STRESS, ANXIETY, & DEPRESSION A research oriented account Waqar Husain

148 Pages·2014·1.03 MB·English

STRESS, ANXIETY, & DEPRESSION
A research oriented account

Waqar Husain

1
PREFACE

Stress, anxiety and depression are the most commonly diagnosed problems in
Psychology. Consequently, many researchers attempt to inquire these problems from
various aspects of psychosocial living. The academic studies conducted in our
colleges and universities are also heavily inclined in investigating these problems.
The current book, in this perspective, can significantly serve the scholars in
reviewing literature regarding stress, anxiety and depression. The book intends to
unite the views and findings of Clinical Psychology, Neurology and Psychiatry,
which enables it to be of equal importance to both Clinical Psychologists and
Psychiatrists.

Dr. Waqar Husain
PhD, Psychology
Head, Department of Psychology,
Foundation University, Pakistan.

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CONTENTS
Title Page

PREFACE 2
INTRODUCTION 4
STRESS 5
Terminological ambiguities 5
Defining stress 7
Work stress 9
ANXIETY DISORDERS 10
Acute Stress Disorder 14
Posttraumatic Stress Disorder 18
Panic Disorder with and without Agoraphobia 27
Agoraphobia without History of Panic Attack 34
Generalized Anxiety Disorder 35
Obsessive-Compulsive Disorder 40
Specific Phobia 45
Social Phobia (Social Anxiety Disorder) 49
DEPRESSIVE DISORDERS 57
Dysthymic Disorder 71
Major Depressive Disorder (Single Episode & Recurrent) 73
Subtypes of major depression 74
Major depression with atypical features 74
Seasonal affective disorder 75
Major depression with melancholic features 75
Major depression with psychotic features 76
Subsyndromal or minor depression 76
Episode Length 77
Risk for Recurrence of Depression 77
The Comorbidity of Anxiety and Depression 78
The Comorbidity of Depression with other Mental and
Medical Disorders 78
Bibliography 80

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INTRODUCTION

Stress, Anxiety, & Depression are widespread psychological problems of working
persons. These are the most commonly diagnosed illnesses in Psychology (Brown,
Chorpita, Korotitsch & Barlow, 1997; Davies, Norman, Cortese & Malla, 1995;
Farmer, 1998; Ollendick, 1990). Much consideration is given to these areas as the
prevalence of these syndromes is increasing (Cyranowski, Frank, Young & Shear,
2000; Kessler et al., 1994). The prominent prevalence of these disorders is
increasingly becoming an issue for many organizations. Moreover, another alarming
fact is that several studies have associated these syndromes to numerous negative
outcomes in the workplace, such as decreased performance and satisfaction
(Cavanaugh, Boswell, Roehling & Boudreau, 2000; Greenberg, 1999; Poole, 1993;
Seaward, 1999).
The outcomes of stress, anxiety, and depression are also associated with negative
outcomes in other aspects of life, including general satisfaction (Kessler et al., 1994;
Youngren & Lewinsohn, 1980), quality of life (Norvel & Murrin, 1993), and social
interactions (Alden & Phillips, 1990; Davies, Norman, Cortese, & Malla, 1995).
Researchers have proposed that all populations, and particularly employees, are being
affected by these three disturbances in epidemic proportions. Researchers (Geller &
Hobfoll, 1994; Greenberg, 1999; Norvell, Hills, & Murrin, 1993) have suggested that
each of these syndromes can be associated with decreased performance on the job,
decreased satisfaction in the work environment, and poor interpersonal skills, which
contribute to poor customer service, increased intention to leave, and impaired peer
relations in the workplace. The disorders of stress, anxiety, and depression each
frequently interfere with normal daily routines, interpersonal relationships, general
wellness, productivity, and the ability of the individual to support him / her
financially (Eaton, Kessler, Wittchen & Magee, 1994; Fifer et. al, 1994; Greenberg,
1999; Kessler et al., 1994; Lovibond, 1998; Seaward, 1999).
Traditionally, it was believed that stress, anxiety, and depression were separate
constructs with varying etiologies and symptoms; however, the high co-morbidity
rates, especially between anxiety and depression, have gained interest and attention
throughout the field. Investigators, therefore, have proposed that depression and
anxiety share numerous cognitive features, and there is evidence of overlapping
genetic risk for several anxiety disorders and depression, which has developed an
increased focus on this type of investigation (Alden & Phillips, 1990; Davies,
Norman, Cortese & Malla, 1995; Ollendick & Yule, 1990). Furthermore, findings of
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shared symptomatology and cognitive features have inspired some researchers to
believe in the possibility that anxiety and depression may be two symptomatic stages of
the same affective disorder with the ratio of anxious and depressive symptoms
varying over time, depending on the point in the illness in which the diagnosis is
made (Lovibond & Lovibond, 1995; Stavrakaki & Vargo, 1986). Some researchers
argue that this may be supported by the lack of divergent validity demonstrated by the
assessment tools for the two disorders (Dobson, 1985; Feldman, 1993). Some
associations are also developed between stress and depression; hence the findings in this
area are not yet too noticeable (Hammen, 1991; Kirkcaldy, Cooper & Ruffalo, 1995;
Lazarus, 1984). In some early research in this area, stressors were found to be
predictors of subsequent depressive symptomatology in observed patients (Hammen,
1991).The development of more complex stress models has provided extra support for a
relationship between the syndromes (Davila, Hammen, Burge, Paley & Daley, 1995).
Studies have contributed to a growing interest in the relationship between the three
constructs, and have established an inability to reliably separate anxiety and
depression in self-report measures (Feldman, 1993). Eventually, some researchers
have proposed that the indices of anxiety and depression can be collapsed into a single
construct (Davies et al., 1995).

STRESS

Terminological ambiguities
The study of stress has been plagued by the confusing use of the term (Lazarus,
1993), to the extent that there are ‘‘clearly wide variations in specific uses, specific
definitions, and specific purposes for which the term stress has been associated’’
(Appley & Trumbull, 1967). Stress has traditionally been defined as a ‘‘stimulus,’’ a
‘‘response,’’ or an ‘‘interaction’’ between the two, raising the issue of whether each
definition tied in some sense to a particular discipline can be easily extended from
one discipline to another (Kasl, 1978). It is Newton (1995) who points out that it is
more difficult to neatly define psychological stress, because of the diversity of
interpretive influences, than stress defined in a biological or physiological sense.
Like most histories, the history of stress is, as we now know, one which is full of
confusion and controversy (Selye, 1975), of intense debates and disputes, of hints of
‘‘disciplinary provincialism’’ (Levine & Scotch, 1970), on the one hand, and
integration attempts that produce nothing but a ‘‘a monster’’ (Singer & Davidson,
1986), on the other; of terminology so ill defined that researchers engage ‘‘in a
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careless discourse’’ moving ‘‘cavalierly from one level of data to another’’ (Levine
& Scotch, 1970) and definitions so bewildering in scope that the stress literature
‘‘steadily becomes less and less clear about what sort of experiences are not
stressful’’ (Abbott, 2001).
There is no doubt that the study of stress has been beleaguered by the bewildering
use of the term (Lazarus, 1993): it is now such a part of our everyday vocabulary, and
so much a part of our everyday lives, that it is difficult at times to know whether what
is being discussed is a scientific reality or a culturally manufactured concept that has
become a ‘‘social fact’’ (Pollock, 1988). Yet in spite of ‘‘almost chaotic
disagreement over its definition’’ (Mason, 1975b), the term has enduring scientific,
popular, and intuitive appeal instilling in many researchers a deep sense that
continuing to search for what is concrete and valid in the term will eventually be
rewarding (Mason, 1975a); an acknowledgment that the fertility of the term greatly
outweighs its obvious disabilities (Abbott, 2001).
One reason that has been given for studying stress is its ‘‘cost’’ to individuals,
communities, organizations, and economies. The cost to individuals has been
expressed in terms of the impact of stress on health and wellbeing, on the quality of
life and working life (Kompier & Cooper, 1999), on work-life balance, and on the
fact that lifestyles are simply more stressful with people perceiving themselves to be
under ever increasing amounts of stress (Charlesworth, 1996). Researchers are, not
surprisingly, quick to point out the difficulties involved in assessing the extent of
stress-related illness (Jones & Bright, 2001), particularly when it comes to asking just
exactly what is being measured when the term stress is used, and whether the
increase in stress-related illness is in part due to the popular usage of the term leading
to a raised awareness of its potential impact (Pollock, 1988). Over the years the
concept of ‘‘stress’’ has been at the center of so much research, and even though it
has become an almost essential part of our vocabulary, it has, despite the controversy
and confusion, significantly contributed to a changing view as to the way illness is
understood (Hinkle, 1973). So another reason for studying stress is that it brings us
closer to understanding how illness is caused and the adaptive processes that
individuals engage in. If we are to intervene in that process, then we have a
responsibility to better understand the nature of those transactions and the role of
stress in causing illness (Bartlett, 1998). Allied to this, is another reason for studying
stress, is that the better our understanding of the stress process, the greater the
probability that intervention strategies will help to significantly reduce the ‘‘human
suffering associated with ill health’’ (Bartlett, 1998).
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Defining stress
Stress, in a general perspective, can be defined as a psychological and physical
response of the body that occurs whenever we must adapt to changing conditions,
whether those conditions be real or perceived. “Distress” is referred to the stress due
to an excess of adaptive demands placed upon humans. The distress element of stress
is considered a psychological problem. Distress may lead to bodily and mental
damage. It is disease-producing stress. Eustress, on the other hand, is the optimal
amount of stress which helps in promoting health and growth. When psychologists
speak of controlling stress or stress management, it usually means quantitatively
reducing the amount of stress that humans experience and an active attempt to change
distress into eustress.
Stress has powerful effects on mental functioning, mental and physical
performance, interpersonal encounters, and physical well-being. Another type of
stress is “Psychophysiological Stress” that can be defined as mental upset that
triggers a physiological stress response. This type of stress is further correlated with
psychosomatic illness which is a condition in which the state of mind (psyche) either
causes or mediates a condition of actual, measurable damage in the body (soma).
Examples of psychosomatic illness include ulcers, asthma, migraine headaches,
arthritis, and even cancer.
Sensory Stimulus, which is also called the stressor, can be any mental or physical
demand put upon our body or our mind. This can be anything from a loud noise to an
exam or work load to physical activity. For example, if someone stucks in a traffic
jam, the traffic jam is the stressor and the mental and physical response to the stressor
is stress. Perception, on the other hand, is the active process of bringing an external
stimulus to the central nervous system (especially the brain) for interpretation. A
stressor is often an external event, but for a stressor to affect a human it must get into
the mind-body system. It is through perception that this occurs. Cognitive Appraisal
is the process of analyzing and processing information as well as categorizing and
organizing it. At the cognitive appraisal level, we put labels on things such as good,
bad, dangerous, pleasant, etc. Thus, for most situations, it is the label that we give to
the information that determines whether it will be deemed stressful and triggers a
physiological response. In addition, appraisal is influenced by personal history,
personal beliefs, morals, etc. When we label something as stressful, it then produces a
physiological or mental response. This leads to emotional experience and emotional
arousal. The entire process involves a constant mind-body connection; thus emotions
produce bodily responses as reactions. These responses may produce changes in the
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nervous and endocrine systems. Once the mind-body connection has been made and
the bodily changes occur, these changes are called physical arousal. When the
internal organs begin to be affected by the physical arousal, for example, increased
heart rate, blood pressure, dilation of the pupils, etc., this is referred to physical
effects. If the physical effects continue for a sustained period of time (this varies) the
imbalance of functioning can result in physical disease or mental disorder. The
leading mental disorders could be anxiety disorders and depressive disorders, as
discussed earlier in this chapter in detail.
Although almost anything can be a source of stress, we may classify these into the
four categories as following:
Frustration.
Frustration is a source of stress due to any situation in which the pursuit of some
goal is thwarted. Frustration is usually short-lived, but some frustrations can be
source of major stress. Frustrations may be based upon failures and losses.
Conflict.
Conflict arises when two or more incompatible motivations or behavioral
impulses compete for expression. When faced with multiple motivations or goals, we
must choose and this is where the problems/conflict arise. Studies have indicated that
the more conflict a person experiences, the greater the likelihood for anxiety,
depression, and physical symptoms. The types of conflicts include (a) approach-
approach, (b) avoidance-avoidance, and (c) approach-avoidance. Conflicts are
usually very unpleasant and highly stressful.
Change.
Life changes are noticeable alterations in one's living circumstances that require
adjustment. Holmes & Rahe (1967) developed the Social Readjustment Rating Scale
(also used in the current study) to measure life changes. They found that, after
interviewing thousands of people, while big changes like death of a loved one are
very stressful, small life changes also have tremendous effects.
Pressure.
Pressure is generated due to the expectations or demands that one must behave in
a certain way. Pressure also involves wearing social masks and behaving in a
culturally acceptable fashion.
Overstress negatively affects human performance and leads to burnout which is
physical, emotional, and mental exhaustion due to work-related stress. Within the
specific context of the current study, work stress needs to be elaborated further as
under.
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Work Stress
In their seminal article on job stress and employee health, Beehr and Newman
(1978) commented that as most people spend around half their waking lives at work,
then it is more than likely that work factors will have an important influence on their
wellbeing. Identifying work stressors ran parallel with considering their impact or
outcome. In the beginning, work stress research, quite naturally began, by using a
simple correlational framework, to investigate the relationship between work
stressors (stimuli, S) and strain (response, R). This S–R approach was important
historically, for it led to three types of research. These included identifying,
describing, and categorizing different work stressors, exploring the relationship
between the different work stressors and a range of strains (responses) and,
eventually to exploring those organizational, situational, and individual variables that
may moderate the stimulus–response relationship (Cooper, Dewe, & O’Driscoll,
2001; Dewe, 2001).
Since Kahn (1964) and his colleagues first talked about tensions, dissatisfactions,
and inner conflicts, a wide variety of strains have been associated with work stress. In
their 1979 article, Newman and Beehr identified under their heading of Human
Consequences Facet – psychological health consequences, physical health
consequences, and behavioral consequences. Since that time most major reviews
have classified job related strains under those three headings – psychological,
physiological, and behavioral.
Of all the models in the work stress literature, the most widely discussed is the
person–environment (P–E) fit model. This model, a product of the ISR program,
presents a ‘‘quantitative approach to adjustment and coping,’’ where adjustment is
perceived ‘‘as the goodness of fit between the characteristics of the person and the
properties of the environment’’ (French, Rodger, and Cobb 1974). The P-E fit model
emphasizes the interrelationship between the person and the environment, ‘‘and the
complex processes which underlie this relationship’’ (Van Harrison, 1978). In brief,
this model proposes that strain occurs when there is a misfit between the person and
the environment, that is, when this P-E relationship is out of equilibrium. Two types
of fit are identified. The first refers to a needs–supplies misfit (opportunities to meet
those needs), where as the second describes a demand–abilities misfit (Caplan, 1983).
Embedded in the notion of misfit is the individual’s ability to manage the encounter.
Despite extensions and refinements to this model (Caplan, 1983; Van Harrison,
1978), there are still considerable difficulties in clarifying the precise nature of misfit
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(Edwards & Cooper, 1988). Although broadly cited, as Eulberg, Weekley, and
Bhagat (1988) point out; it is still the ISR model that preceded it that has generated
‘‘an enormous amount of research’’. In 1978, Beehr and Newman proposed their
general model of stress. Their model is ‘‘general enough to be a framework for most
approaches to and research on job stress’’ (Beehr & Franz, 1987). One of the
important aspects of the Beehr and Newman model is their ‘‘process facet’’ of
psychological and physical processes that is initiated in any stressful encounter.
These process facets they describe, are those activities within the individual ‘‘which
transform input (stimuli)’’ and ‘‘produce output (consequences)’’ (Beehr & Newman,
1978), and include, for example, ‘‘appraisal of the situation’’ and ‘‘decision making
regarding an appropriate response’’. The aim of their proposals was to motivate
researchers towards developing a more systematic approach to the field of work
stress. Other work stress models were to follow including, for example, the stress
cycle model (McGrath, 1976), the job demand–job control model (Karasek, 1979),
the general systems approach (Cox & McKay, 1981), and the cybernetic model of
Cummings and Cooper (1979). These models and others (see Cooper, 1998) have a
number of notable points of convergence (Kahn & Byosiere, 1991). These include a
demanding encounter, the recognition that the encounter is significant and
consequences that affect the well-being of the individual.

ANXIETY DISORDERS

Anxiety disorders are the most prevalent psychological illness in adults, with a
lifetime prevalence of 25% (Kessler et al., 1994). Anxiety disorders are also among
the most common mental disorders in children and adolescents (Bernstein &
Borchardt, 1991).
Mowrer’s (1939) two-factor model suggests that phobias are developed by
classical conditioning and sustained by operant conditioning. Barlow (2002)
suggested a theory of panic disorder that incorporates biological and cognitive
factors. On the biological side, he suggests that there are inherited individual
differences in autonomic reactivity and anxiety sensitivity which is the tendency to
respond to the symptoms of anxiety. When an individual has already experienced a
panic attack in response to a real-life stressor, s/he becomes hyper-vigilant to cues
and sensations linked with the panic attack, which are then more probable to activate
a second attack. Combining Klein’s (1993) suffocation false alarm theory with
Barlow’s theory might construct a broader explanation. Ohman (2000) suggested a
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