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psychosocial stress

Etiology: - family & marital difficulty - financial problems - job stress - physical or mental illness - shiftwork or night work - school stress, especially when combined with work & family obligations - substance abuse, including tobacco & alcohol - care of aging parents, often combined with raising one's own children - loneliness Pathology: 1) activation the hypothalamic-pituitary-adrenal axis -> secretion of cortisol & aldosterone by the adrenal cortex 2) increased sympathetic tone a) activation of sympathetic nervous system b) release of catecholamines by the adrenal medulla c) serotonin system may modulate sympathetic activity 3) oxytocin facilitates the sensation of social stress [8] 4) the inflammatory response may be activated - may increase cellular oxidative stress [2] 5) the immune system may be suppressed 6) blood pressure may increase 7) heart rate may increase 8) oxygen demand may increase 9) arrhythmias may occur 10) the duration of psychosocial stress as well as the response of the individual to the stress have a major influence 11) may accelerate telomere shortening in mitotic cells [2] Complications: - even low levels of psychosocial stress linked to increased mortality [3] - stress-related disorders are associated with increased risk for life-threatening infections - job stress contributes modestly to cardiovascular risk (HR=1.23) [4] - psychosocial stress is the third most important modifiable risk factor for myocardial infarction (after dyslipidemia & smoking), more important than diabetes mellitus, hypertension, or obesity [9] - emotional stress stimulates sympathetic activity & increases risk of MI [11] (RR=2.44) - emotional stress in combination with intense exercise further increases risk of MI [11] (RR=3.05) - childhood psychosocial stress increases risk for early coronary artery disease [10] - stress-related psychiatric disorder (including posttraumatic stress disorder, acute stress reaction, & adjustment disorder) associated with increased risk of cardiovascular disease (RR=1.7) [14] - increased risk of peptic ulcer independent of NSAID use or H pylori infection [7] - psychosocial stress may impair decision-making [12] - may result in increased tendency to remain in unfavorable situations [12] - perceived psychosocial stress is associated with both prevalent & incident cognitive impairment in the elderly (RR=1.4-1.6) [17] - psychosocial stress may increase subsequent risk for neurodegenerative disease [16] Differential diagnosis: - post-traumatic stress disorder Management: 1) strategies a) removal or alteration of the stressor b) change in perception of the stressful event c) reduction in the physiological sequellae of stress d) use of alternative coping strategies 2) techniques a) relaxation techniques 1] muscle relaxation 2] quiet environment 3] passive attitude 4] deep breathing b) biofeedback c) behavior modification 1] healthy behavior can modify the effects of stress [6] 2] anger management 3] life-style changes 4] diet 5] exercise 3) treatment of concurrent depression 4) general recommendations a) daily exercise b) eat a diet rich in fruits & vegetables & whole grains c) do not smoke d) use alcohol in moderation or not at all e) relaxation (see above) f) support from family & friends (biofeedback) 1] active social networks 2] positive interpersonal relationships [6] g) treat comorbidities Comparative biology: - chronic restraint* produces generalized dendritic hypertrophy in the basolateral amygdala [13] - selective maturation of dendrites that project to the ventral hippocampus (& not dorsomedial prefrontal cortex) - activity in glutaminergic synapses that strengthen connections between the basolateral amygdala & ventral hippocampus [13] * established stress stimulus in animal studies

Interactions

disease interactions

Related

metal

Specific

adjustment disorder bullying caregiver stress (caregiver burden, caregiver burnout) posttraumatic stress disorder (PTSD); includes acute stress disorder sexual harassment

General

stress social disorder

References

  1. UpToDate version 11.3, 2003 http://www.uptodate.com
  2. Journal Watch 25(2):18, 2005 Epel ES, Blackburn EH, Lin J, Dhabhar FS, Adler NE, Morrow JD, Cawthon RM. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci U S A. 2004 Dec 7;101(49):17312-5. Epub 2004 Dec 01. PMID: 15574496
  3. Russ TC et al Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies BMJ 2012;345:e4933 PMID: 22849956 http://www.bmj.com/content/345/bmj.e4933
  4. Kivimaki M et al Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data Lancet, Early Online Publication, 14 September 2012 PMID: 22981903 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60994-5/abstract
  5. World Health Organization Assessment and Management of Conditions Specifically Related to Stress. http://apps.who.int/iris/bitstream/10665/85623/1/9789241505932_eng.pdf
  6. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  7. Levenstein S et al. Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti- inflammatory drugs. Clin Gastroenterol Hepatol 2014 Aug 8 PMID: 25111233 http://www.cghjournal.org/article/S1542-3565%2814%2901136-7/abstract
  8. Eckstein M, Scheele D, Weber K et al Oxytocin facilitates the sensation of social stress. Hum Brain Mapp. 2014 Sep;35(9):4741-50 PMID: 24659430
  9. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  10. Juonala M, Pulkki-Raback L, Elovainio M, et al. Childhood psychosocial factors and coronary artery calcification in adulthood: The Cardiovascular Risk in Young Finns Study. JAMA Pediatr 2016 Mar 14 PMID: 26974359 http://archpedi.jamanetwork.com/article.aspx?articleid=2502623
  11. Smyth A, O'Donnell M, Lamelas P et al Physical Activity and Anger or Emotional Upset as Triggers of Acute Myocardial Infarction. The INTERHEART Study. Circulation. 2016;134:1059-1067 PMID: 27753614 http://circ.ahajournals.org/content/134/15/1059
  12. Lenow JK et al. Chronic and acute stress promote overexploitation in serial decision making. J Neurosci 2017 Jun 7; 37:5681 PMID: 28483979 http://www.jneurosci.org/content/37/23/5681
  13. Zhang JY, Liu TH, He Y et al Chronic stress remodels synapses in an amygdala circuit- specific manner. Biol Psychiatry 2018 Jul 4; PMID: 30060908 https://www.biologicalpsychiatryjournal.com/article/S0006-3223(18)31633-0/fulltext
  14. Song H, Fang F, Arnberg FK et al Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study. BMJ 2019;365:l1255 PMID: 30971390 Free full text https://www.bmj.com/content/365/bmj.l1255 - Bacon SL Stress, psychiatric disorders, and cardiovascular disease. BMJ 2019;365:l1577 Not indexed in PubMed https://www.bmj.com/content/365/bmj.l1577
  15. Song H, Fall K, Fang F et al Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study. BMJ 2019;367:l5784 PMID: 31645334 https://www.bmj.com/content/367/bmj.l5784
  16. Song H, Sieurin J, Wirdefeldt K et al Association of Stress-Related Disorders With Subsequent Neurodegenerative Diseases. JAMA Neurol. Published online March 9, 2020. PMID: 32150226 https://jamanetwork.com/journals/jamaneurology/fullarticle/2762514
  17. George J Incident Cognitive Impairment Tied to Stress. More than one in five older adults report high levels of perceived stress. MedPage Today March 7, 2023 https://www.medpagetoday.com/neurology/dementia/103420 - Kulshreshtha A, Alonso A, McClure LA et al Association of Stress With Cognitive Function Among Older Black and White US Adults. JAMA Netw Open. 2023;6(3):e231860. PMID: 36881411 PMCID: PMC9993177 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802090