress in dentistry Dental anxiety • Odontophobia • Dental fear = specific Phobia 68 6. Anxiety and stress in dentistry Dental anxiety The vicious cycle (Appukutan, 2016) 69 70 6. Anxiety and stress in dentistry What a good dentist must do (Appukutan, 2016) There are two strategies to fight against dental fear: 1. Psychotherapy 2. Communication You are not Psychologists, so go ahead by improving your communication skills! 71 6. Anxiety and stress in dentistry What you can say as a dentist 72 BIBLIOGRAPHIC REFERENCES Appukuttan, D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, cosmetic and investigational dentistry, 8, 35. Larsen, R. J. & Buss, D. M. (2018). Personality psychology: Domains of knowledge about human nature. Sixth edition. Mc Graw Hill. Taylor, S. (2015). Health Psychology. 9th edition. McGraw Hill. 73 Mercedes Hurtado Riquelme [email protected] UCAM Universidad Católica de Murcia © © UCAM UCAM