na kom sajtu mogu da nadjem vise podataka o anksioznoj depresiji?
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unapred zahvalan
- Začetnik teme Leo221
- Datum pokretanja
WithdrawnWater
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Leo221:
Hm, nisam tacno sigurna sta Vas interesuje, ne postoji 'anksiozna depresija': depresija je (moze biti) klinicko stanje-poremecaj (ili moze biti laicki termin za oscilacije raspolozenja u svakodnevnom zivotu), anksioznost je simptom (deo klinicke slike mnogih psihickih poremecaja a takodje se javlja kod 'zdravih neuroticnih' osoba). Mozda Vas zanima nesto o depresiji? Ili o strahovima (fobijama) koji se cesto pogresno laicki nazivaju anksioznoscu? Ili Vas mozda zanima dijagnoza 'anksiozno-depresivni poremecaj'? Bilo bi nam lakse da Vam pomognemo kada bi znali sta trazite.
...ili prevedeno na srpski je depresije uzrokovane
zbog "straha" u vezi jedne situacije ili stanja koje preokupira pojedinca, kroz jedno duze vreme....
Uzrok je povacani nivo kortizola u serumu,i u mokraci
(24/h)a posledica je mnogih stresnih situacija kroz duze vreme...
skolska medizina to naziva stresnom depresijom,ali stvarne pomoci covek ne mze da ocekuje ,jer se daju kao po pravilu antidepresiva ,sto stvara samo jedno euforicno stanje ,ali ne uklanja razlog depresije.
u koliko zelis vise informacija javi se na moj email.
mj
zbog "straha" u vezi jedne situacije ili stanja koje preokupira pojedinca, kroz jedno duze vreme....
Uzrok je povacani nivo kortizola u serumu,i u mokraci
(24/h)a posledica je mnogih stresnih situacija kroz duze vreme...
skolska medizina to naziva stresnom depresijom,ali stvarne pomoci covek ne mze da ocekuje ,jer se daju kao po pravilu antidepresiva ,sto stvara samo jedno euforicno stanje ,ali ne uklanja razlog depresije.
u koliko zelis vise informacija javi se na moj email.
mj
WithdrawnWater
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Gluposti.
WithdrawnWater:
ako ja napisem jednu izmisljenu glupost onda si u pravu ali kad se ta glupost zaniva na izvorima WHO
onda se pitam na kojem medizinskom novou ti dajes savet????
ps: istocno od bezdana je samo pustinja,te se pitam gde se nalazi taj visoki medizinski zentar u tom regionu.samo za info ja sam ziveo u tom regionu mnogo godina i poznajem ako ne sve onda vecinu spezialista iz tog regiona...u koliko zelis mogu ti poslati mnogo fajlova da procitas .... u dobroj nameri
WithdrawnWater
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blankiat:
Ziveli ste u regionu Istocno od bezdana? Milo mi je zbog Vas! Cudo onda kako to da ne znate gde se nalazi taj visoki mediZinski Zentar u tom regionu?? :shock:
WithdrawnWater
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blankiat:
Sta ste Vi mislili - to ne znam, a sta ste rekli i kako ste to interpretirali, svakako je vise nego nejasno i zbrda-zdola, prilicno bez smisla: da li je dakle pomenuta tz. 'anksiozna depresija' uzrokovana (po Vama) 'jednom situacijom ili stanjem koje preokupira pojedinca kroz jedno duze vreme' ili 'posledica stresnih situacija...kroz duze vreme'? Sto su vec dve oprecene izjave.
Takodje, nivo kortizola u serumu i mokraci povecan je kod mnogih fizickih i psihickih poremecaja, ukljucujuci tu i sva anksiozna stanja, kao i sva depresivna stanja (zbog cega se i koristi kao bioloski marker za potvrdu major depresije u kojoj je izmedju ostalog takodje povisen!), i jos nije sa sigurnoscu utvrdjeno da li povisen nivo kortizola zbog poremecaja ose hipotalamus-hipofiza-nadbubreg ucestvuje u izazivanju ovih poremecaje, ili se zbog ovih poremecaja povecava nivo kortizola, tako da je i ova Vasa tvrdnja u svojoj biti neprecizna (da ne kazem netacna) iako je prihvacena cinjenica da povisen se nivo kortizola manifestuje depresivnim raspolozenjem.
Sto se tice davanja antidepresiva, noviji protokoli (poslednjih 5 godina) podrazumevaju lecenje depresivnih poremecaja antidepresivima ali skoro po pravilu uz njih idu i anxsiolitici, bas zbog cinjenice da se u okviru prakticno svih depresivnih poremecaja kao jedan od bitnih simptoma javlja i anksioznost, tako da nije tacno ni to da antidepresivi (ukoliko se daju u ispravno dijagnostikovanom deprsivnom poremecaju) ne resavaju simptome;
iz slicnih razloga kod grupe anksioznih poremecaja (ponaosob fobicnih) cesto se, skoro po pravilu, uz anksiolitike daju antidepresivi jer depresija kao simptom moze da prebojava ove poremecaje, a moze i da se skriva iza njih kao vodeca bolest.
Posto ste se vec pozvali na WHO, sigurno Vam nece biti tesko da nam date citat sa WHO sajta na kome ste nasli ono sto ste nam nesebicno preveli na 'srpski' o 'anksioznoj depresiji' (budite samo ljubazni u originalu, dakle na engleskom), a posto ste vise od mene upuceni u psihijatriju kako stvari stoje, bilo bi lepo da mene (a i ostali zainteresovani auditorijum za temu, ako takav postoji) uputite u kojoj ste od dve trenutno vazece i koriscene klasifikacije mentalnih bolesti (ICD 10 i DSM IV) pronasli klasifikaciju 'anksiozna depresija' kao i njene dijagnosticke kriterijume? Svakako me uvek zanima da nesto novo naucim iz oblasti kojom se bavim, od bilo koga ko moze da mi ponudi validne podatke i nove informacije.
Takodje, ja ne znam odakle ste Vi i kako Vasa skolska medicina naziva stanje koje ste opisal u prevodu na srpski kao 'anksioznu depresiju', ali nasa skolska medicina nista ne naziva 'stresnom depresijom';
neuroticnom depresijom jos uvek ponesto mozda (iako vise laicki, tj. zargonski nego strucno), reaktivnom depresijom takodje, ali one se ne lece lekovima i to nije predmet naseg razgovora, zar ne?
Anksiozno-depresivni poremecaj je takodje nesto sasvim drugo i pripada grupi anksioznih poremecaja po klasifikacijama, pa bi bilo lepo da nas uputite kakve nove informacije ima Vasa skolska medicina u regionu u kome sad zivite o onome sto tvrdite da je 'anksiozna depresija' ili 'stresna depresija'(?).
Unapred zahvalna, i u nestrpljivom iscekivanju Vaseg brzog i podrobnog odgovora!
da li treba da prevedem tekst ili da posaljem u originalu na nemackom ili engleskom jeziku?
ps: ja sam danas nazalost zauzet do sedam uvece ali cu da posaljem odgovor najkasnije do sutra prepodne.
ujedno se izvinjavam zbog mog eventualno neprijatnog komentara....inace sam uvek za slobodnu razmenu iskustva.
mj
ps: ja sam danas nazalost zauzet do sedam uvece ali cu da posaljem odgovor najkasnije do sutra prepodne.
ujedno se izvinjavam zbog mog eventualno neprijatnog komentara....inace sam uvek za slobodnu razmenu iskustva.
mj
WithdrawnWater
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blankiat:
Nema potrebe da se izvinjavate, ovo je forum, razmene su nekad pune varnica!
I ja sam uvek za razmenu, i za nova saznanja, zato i kazem - dajte ako nesto novo ima iz oblasti da i mi saznamo! Ne morate se patiti da prevodite, na engleskom ce biti sasvim u redu. Pozdrav.
Grundlagen und Ursachen
Die Entstehung affektiver Störungen ist im Sinne einer anlagebedingten Verletzlichkeit zu verstehen, die von vielen weiteren äußeren Faktoren beeinflusst wird. Ob ein Lebensereignis eine Depression auslöst, hängt also von der individuellen Disposition ab. Folgende Faktoren werden als ursächlich angesehen:
Genetische Faktoren
In Zwillings-, Familien-, und Adoptionsstudien konnte gezeigt werden, dass bei Verwandten ersten Grades von Patienten mit affektiven Störungen eine Häufung solcher Erkrankungen auftritt. So zeigt sich beispielsweise, dass, wenn ein Elternteil erkrankt ist, bei dem Kind eine Wahrscheinlichkeit von 10 - 20% besteht, an der selben Störung zu erkranken. Sind beide Elternteile betroffen, liegt das Erkrankungsrisiko sogar bei 50 - 60%. Leidet ein eineiiger Zwilling an einer affektiven Störung, so ist sein Zwilling mit einer 65-prozentigen Wahrscheinlichkeit ebenfalls erkrankt.
Biologische Faktoren
Bei Patienten mit affektiven Störungen ist ein veränderter Neurotransmitterhaushalt festgestellt worden. Unter Neurotransmittern versteht man chemische Botenstoffe, die an der Weiterleitung von Nervenimpulsen beteiligt sind. So fand sich bei Depressiven ein Mangel an den Neurotransmittern Noradrenalin und Serotonin. Bei der Behandlung der Depression werden Medikamente eingesetzt, die dazu führen, dass die Konzentration dieser Stoffe erhöht wird. Inzwischen wird davon ausgegangen, dass nicht einzelne Veränderungen der Neurotransmitter, sondern eine Störung des Gleichgewichts verschiedener Transmitter ursächlich ist. Außerdem ist bei Depressiven die Empfindlichkeit und Dichte der Rezeptoren, auf die die Neurotransmitter einwirken, verändert. Neurotransmitter scheinen auch bei der Entstehung der Manie eine Rolle zu spielen. Bei dieser Störung liegt eine erhöhte Konzentration der Neurotransmitter Dopamin und Noradrenalin vor.
Affektive Störungen scheinen auch im Zusammenhang mit einem gestörten Hormonhaushalt zu stehen. So konnte beispielsweise bei Depressiven ein Überschuss des Hormons Cortisol nachgewiesen werden. Möglicherweise steht dieser Befund in Verbindung mit dem gestörten Neurotransmitterhaushalt. Es konnte z.B. gezeigt werden, dass eine hohe Cortisolkonzentration zu einer Verringerung der Dichte der Serotoninrezeptoren führen kann.
Auch körperliche Erkrankungen und Medikamente können Ursachen, Begleitfaktoren oder Auslöser für affektive Störungen sein. Beispiele dafür sind die Parkinsonsche Erkrankung oder Cortisolbehandlung.
In neuster Zeit lassen Untersuchungen vermuten, dass ein Virus an der Entstehung affektiver Störungen beteiligt sein könnte. Im Blut von Personen, die an Depressionen oder bipolaren affektiven Störungen litten, konnte ein Virus identifiziert werden, der nur während der Krankheitsschübe aktiv ist.
Psychologische Erklärungen
Untersuchungen haben gezeigt, dass im Vorfeld von Depressionen gehäuft krisenhafte Ereignisse, wie der Verlust einer geliebten Person oder anhaltende Konflikte, aufgetreten waren. Diese Faktoren scheinen allerdings nicht ursächlich Depressionen auszulösen, sondern eher zu einer unspezifischen Stressreaktion zu führen, die sich in Depressionen äußern kann.
Die psychoanalytische Theorie der Depression geht davon aus, dass die Wurzel der Depression schon in der frühen Kindheit liegt. Wenn in der oralen Phase (etwa erstes Lebensjahr) die Bedürfnisse des Kindes unzureichend oder übermäßig befriedigt werden, führt das dazu, dass die Person auf dieser Entwicklungsstufe stehen bleibt. Dies äußert sich darin, dass das Selbstwertgefühl der Person in großem Ausmaß von anderen Menschen abhängt. Darüber hinaus nimmt Freud an, dass eine Person sich nach dem Verlust eines geliebten Menschen mit diesem Menschen identifiziert, um so den Verlust auszugleichen. Da man, nach Freud, denjenigen, die man liebt auch unbewusste negative Gefühle entgegenbringt, wird die Person nun selber Objekt dieser negativen Gefühle. Normalerweise gelingt es, sich in einer Phase von Trauerarbeit durch die Erinnerung an den Verstorbenen aus der Identifizierung zu lösen. Bei sehr abhängigen Personen aber misslingt diese Trauerarbeit. Sie können sich nicht lösen und bestrafen sich selbst für die Fehler des Verstorbenen, mit dem sie sich identifizieren. Das führt zu fortgesetzter Selbstbeschuldigung und Depression. In der psychoanalytischen Theorie ist mit dem Verlust eines geliebten Menschen allerdings nicht unbedingt dessen Tod gemeint, es kann sich auch um einen symbolischen Verlust wie z.B. die Zurückweisung durch einen Menschen oder den Verlust eines Partners handeln.
Die kognitive Theorie von Beck bietet folgende Erklärung für das Entstehen von Depressionen: Durch negative Erlebnisse in Kindheit oder Jugend (z.B. Verlust der Eltern, Kritik durch Lehrer) erwirbt eine Person ein negatives Denkmuster. Erlebt die Person die gleiche oder eine ähnliche Situation erneut, wird dieses Muster aktiviert und verstärkt. Das negative Denkmuster beeinflusst das Verhalten und die Wahrnehmung eines Menschen. So wird z.B. ein Depressiver aus der Tatsache, dass er von einem Bekannten nicht gegrüßt wurde, nicht darauf schließen, dass dieser ihn nicht gesehen hat, sondern darauf, dass er ihn nicht mag. Solche Denkfehler bestätigen dann erneut die negative Sicht der eigenen Person ("Wie kann diese Person mich auch mögen, wo ich doch ein wertloser Mensch bin.").
Eine weitere Theorie der Depression geht von der so genannten gelernten Hilflosigkeit aus. Durch Erfahrungen, in denen die Person bei dem Versuch, eine Situation zu kontrollieren, versagt hat, entsteht die Passivität der Depressiven, ihr Gefühl, unfähig zu sein, das eigene Leben zu meistern. Allein dieses Versagen führt aber noch nicht zu Depressionen. Es kommt darauf an, wie die Person ihr Verhalten erklärt. Hat eine Person beispielsweise in einer Prüfung versagt, kann sie verschiedene Gründe für dieses Versagen finden. Man kann sich entweder als zu dumm bezeichnen, erklären, die Prüfung sei unfair gewesen, oder sagen, man sei einfach zu müde gewesen. Depressive neigen dazu die Erklärung zu finden, die sie am schlechtesten dastehen lässt ("Ich bin zu dumm"). Darüber hinaus führen negative Ereignisse und ihre Erklärung dann dazu, dass auch für die Zukunft nur das schlechteste angenommen wird ("Da ich zu dumm bin, werde ich auch bei der nächsten Prüfung durchfallen.").
Theorien, die die Entstehung bipolarer affektiver Störung erklären, sind rar. Für die depressiven Phasen werden meist dieselben Erklärungsmodelle herangezogen, wie für die Depression selbst. Bezüglich der manischen Schübe wird generell angenommen, dass es sich um die Vermeidung eines negativen Zustandes (z.B. niedriges Selbstwertgefühl) handelt.
Symptomatik und klinische Untertypen
Bei den affektiven Erkrankungen werden aufgrund von Verlauf und Schweregrad der Störung verschiedene Formen unterschieden:
Depressive Episode
Hierbei handelt es sich um eine depressive Verstimmung, die meist mit Hemmung von Denken und Antrieb und Schlafstörungen einher geht. Das Ausmaß reicht von leicht gedrückter Stimmung bis zu einem schwermütigen "Gefühl der Gefühllosigkeit". Oft herrschen quälende Angst und innere Unruhe. Der Depressive erlebt die Umwelt als grau, häufig kommt es zu sozialem Rückzug. Das Selbstmordrisiko ist bei dieser Erkrankung sehr hoch, 40 - 80% der Patienten haben Selbstmordgedanken. Äußerlich ist bei Depressiven häufig mangelnde Mimik und Gestik und eine leise, zögernde Stimme zu bemerken. Aufgrund des Erscheinungsbildes unterscheidet man folgende Untertypen:
• Gehemmte Depression: Diese Form ist gekennzeichnet durch reduzierte Aktivität, bis hin zur Bewegungslosigkeit.
• Agitierte Depression: Sie zeichnet sich durch ängstliche Getriebenheit, Bewegungsunruhe und unproduktive Hektik aus.
• Larvierte Depression: Bei dieser Erscheinungsformen stehen körperliche Beschwerden (z.B. Schwindel, Kopfdruck) im Vordergrund.
• Psychotische Depression: Hierbei treten Wahnideen und Halluzinationen auf.
Dysthymia
Bei dieser Störung handelt es sich um eine chronische depressive Verstimmung leichten Grades. Zwar klagt der Betroffene über Müdigkeit, Unzulänglichkeit, Anstrengung, Schlafstörungen und den Verlust der Genussfähigkeit, ist aber in der Regel fähig, mit dem Alltag zurechtzukommen. Diese Form beginnt meist im frühen Erwachsenenalter. Folgende Sonderformen lassen sich unterscheiden:
• Spätdepression: Sie tritt nach dem 45. Lebensjahr auf, das Selbstmordrisiko ist besonders hoch.
• Altersdepression: Die Ersterkrankung liegt nach dem 60. Lebensjahr.
• Wochenbettdepression: Nach der Geburt eines Kindes verfällt die Mutter in eine depressive Stimmung.
• Erschöpfungsdepression: Sie tritt auf nach einer Dauerbelastung oder wiederholten schweren Schicksalsschlägen.
Manie
Diese affektive Störung ist durch folgende Symptome gekennzeichnet: unangemessen gehobene Stimmung, Antriebssteigerung, beschleunigtes Denken und Selbstüberschätzung (bis hin zum Größenwahn). Häufig treten im Zusammenhang mit der Manie leichtsinnige Geldausgabe und sexuelle Enthemmung auf, was zu schweren familiären, finanziellen und gesundheitlichen Folgen führen kann. Dem Betroffenen fehlt die Krankheitseinsicht, was eine Zwangseinweisung notwendig machen kann.
Zyklothymia (bipolare affektive Störung)
Dabei handelt es sich um eine anhaltende Störung, die im frühen Erwachsenenalter beginnt und chronisch verläuft. Es handelt sich um eine Instabilität der Stimmung mit zahlreichen Perioden leichter Depression und leicht gehobener Stimmung. Die Stimmungschwankungen stehen meist nicht im Zusammenhang mit Lebensereignissen. Sehr selten treten depressive und manische Symptome gleichzeitig auf, wie etwa depressive Stimmung mit Rededrang. Man spricht dann von einer gemischten Episode einer bipolaren affektiven Störung.
Verlauf
Affektive Störungen verlaufen phasenweise, d.h. es kommt zu mehr oder weniger ausgeprägten Symptomschüben mit (bei der Zyklothymia abwechselnder) gedrückter oder gehobener Stimmung, die aber nach einer Weile abklingen, so dass die Stimmung bis zur nächsten Phase auf ein normales Niveau zurückkehrt.
Dabei kann der Beginn von depressiven Phasen sowohl schleichend als auch plötzlich einsetzen, während manische Phasen meist rasch (innerhalb weniger Stunden oder Tage) beginnen. Bei reinen Manien oder Depressionen muss man mit ca. 4 Phasen im Laufe des Lebens rechnen. Bei der bipolaren Störung treten mehr, aber kürzere Phasen auf. Je länger die Störung besteht, desto schneller folgen die Phasen aufeinander. Unbehandelte manische oder depressive Phasen dauern ca. 4 - 12 Monate, auch hier verkürzt sich mit steigender Phasenzahl die symptomfreie Zeit zwischen den Schüben.
Therapie
Medikamentöse Therapie
Die Frage, mit welchen Mitteln eine affektive Störung behandelt werden sollte, muss auf den Einzelfall abgestimmt werden. Dabei spielen unter anderem die angenommenen Entstehungsfaktoren eine wichtige Rolle.
Häufig wird Depression medikamentös durch den Einsatz von Antidepressiva behandelt. Die Auswahl eines Antidepressivums richtet sich nach den erwarteten Nebenwirkungen (z.B. Mundtrockenheit und Blutdrucksenkung), insbesondere aber nach dem Erscheinungsbild. So sollte z.B. bei der agitierten Depression ein Mittel eingesetzt werden, das neben antidepressiver auch eine beruhigende Wirkung hat. Auch können einzelne Symptome wie Schlafstörungen oder Unruhe mit spezifischen Medikamenten behandelt werden. Nach Abklingen der Symptome sollte die Behandlung mindestens 6 - 12 Monate fortgesetzt werden, da ein hohes Rückfallrisiko besteht.
In Folge einiger neuer Befunde, die eine aktive Virusinfektion mit dem Bornavirus als einen auslösenden Faktor nahelegen, hat sich auch eine neue medikamentöse Behandlungsform entwickelt. Dabei hat sich in ersten Studien gezeigt, dass Amantadin, eine Substanz, die zur Behandlung bestimmter Formen der Parkinsonschen Krankheit eingesetzt wird, dazu führt, dass der Virus nicht mehr im Blut der Patienten nachweisbar ist und auch die Symptome verschwinden. Andere wissenschaftliche Untersuchungen stellten direkte Wirkungen von Amantadin auf das Nervensystem fest, und den Zusammenhang zwischen Virusinfektion und Wirkung des Medikaments in Frage. Die Ergebnisse verlässlicher größerer klinischer Studien werden Klarheit schaffen, aber leider noch eine Weile auf sich warten lassen.
Biologische Verfahren
Abgesehen von der medikamentösen Behandlung haben sich bei der Therapie von Depressionen je nach Unterform auch Schlafentzug (zur Korrektur des gestörten Wach-Schlaf-Rhythmus) und Lichttherapie (bei Depressionen die jahreszeitlich bedingt auftreten) bewährt. Als letzter Ausweg wird auch Elektrokrampftherapie (z.B. bei hoher Selbstmordgefahr) eingesetzt.
Die Akutbehandlung von Manien ist wegen der fehlenden Krankheitseinsicht der Betroffenen häufig schwierig. Deswegen ist gerade bei ausgeprägter Symptomatik die stationäre Behandlung notwendig. Der Patient sollte von stimulierenden Außenreizen abgeschirmt werden und die Möglichkeit erhalten, sich abzureagieren. Als medikamentöse Behandlung eignet sich eine Kombination von Präparaten, die der wahnhaften Symptomatik entgegenwirken und Substanzen, die eine generell beruhigende Wirkung haben. Auch die Langzeitbehandlung und Rückfallverhinderung gestalten sich schwierig und verlangen einige Überzeugungsarbeit.
Psychologische Verfahren
Bei der kognitiven Verhaltenstherapie und der interpersonalen Therapie geht es darum, die negativen Realitäts- und Selbstbewertungen zu prüfen und zu korrigieren. Dabei werden Alltagsprobleme des Betroffenen betrachtet und untersucht, wie der Patient denkt, erlebt und mit seiner Umwelt in Kontakt tritt. Dadurch sollen unrealistische Erwartungen und depressive Gedankenverzerrungen entdeckt werden. Aufgrund der Kenntnis der zugrundeliegenden Probleme wird dann dem Patienten geholfen, Problembewältigungsfähigkeiten aufzubauen. Auch die Aktivität des Patienten soll gesteigert werden. Ziel ist es allgemein, die sozialen Fähigkeiten und das Selbstvertrauen des Depressiven zu verbessern.
Nach Abklingen der akuten Symptomatik kann auch in einer psychoanalytischen Therapie die grundlegende Verlusterfahrung des Patienten aufgedeckt werden. Die psychodynamische Situation bei Auslösung der Depression soll rekonstruiert und so die frühkindliche Erfahrung wiedererlebt und reif bearbeitet werden. Dabei ist die Beziehung von Patient und Therapeut besonders wichtig.
Soziotherapie
Bei der stationären Behandlung ist die Arbeits- und Beschäftigungstherapie ein wichtiger Bestandteil. Je nach Zustand des Patienten ist Hilfe bei der Tagesstrukturierung, Entdeckung kreativer Fähigkeiten, nicht-sprachliche Gefühlsverarbeitung oder Konzentrations- und Ausdauertraining Ziel der Behandlung.
Generell sollte im Umgang mit Personen, die unter affektiven Störungen leiden, darauf geachtet werden, dass sie in ihren Problemen unbedingt ernst genommen werden. So sollte man ihnen weder raten, sich zusammenzureißen, noch versuchen, ihnen eventuelle Wahnideen auszureden. Während akuter Phasen soll der Betroffene möglichst keine wichtigen Entscheidungen treffen. Bei der Therapie ist die Einbeziehung der Familie sehr zu empfehlen.
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Source: http://www.medicinenet.com
Stress
Medical Author: Peter J. Panzarino, Jr. M.D. F.A.P.A.
Medical Editor: Leslie J. Schoenfield, MD, PhD
• What is stress?
• A brief history of stress
• What is the healthy response to stress?
• How does the response to stress work?
• What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
• What is the role of the locus coeruleus in stress?
• How do the connections in the brain work in stress?
• What do we know about using (activating) and over-using our internal systems that respond to stress?
• Conclusions about the effects of stress
• How can we manage stress?
• What's in the future for stress?
• Stress At A Glance
What is stress?
Stress is simply a fact of nature -- forces from the outside world affecting the individual. Hence, all living creatures are in a constant interchange with their surroundings (the ecosystem), both physically and behaviorally. This interplay of forces, or energy, is of course present in the relationships between all matter in the universe, whether they are living (animate) or not living (inanimate). However, there are critical differences in how different living creatures relate to their environment. These differences have far reaching consequences for survival. Because of the overabundance of stress in our modern lives, we usually think of stress as a negative experience. But from a biological point of view, stress can be neutral, negative, or positive.
Stress has driven evolutionary change (the development and natural selection of species over time). Thus, the species that adapted best to the causes of stress (stressors) have survived and evolved into the plant and animal kingdoms we now observe. Man, because of the evolution of the human brain, especially the part called the neo-cortex, is the most adaptive creature on the planet. This adaptability is largely due to the changes and stressors that we have faced and mastered. Therefore, we, unlike other animals, can live in any climate or ecosystem, at various altitudes, and avoid the danger of predators. Moreover, most recently, we have learned to live in the air, under the sea, and even in space, where no living creatures that we know of have ever survived. So then, what is so wrong with stress?
A brief history of stress
A key to the understanding of the negative aspects of stress is the concept of milieu interiur (the internal environment of the body), which was first advanced by the great French physiologist, Claude Bernard. In this concept, he described the principles of dynamic equilibrium. In dynamic equilibrium, constancy, a steady state (situation) in the internal bodily environment, is essential to survival. Therefore, external changes in the environment or external forces that change the internal balance must be reacted to and compensated for if the organism was to survive. Examples of such external forces include temperature, oxygen concentration in the air, the expenditure of energy, and the presence of predators. In addition, diseases were also stressors that threatened the constancy of the milieu interiur.
The great neurologist, Walter Cannon, coined the term "homeostasis" to further define the dynamic equilibrium that Bernard had described. He was also the first to recognize that stressors could be emotional as well as physical. Through his experiments, he demonstrated the "fight or flight" response that man and other animals share when threatened. Further, Cannon traced these reactions to the release of a powerful neurotransmitter, called nor-epinephrine (nor-adrenaline), from a part (the medulla) of the adrenal gland. (Neurotransmitters are the body's chemicals that carry messages to and from the nerves.)
Hans Selye, another early scientist of stress, extended Cannon's observations. He included, as part of the body's stress response system, a small gland at the base of the brain, called the pituitary. He described the control by this gland of the secretion of hormones (e.g., cortisol) by the other part (the cortex) of the adrenal gland. Additionally, he actually introduced the term "stress" from physics and engineering and defined it as "mutual actions of forces that take place across any section of the body, physical or psychological."
In his experiments, Selye induced stress in rats in a variety of ways. He found typical and constant psychological and physical responses to the adverse situations that were imposed on the rats. In rats exposed to constant stress, he observed enlargement of the adrenal glands, gastrointestinal ulcers, and a wasting away (atrophy) of the immune (defense) system. He called these responses to stress the general adaptation (adjustment), or stress syndrome. He discovered that these processes, which were adaptive (healthy, appropriate adjustment) and normal for the organism in warding off stress, could become much like illnesses. That is, the adaptive processes, if they were excessive, could damage the body. Here then, is the beginning of an understanding of why stress, really over-stress, can be harmful, and why the word stress has earned such a bad name.
There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions. These include anxiety disorders, depression, high blood pressure, certain ulcers and other gastrointestinal diseases, some cancer, and even aging itself. Stress also seems to increase the frequency and severity of migraine headaches, asthma attacks, and blood sugar fluctuations in diabetics. Overwhelming psychological stress (such as the events of Sept. 11th) can cause both temporary (transient) and long lasting (chronic) symptoms of a serious psychiatric illness called posttraumatic stress disorder (PTSD). (For more information on PTSD, read the posttraumatic stress disorder article.) But, how does a healthy, adaptive response to stress become our enemy?
What is the healthy response to stress?
A key aspect of an adaptational response to stress is the time course. Responses must be initiated rapidly, maintained for a proper amount of time, and then turned off to insure an optimal result. An over-response or the failure to shut off a response can have negative biological consequences to the individual. Healthy human responses to stress involve three components:
• The brain handles (mediates) the immediate response. This response signals the adrenal medulla to release norepinephrine.
• The hypothalamus (a central area in the brain) and the pituitary gland initiate (trigger) the slower, maintenance response. This response signals the adrenal cortex to release cortisol and other hormones.
• Many neural (nerve) circuits are involved in the behavioral response. This response increases arousal (alertness, heightened awareness), focuses attention, inhibits feeding and reproductive behavior, reduces pain perception, and redirects behavior.
The combined results of these three components of the stress response maintain the internal balance (homeostasis), increase energy production and utilization, and alter electrolyte (chemical elements) and fluid balance. They also gear up the organism for a quick reaction through the sympathetic nervous system (SNS). The sympathetic nervous system operates by increasing the heart rate, increasing blood pressure, redirecting blood flow to the heart, muscles, and brain and away from the GI tract, and releasing fuel (glucose and fatty acids) to help fight or flee the danger.
How does the response to stress work?
While the complete story is not fully known, the last 20 years of research has taught us much about how the response to stress works. The two main systems involved are the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. (These systems are described below.) Triggered (activated) primarily by an area in the brain stem (lowest part of brain) called the locus coeruleus, the sympathetic nervous system secretes nor-epinephrine. The 5 most important concepts to remember about these two systems are:
1. They are governed by a feedback loop to regulate their response. (In a feedback loop, increased amounts of a substance -- e.g., a hormone -- inhibits the release of more of that substance, while decreased amounts of the substance stimulates the release of more of that substance.)
2. They interact with each other.
3. They influence other brain systems and functions.
4. Genetic (inherited) variability affects the responses of both systems. (That is, depending on their genes, people can respond differently to similar stresses.)
5. Prolonged or overwhelming responses of these systems can be harmful to an individual.
What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
The HPA axis is a grouping of responses to stress by the brain and the pituitary and adrenal glands. First, the hypothalamus (a central part of the brain) releases a compound called corticotrophin releasing factor (CRF), which was discovered in 1981. The CRF then travels to the pituitary gland, where it triggers the release of a hormone, ACTH. The ACTH is released into the bloodstream and causes the cortex of the adrenal gland to release the stress hormones, particularly cortisol, which is a corticosteroid. Cortisol affects the availability of the fuel supply (carbohydrate, fat, and glucose metabolism), which is needed to respond to stress. However, if cortisol levels stay increased for too long, then muscle breakdown, a decreased inflammatory response, and suppression of the immune (defense) system occur.
Because they suppress the immune system, corticosteroids in measured doses are used to treat many illnesses that are characterized by an overactive immune system, such as asthma and inflammatory bowel disease. For the same reason, they are used to help reduce the chances that our body will immunologically reject a transplanted organ. Corticosteroids also can cause fluid retention and high blood pressure. Therefore, it is critical that the response to corticosteroids be carefully controlled (modulated). This control is usually accomplished by a feedback mechanism in which increased cortisol levels feeding back to the hypothalamus and pituitary turn off production of ACTH. In addition, extremely high levels of cortisol can cause depression and psychosis, which, however, disappear when the levels return to normal.
What is the role of the locus coeruleus in stress?
The locus coeruleus has many connections to other parts of the brain, particularly areas that bring in and process sensory information. (The senses include sight, hearing, smell, taste, and touch.) The locus coeruleus secretes nor-epinephrine and stimulates other brain centers to do the same. It is like the pacemaker (controls the tempo) of the brain. Thus, it increases arousal (heightened awareness, alertness) and vigilance (watchfulness, carefulness), and adjusts (modulates) the action of the autonomic nervous system. The autonomic nervous system regulates blood flow, heart rate, blood pressure, and breathing (respiration). It can also temporarily shut down the gastrointestinal (GI) and sexual systems until the crisis is over. These initial reactions, to get our blood flowing, heart pumping, and muscles energized, occur very quickly and automatically.
How do the connections in the brain work in stress?
The HPA axis and the locus coeruleus systems are linked through the hypothalamus and the brain area known as the limbic system. The limbic system is the control area for emotion and the processing area for memory. These linkages are critical. For example, if you see the bushes rustling, your locus coeruleus immediately starts things (the stress response) rolling. However, then, if you see that it is not a mountain lion, but a golden retriever in the bush, your memory of the tameness of the dog will turn off the stress response. Similarly, if a person is nervous before a public speaking engagement and the first minute or two goes well, this happy feeling will turn down the locus coeruleus. These internal adjustments are why experienced public speakers often start off with a joke. It's as much to calm themselves down (if the joke goes well), as it is to entertain you.
The connections also include the endogenous (within the body) opiate (opium-like) system and the reward (dopamine) system. Thereby, during stress, pain is reduced and an extremely happy feeling (euphoria) may result. These connections partially account for "runner's high" and have a great deal to do with why we like roller coasters and scary movies.
Here's how the connections work. The limbic system performs an emotional analysis and memory review of the information provided by the senses. Then, the multiplicity of connections allows us to determine whether the current stress is:
• One that has been mastered in the past and successfully adapted to
• Not a threat at all
• A clear and present danger
All of this internal activity must occur in milliseconds, and it does.
What do we know about using (activating) and over-using our internal systems that respond to stress?
Animal and human research has taught us much about our internal stress systems. When laboratory animals are exposed to a prolonged stress (usually food deprivation, mild electrical stimulation of the foot, or handling), they develop a stress syndrome. This syndrome consists of high blood pressure (hypertension), loss of appetite, weight loss, muscle wasting, GI ulcers, loss of reproductive function, suppression of the immune system, and depression. Researchers also noticed that long duration (chronic) stress sensitizes (makes more responsive) the stress system. That is, the system then over-responds to new acute stressors. They further noticed that the administration of certain drugs, such as amphetamines or cocaine, could also sensitize the stress response. Moreover, constant stress increases the self-administration of drugs in laboratory animals. So, the more stress there is, the more mice seek the drugs, and the more the sensitivity (increased responsiveness) to stress is increased!
Early separation from the mother has also been seen as another potent stressor in animals. Such separation has been linked to increased levels of the stress hormones that cause the stress syndrome, including depression. Studies in humans are underway to evaluate how maternal stress, even early in the pregnancy, can affect the developing fetus. For example, maternal stress may predispose fetuses to developing depression as children or adults.
Why does maternal stress affect the fetus? The answer is the shared blood circulation between the mother and the fetus. You see, from the mother's blood, the fetus gets both the good (e.g., nutrients and oxygen) and the bad. The bad components of the blood can include alcohol, nicotine, illicit drugs, prescription drugs, and stress chemicals, such as cortisol and nor-epinephrine.
These animal and human studies seem to indicate that stress leads to depression. In other words, chronic stress in the mother's womb (in utero) or early deprivation (separation from the mother) can predispose a person to developing the psychiatric syndrome of clinical depression in later life. Furthermore, other experiments show that the administration of stress hormones can actually decrease brain connections and even brain cells in crucial areas, such as the limbic system (area of the brain controlling emotion and memory). This loss of brain connections and cells then can lead to further maladaptive (inadequate adjustment) responses to stress.
What's more, some particular kinds of stress seem to be even more detrimental than other types. That is, some types of stress can actually lead to diseases. For example, stresses that are unpredictable and uncontrollable seem to be the greatest culprits. (This is why we don't yet know the full effects of Sept 11th.) On the other hand, stresses with which we can cope and master are not necessarily bad. In fact, we can learn from these stresses, predict their reoccurrence, and develop action plans to reduce or avoid them in the future. In this way, some stresses can actually trigger new personality growth and biologically brought about adaptive (healthy adjustment) changes. Indeed, much of psychotherapy is empirically (guided by practical experience rather than theory) based on this concept. As a matter of fact, many therapists are unaware of the biological processes (mechanisms) that form the basis of their work.
Conclusions about the effects of stress
Uncontrollable, unpredictable, and constant stress has far-reaching consequences on our physical and mental health. Stress can begin in the womb and recur throughout the lifespan. One of the pathological (abnormal) consequences of stress is a learned helplessness that leads to the hopelessness and helplessness of clinical depression. But, in addition, many illnesses, such as chronic anxiety states, high blood pressure (hypertension), heart (cardiovascular) disease, and addictive disorders, to name a few, also seem to be influenced by chronic or overwhelming stress.
Nature, however, has provided us with wonderful processes (mechanisms) to cope with stressors through the HPA axis and the locus coeruleus/sympathetic nervous system. Furthermore, research has shown us the biological processes (mechanisms) that explain what we all intuitively know is true. Which is, that too much stress, particularly when we cannot predict it or control its reoccurrence, is harmful to our health.
How can we manage stress?
If we think about the causes of stress, the nature of the stress response, and the negative effects of some types of stress (prolonged, unexpected, unmanageable), several healthy management strategies become clear. First, exercise. You see, since the stress response prepares us to fight or flee, our bodies are primed for action. Unfortunately, however, we usually handle our stresses while sitting at our desk, standing at the water cooler, or behind the wheel stuck in traffic. Exercise on a regular basis helps to burn off and use up the stress hormones and neurochemicals. Thus, exercise can help avoid the damage to our health that prolonged stress can cause. In fact, studies have found that exercise is a potent anti-depressant, anxiolytic (combats anxiety), and sleeping pill for many people, without taking any pills.
For centuries in Eastern religious traditions, the benefits of meditation and other relaxation techniques have been well known. Now, Western medicine and psychology have rediscovered that particular wisdom, translated it into simple non-spiritual methods, and scientifically verified its effectiveness. Thus, one or two 20 to 30 minute meditation sessions a day can have lasting beneficial effects on health. Indeed, advanced meditators can even significantly control blood pressure and heart rate as well.
Elimination of drug use and no more than moderate alcohol use are key to the successful management of stress. We know that people, when stressed, seek these outlets. But, we also know that many of these substances sensitize (make even more responsive) the stress response. As a result, small problems produce big surges of stress chemicals. What's more, these attempts with drugs and alcohol to mask stress often prevent the person from facing the problem directly. Consequently, they are not able to develop effective ways to cope with or eliminate the stress.
In fact, even prescription drugs for anxiety, such as diazepam (Valium), lorazepam (Ativan), or alprazolam (Xanax), can be counterproductive in the same way. Therefore, these medications should only be used cautiously under the strict guidance of a physician. If, however, stress produces a full blown psychiatric problem, like posttraumatic stress disorder (PTSD), clinical depression, or anxiety disorders, then psychotropic medications, particularly the SSRIs, are extremely useful. Examples of the SSRI (selective serotonin reuptake inhibitor) medications include sertraline (Zoloft), paroxetine (Paxil), or fluoxetine (Prozac).
We know that chronic or uninterrupted stress is very harmful. It is important, therefore, to take breaks and decompress. Take lunch and don't talk about work. Take a walk instead of a coffee break. Use weekends to relax and don't schedule so many events that Monday morning will seem like a relief. Learn your stress signals. Take regular vacations, or even long weekends or mental health days, at intervals that you have learned are right for you.
Create predictability in your work and home life as much as possible. Structure and routine in your life can't prevent the unexpected from happening. However, they can provide a comfortable framework from which to respond to the unexpected. Think ahead and try to anticipate the varieties of possibilities, good and bad, that may become realities at work or home. Generate scenarios and response plans. You may find that the "unexpected" really doesn't always come out of the blue. With this kind of preparation, you can turn stress into a positive force to work for your growth and change.
What's in the future for stress?
Stress is part of life and will always be around. The keys to dealing with stress are appropriate control of stressful factors and management of our physical (physiological) and mental (psychological) responses. In this regard, some exciting work is being done on early treatment (intervention) in extremely stressful events (such as Sept. 11th). This intervention, called CISD (critical incident stress debriefing), involves discussing the traumatic event as soon as possible after the event. In fact, CISD can lessen extreme (pathological) reactions to stress and often prevent PTSD in its worst forms from occurring. Hopefully, the concepts of CISD can be translated into helpful strategies for managing the more common (normal) types of stress.
We all have slightly different stress responses because of our genetic make-up. In the future, perhaps, we will be able to alter our genes, for example, if we are genetically determined to be over or under reactors. In fact, the field of pharmacogenetics (medicines that enter the cells' DNA and turn on or off certain genes) is very promising in the area of stress.
Stress At A Glance
• Stress is a normal part of life that can either help us learn and grow or can cause us significant problems.
• Stress releases powerful neurochemicals and hormones that prepare us for action (to fight or flee).
• If we don't take action, the stress response can lead to health problems.
• Prolonged, uninterrupted, unexpected, and unmanageable stresses are the most damaging types of stress.
• Early separation from a mother can lead to altered stress responses and depression later in life.
• The stresses of the mother can affect the stress response of the fetus, and perhaps predispose the child to psychiatric illness later in life.
• Stress can be managed by regular exercise, meditation or other relaxation techniques, structured time outs, and learning new coping strategies to create predictability in our lives.
• Many of our ways in dealing with stress - drugs, pain medicines, alcohol, smoking, and eating -- actually worsen the stress and can make us more reactive (sensitive) to further stress.
• While there are promising treatments for stress, the management of stress is mostly dependent on the willingness of a person to make the changes necessary for a healthy lifestyle.
Anxiety and Depression Together
Provided by Psychology Today
Are you anxious or are you depressed? In the world of mental health care, where exact diagnosis dictates treatment, anxiety and depression are regarded as two distinct disorders. But in the world of real people, many suffer from both conditions. In fact, most mood disorders present as a combination of anxiety and depression. Surveys show that 60-70% of those with depression also have anxiety. And half of those with chronic anxiety also have clinically significant symptoms of depression.
The coexistence of anxiety and depression--called comorbidity in the psych biz--carries some serious repercussions. It makes the course of disorder more chronic, it impairs functioning at work and in relationships more, and it substantially raises suicide risk.
Over the past couple of years, clinicians and researchers alike have been moving towards a new conclusion: Depression and anxiety are not two disorders that coexist. They are two faces of one disorder.
"They're probably two sides of the same coin," says David Barlow, Ph.D., director of the Center for Anxiety and Related Disorders at Boston University. "The genetics seem to be the same. The neurobiology seems to overlap. The psychological and biological nature of the vulnerability are the same. It just seems that some people with the vulnerability react with anxiety to life stressors. And some people, in addition, go beyond that to become depressed."
They close down. "Depression seems to be a shutdown," explains Barlow. "Anxiety is a kind of looking to the future, seeing dangerous things that might happen in the next hour, day or weeks. Depression is all that with the addition of 'I really don't think I'm going to be able to cope with this, maybe I'll just give up.' It's shutdown marked by mental, cognitive or behavioral slowing."
At the core of the double disorder is some shared mechanism gone awry. Research points to overreactivity of the stress response system, which sends into overdrive emotional centers of the brain, including the "fear center" in the amygdala. Negative stimuli make a disproportionate impact and hijack response systems.
Mental health professionals often have difficulty distinguishing anxiety from depression, and to some degree they're off the hook. The treatments that work best for depression also combat anxiety. Cognitive-behavioral therapy (CBT) gets at response patterns central to both conditions. And the drugs most commonly used against depression, the SSRIs, or selective serotonin reuptake inhibitors, have also been proved effective against an array of anxiety disorders, from social phobia to panic and post-traumatic stress disorder (PTSD). Which drug a patient should get is based more on what he or she can tolerate rather than on symptoms.
And therein lies a problem. According to physicians Edward Shorter of Canada and Peter Tyrer of England, the prevailing view of anxiety and depression as two distinct disorders, with multiple flavors of anxiety, is a "wrong classification" that has led the pharmaceutical industry down a "blind alley." It's bad enough that the separation of anxiety and depression lacks clinical relevance. But it's also "one reason for the big slowdown in drug discovery in psychiatric drugs," the two contend in a recent article published in the British Medical Journal. It's difficult to create effective drugs for marketing-driven disease "niches."
Who is at risk for combined anxiety and depression? There's definitely a family component. "Looking at [what disorders populate] the family history of a person who presents with either primary anxiety or depression provides a clue to whether he or she will end up with both," says Joseph Himle, Ph.D., associate director of the anxiety disorders unit at University of Michigan.
The nature of the anxiety disorder also has an influence. Obsessive-compulsive disorder, panic disorder and social phobia are particularly associated with depression. Specific phobias are less so.
Age plays a role, too. A person who develops an anxiety disorder for the first time after age 40 is likely also to have depression, observes Himle. "Someone who develops panic attacks for the first time at age 50 often has a history of depression or is experiencing depression at the same time."
_ Usually, anxiety precedes depression, typically by several years. Currently, the average age of onset of any anxiety disorder is late childhood/early adolescence. Psychologist Michael Yapko, Ph.D., contends that presents a huge opportunity for the prevention of depression, as the average age of first onset is now mid-20s. "A young person is not likely to outgrow anxiety unless treated and taught cognitive skills," he says. "But aggressive treatment of the anxiety when it appears can prevent the subsequent development of depression."
"The shared cornerstone of anxiety and depression is the perceptual process of overestimating the risk in a situation and underestimating personal resources for coping." Those vulnerable see lots of risk in everyday things--applying for a job, asking for a favor, asking for a date.
Further, anxiety and depression share an avoidant coping style. Sufferers avoid what they fear instead of developing the skills to handle the kinds of situations that make them uncomfortable. Often enough a lack of social skills is at the root.
In fact, says Jerilyn Ross, LICSW, president of the Anxiety Disorders Association of America, the link between social phobia and depression is "dramatic. It often affects young people who can't go out, can't date, don't have friends. They're very isolated, all alone, and feel cut off."
Sometimes anxiety is dispositional, andsometimes it's transmitted to children by parental overconcern. "The largest group of depression/anxiety sufferers is Baby Boomers," says Yapko. "The fastest growing group is their children. They can't teach kids what they don't know. Plus their desire to raise perfect children puts tremendous pressures on the kids. They're creating a bumper crop of anxious/depressed children."
_ Treatment seldom hinges on which disorder came first. "In many cases," says Ross, "the depression exists because the anxiety is so draining. Once you treat the anxiety, the depression lifts."
In practice, treatment is targeted at depression and anxiety simultaneously. "There's increasing interest in treating both disorders at the same time," reports Himle. "Cognitive behavioral therapy is particularly attractive because it has applications to both."
Studies show that it is effective against both. But sometimes the depression is so incapacitating that it has to be tackled first. Depression, for example, typically interferes with exposure therapy for anxiety, in which people confront in a graduated way situations they avoid because they give rise to overwhelming fear.
"Exposure therapy requires substantial effort," explains Himle. "That's effort that depressed people often do not have available to them." Antidepressants can make a difference. Most SSRIs are approved for use in anxiety disorders and are the first line of drug therapy. But which drug works best for whom can not be predicted in advance. It takes some trial and error.
Ross finds CBT 80-90% successful in getting people functioning well, "provided it's done correctly." Not all psychotherapy is CBT, which has a very specific set of procedures, nor is every mental health professional trained in CBT. "Patients have to make sure that is what they are really getting."
Medication and CBT are equally effective in reducing anxiety/depression. But CBT is better at preventing relapse, and it creates greater patient satisfaction. "It's more empowering," says Yapko. "Patients like feeling responsible for their own success." Further, new data suggests that the active coping CBT encourages creates new brain circuits that circumvent the dysfunctional response pathways.
Treatment averages 12 to 15 weeks, and patients can expect to see significant improvement by six weeks. "CBT doesn't involve years and years of talk therapy," says Ross. "There's homework, practice and development of lifestyle changes. Once patients learn how to identify the trigger thoughts or feelings, or events or people, they need to keep doing that. CBT gives people the tools they need."
Die Entstehung affektiver Störungen ist im Sinne einer anlagebedingten Verletzlichkeit zu verstehen, die von vielen weiteren äußeren Faktoren beeinflusst wird. Ob ein Lebensereignis eine Depression auslöst, hängt also von der individuellen Disposition ab. Folgende Faktoren werden als ursächlich angesehen:
Genetische Faktoren
In Zwillings-, Familien-, und Adoptionsstudien konnte gezeigt werden, dass bei Verwandten ersten Grades von Patienten mit affektiven Störungen eine Häufung solcher Erkrankungen auftritt. So zeigt sich beispielsweise, dass, wenn ein Elternteil erkrankt ist, bei dem Kind eine Wahrscheinlichkeit von 10 - 20% besteht, an der selben Störung zu erkranken. Sind beide Elternteile betroffen, liegt das Erkrankungsrisiko sogar bei 50 - 60%. Leidet ein eineiiger Zwilling an einer affektiven Störung, so ist sein Zwilling mit einer 65-prozentigen Wahrscheinlichkeit ebenfalls erkrankt.
Biologische Faktoren
Bei Patienten mit affektiven Störungen ist ein veränderter Neurotransmitterhaushalt festgestellt worden. Unter Neurotransmittern versteht man chemische Botenstoffe, die an der Weiterleitung von Nervenimpulsen beteiligt sind. So fand sich bei Depressiven ein Mangel an den Neurotransmittern Noradrenalin und Serotonin. Bei der Behandlung der Depression werden Medikamente eingesetzt, die dazu führen, dass die Konzentration dieser Stoffe erhöht wird. Inzwischen wird davon ausgegangen, dass nicht einzelne Veränderungen der Neurotransmitter, sondern eine Störung des Gleichgewichts verschiedener Transmitter ursächlich ist. Außerdem ist bei Depressiven die Empfindlichkeit und Dichte der Rezeptoren, auf die die Neurotransmitter einwirken, verändert. Neurotransmitter scheinen auch bei der Entstehung der Manie eine Rolle zu spielen. Bei dieser Störung liegt eine erhöhte Konzentration der Neurotransmitter Dopamin und Noradrenalin vor.
Affektive Störungen scheinen auch im Zusammenhang mit einem gestörten Hormonhaushalt zu stehen. So konnte beispielsweise bei Depressiven ein Überschuss des Hormons Cortisol nachgewiesen werden. Möglicherweise steht dieser Befund in Verbindung mit dem gestörten Neurotransmitterhaushalt. Es konnte z.B. gezeigt werden, dass eine hohe Cortisolkonzentration zu einer Verringerung der Dichte der Serotoninrezeptoren führen kann.
Auch körperliche Erkrankungen und Medikamente können Ursachen, Begleitfaktoren oder Auslöser für affektive Störungen sein. Beispiele dafür sind die Parkinsonsche Erkrankung oder Cortisolbehandlung.
In neuster Zeit lassen Untersuchungen vermuten, dass ein Virus an der Entstehung affektiver Störungen beteiligt sein könnte. Im Blut von Personen, die an Depressionen oder bipolaren affektiven Störungen litten, konnte ein Virus identifiziert werden, der nur während der Krankheitsschübe aktiv ist.
Psychologische Erklärungen
Untersuchungen haben gezeigt, dass im Vorfeld von Depressionen gehäuft krisenhafte Ereignisse, wie der Verlust einer geliebten Person oder anhaltende Konflikte, aufgetreten waren. Diese Faktoren scheinen allerdings nicht ursächlich Depressionen auszulösen, sondern eher zu einer unspezifischen Stressreaktion zu führen, die sich in Depressionen äußern kann.
Die psychoanalytische Theorie der Depression geht davon aus, dass die Wurzel der Depression schon in der frühen Kindheit liegt. Wenn in der oralen Phase (etwa erstes Lebensjahr) die Bedürfnisse des Kindes unzureichend oder übermäßig befriedigt werden, führt das dazu, dass die Person auf dieser Entwicklungsstufe stehen bleibt. Dies äußert sich darin, dass das Selbstwertgefühl der Person in großem Ausmaß von anderen Menschen abhängt. Darüber hinaus nimmt Freud an, dass eine Person sich nach dem Verlust eines geliebten Menschen mit diesem Menschen identifiziert, um so den Verlust auszugleichen. Da man, nach Freud, denjenigen, die man liebt auch unbewusste negative Gefühle entgegenbringt, wird die Person nun selber Objekt dieser negativen Gefühle. Normalerweise gelingt es, sich in einer Phase von Trauerarbeit durch die Erinnerung an den Verstorbenen aus der Identifizierung zu lösen. Bei sehr abhängigen Personen aber misslingt diese Trauerarbeit. Sie können sich nicht lösen und bestrafen sich selbst für die Fehler des Verstorbenen, mit dem sie sich identifizieren. Das führt zu fortgesetzter Selbstbeschuldigung und Depression. In der psychoanalytischen Theorie ist mit dem Verlust eines geliebten Menschen allerdings nicht unbedingt dessen Tod gemeint, es kann sich auch um einen symbolischen Verlust wie z.B. die Zurückweisung durch einen Menschen oder den Verlust eines Partners handeln.
Die kognitive Theorie von Beck bietet folgende Erklärung für das Entstehen von Depressionen: Durch negative Erlebnisse in Kindheit oder Jugend (z.B. Verlust der Eltern, Kritik durch Lehrer) erwirbt eine Person ein negatives Denkmuster. Erlebt die Person die gleiche oder eine ähnliche Situation erneut, wird dieses Muster aktiviert und verstärkt. Das negative Denkmuster beeinflusst das Verhalten und die Wahrnehmung eines Menschen. So wird z.B. ein Depressiver aus der Tatsache, dass er von einem Bekannten nicht gegrüßt wurde, nicht darauf schließen, dass dieser ihn nicht gesehen hat, sondern darauf, dass er ihn nicht mag. Solche Denkfehler bestätigen dann erneut die negative Sicht der eigenen Person ("Wie kann diese Person mich auch mögen, wo ich doch ein wertloser Mensch bin.").
Eine weitere Theorie der Depression geht von der so genannten gelernten Hilflosigkeit aus. Durch Erfahrungen, in denen die Person bei dem Versuch, eine Situation zu kontrollieren, versagt hat, entsteht die Passivität der Depressiven, ihr Gefühl, unfähig zu sein, das eigene Leben zu meistern. Allein dieses Versagen führt aber noch nicht zu Depressionen. Es kommt darauf an, wie die Person ihr Verhalten erklärt. Hat eine Person beispielsweise in einer Prüfung versagt, kann sie verschiedene Gründe für dieses Versagen finden. Man kann sich entweder als zu dumm bezeichnen, erklären, die Prüfung sei unfair gewesen, oder sagen, man sei einfach zu müde gewesen. Depressive neigen dazu die Erklärung zu finden, die sie am schlechtesten dastehen lässt ("Ich bin zu dumm"). Darüber hinaus führen negative Ereignisse und ihre Erklärung dann dazu, dass auch für die Zukunft nur das schlechteste angenommen wird ("Da ich zu dumm bin, werde ich auch bei der nächsten Prüfung durchfallen.").
Theorien, die die Entstehung bipolarer affektiver Störung erklären, sind rar. Für die depressiven Phasen werden meist dieselben Erklärungsmodelle herangezogen, wie für die Depression selbst. Bezüglich der manischen Schübe wird generell angenommen, dass es sich um die Vermeidung eines negativen Zustandes (z.B. niedriges Selbstwertgefühl) handelt.
Symptomatik und klinische Untertypen
Bei den affektiven Erkrankungen werden aufgrund von Verlauf und Schweregrad der Störung verschiedene Formen unterschieden:
Depressive Episode
Hierbei handelt es sich um eine depressive Verstimmung, die meist mit Hemmung von Denken und Antrieb und Schlafstörungen einher geht. Das Ausmaß reicht von leicht gedrückter Stimmung bis zu einem schwermütigen "Gefühl der Gefühllosigkeit". Oft herrschen quälende Angst und innere Unruhe. Der Depressive erlebt die Umwelt als grau, häufig kommt es zu sozialem Rückzug. Das Selbstmordrisiko ist bei dieser Erkrankung sehr hoch, 40 - 80% der Patienten haben Selbstmordgedanken. Äußerlich ist bei Depressiven häufig mangelnde Mimik und Gestik und eine leise, zögernde Stimme zu bemerken. Aufgrund des Erscheinungsbildes unterscheidet man folgende Untertypen:
• Gehemmte Depression: Diese Form ist gekennzeichnet durch reduzierte Aktivität, bis hin zur Bewegungslosigkeit.
• Agitierte Depression: Sie zeichnet sich durch ängstliche Getriebenheit, Bewegungsunruhe und unproduktive Hektik aus.
• Larvierte Depression: Bei dieser Erscheinungsformen stehen körperliche Beschwerden (z.B. Schwindel, Kopfdruck) im Vordergrund.
• Psychotische Depression: Hierbei treten Wahnideen und Halluzinationen auf.
Dysthymia
Bei dieser Störung handelt es sich um eine chronische depressive Verstimmung leichten Grades. Zwar klagt der Betroffene über Müdigkeit, Unzulänglichkeit, Anstrengung, Schlafstörungen und den Verlust der Genussfähigkeit, ist aber in der Regel fähig, mit dem Alltag zurechtzukommen. Diese Form beginnt meist im frühen Erwachsenenalter. Folgende Sonderformen lassen sich unterscheiden:
• Spätdepression: Sie tritt nach dem 45. Lebensjahr auf, das Selbstmordrisiko ist besonders hoch.
• Altersdepression: Die Ersterkrankung liegt nach dem 60. Lebensjahr.
• Wochenbettdepression: Nach der Geburt eines Kindes verfällt die Mutter in eine depressive Stimmung.
• Erschöpfungsdepression: Sie tritt auf nach einer Dauerbelastung oder wiederholten schweren Schicksalsschlägen.
Manie
Diese affektive Störung ist durch folgende Symptome gekennzeichnet: unangemessen gehobene Stimmung, Antriebssteigerung, beschleunigtes Denken und Selbstüberschätzung (bis hin zum Größenwahn). Häufig treten im Zusammenhang mit der Manie leichtsinnige Geldausgabe und sexuelle Enthemmung auf, was zu schweren familiären, finanziellen und gesundheitlichen Folgen führen kann. Dem Betroffenen fehlt die Krankheitseinsicht, was eine Zwangseinweisung notwendig machen kann.
Zyklothymia (bipolare affektive Störung)
Dabei handelt es sich um eine anhaltende Störung, die im frühen Erwachsenenalter beginnt und chronisch verläuft. Es handelt sich um eine Instabilität der Stimmung mit zahlreichen Perioden leichter Depression und leicht gehobener Stimmung. Die Stimmungschwankungen stehen meist nicht im Zusammenhang mit Lebensereignissen. Sehr selten treten depressive und manische Symptome gleichzeitig auf, wie etwa depressive Stimmung mit Rededrang. Man spricht dann von einer gemischten Episode einer bipolaren affektiven Störung.
Verlauf
Affektive Störungen verlaufen phasenweise, d.h. es kommt zu mehr oder weniger ausgeprägten Symptomschüben mit (bei der Zyklothymia abwechselnder) gedrückter oder gehobener Stimmung, die aber nach einer Weile abklingen, so dass die Stimmung bis zur nächsten Phase auf ein normales Niveau zurückkehrt.
Dabei kann der Beginn von depressiven Phasen sowohl schleichend als auch plötzlich einsetzen, während manische Phasen meist rasch (innerhalb weniger Stunden oder Tage) beginnen. Bei reinen Manien oder Depressionen muss man mit ca. 4 Phasen im Laufe des Lebens rechnen. Bei der bipolaren Störung treten mehr, aber kürzere Phasen auf. Je länger die Störung besteht, desto schneller folgen die Phasen aufeinander. Unbehandelte manische oder depressive Phasen dauern ca. 4 - 12 Monate, auch hier verkürzt sich mit steigender Phasenzahl die symptomfreie Zeit zwischen den Schüben.
Therapie
Medikamentöse Therapie
Die Frage, mit welchen Mitteln eine affektive Störung behandelt werden sollte, muss auf den Einzelfall abgestimmt werden. Dabei spielen unter anderem die angenommenen Entstehungsfaktoren eine wichtige Rolle.
Häufig wird Depression medikamentös durch den Einsatz von Antidepressiva behandelt. Die Auswahl eines Antidepressivums richtet sich nach den erwarteten Nebenwirkungen (z.B. Mundtrockenheit und Blutdrucksenkung), insbesondere aber nach dem Erscheinungsbild. So sollte z.B. bei der agitierten Depression ein Mittel eingesetzt werden, das neben antidepressiver auch eine beruhigende Wirkung hat. Auch können einzelne Symptome wie Schlafstörungen oder Unruhe mit spezifischen Medikamenten behandelt werden. Nach Abklingen der Symptome sollte die Behandlung mindestens 6 - 12 Monate fortgesetzt werden, da ein hohes Rückfallrisiko besteht.
In Folge einiger neuer Befunde, die eine aktive Virusinfektion mit dem Bornavirus als einen auslösenden Faktor nahelegen, hat sich auch eine neue medikamentöse Behandlungsform entwickelt. Dabei hat sich in ersten Studien gezeigt, dass Amantadin, eine Substanz, die zur Behandlung bestimmter Formen der Parkinsonschen Krankheit eingesetzt wird, dazu führt, dass der Virus nicht mehr im Blut der Patienten nachweisbar ist und auch die Symptome verschwinden. Andere wissenschaftliche Untersuchungen stellten direkte Wirkungen von Amantadin auf das Nervensystem fest, und den Zusammenhang zwischen Virusinfektion und Wirkung des Medikaments in Frage. Die Ergebnisse verlässlicher größerer klinischer Studien werden Klarheit schaffen, aber leider noch eine Weile auf sich warten lassen.
Biologische Verfahren
Abgesehen von der medikamentösen Behandlung haben sich bei der Therapie von Depressionen je nach Unterform auch Schlafentzug (zur Korrektur des gestörten Wach-Schlaf-Rhythmus) und Lichttherapie (bei Depressionen die jahreszeitlich bedingt auftreten) bewährt. Als letzter Ausweg wird auch Elektrokrampftherapie (z.B. bei hoher Selbstmordgefahr) eingesetzt.
Die Akutbehandlung von Manien ist wegen der fehlenden Krankheitseinsicht der Betroffenen häufig schwierig. Deswegen ist gerade bei ausgeprägter Symptomatik die stationäre Behandlung notwendig. Der Patient sollte von stimulierenden Außenreizen abgeschirmt werden und die Möglichkeit erhalten, sich abzureagieren. Als medikamentöse Behandlung eignet sich eine Kombination von Präparaten, die der wahnhaften Symptomatik entgegenwirken und Substanzen, die eine generell beruhigende Wirkung haben. Auch die Langzeitbehandlung und Rückfallverhinderung gestalten sich schwierig und verlangen einige Überzeugungsarbeit.
Psychologische Verfahren
Bei der kognitiven Verhaltenstherapie und der interpersonalen Therapie geht es darum, die negativen Realitäts- und Selbstbewertungen zu prüfen und zu korrigieren. Dabei werden Alltagsprobleme des Betroffenen betrachtet und untersucht, wie der Patient denkt, erlebt und mit seiner Umwelt in Kontakt tritt. Dadurch sollen unrealistische Erwartungen und depressive Gedankenverzerrungen entdeckt werden. Aufgrund der Kenntnis der zugrundeliegenden Probleme wird dann dem Patienten geholfen, Problembewältigungsfähigkeiten aufzubauen. Auch die Aktivität des Patienten soll gesteigert werden. Ziel ist es allgemein, die sozialen Fähigkeiten und das Selbstvertrauen des Depressiven zu verbessern.
Nach Abklingen der akuten Symptomatik kann auch in einer psychoanalytischen Therapie die grundlegende Verlusterfahrung des Patienten aufgedeckt werden. Die psychodynamische Situation bei Auslösung der Depression soll rekonstruiert und so die frühkindliche Erfahrung wiedererlebt und reif bearbeitet werden. Dabei ist die Beziehung von Patient und Therapeut besonders wichtig.
Soziotherapie
Bei der stationären Behandlung ist die Arbeits- und Beschäftigungstherapie ein wichtiger Bestandteil. Je nach Zustand des Patienten ist Hilfe bei der Tagesstrukturierung, Entdeckung kreativer Fähigkeiten, nicht-sprachliche Gefühlsverarbeitung oder Konzentrations- und Ausdauertraining Ziel der Behandlung.
Generell sollte im Umgang mit Personen, die unter affektiven Störungen leiden, darauf geachtet werden, dass sie in ihren Problemen unbedingt ernst genommen werden. So sollte man ihnen weder raten, sich zusammenzureißen, noch versuchen, ihnen eventuelle Wahnideen auszureden. Während akuter Phasen soll der Betroffene möglichst keine wichtigen Entscheidungen treffen. Bei der Therapie ist die Einbeziehung der Familie sehr zu empfehlen.
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Source: http://www.medicinenet.com
Stress
Medical Author: Peter J. Panzarino, Jr. M.D. F.A.P.A.
Medical Editor: Leslie J. Schoenfield, MD, PhD
• What is stress?
• A brief history of stress
• What is the healthy response to stress?
• How does the response to stress work?
• What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
• What is the role of the locus coeruleus in stress?
• How do the connections in the brain work in stress?
• What do we know about using (activating) and over-using our internal systems that respond to stress?
• Conclusions about the effects of stress
• How can we manage stress?
• What's in the future for stress?
• Stress At A Glance
What is stress?
Stress is simply a fact of nature -- forces from the outside world affecting the individual. Hence, all living creatures are in a constant interchange with their surroundings (the ecosystem), both physically and behaviorally. This interplay of forces, or energy, is of course present in the relationships between all matter in the universe, whether they are living (animate) or not living (inanimate). However, there are critical differences in how different living creatures relate to their environment. These differences have far reaching consequences for survival. Because of the overabundance of stress in our modern lives, we usually think of stress as a negative experience. But from a biological point of view, stress can be neutral, negative, or positive.
Stress has driven evolutionary change (the development and natural selection of species over time). Thus, the species that adapted best to the causes of stress (stressors) have survived and evolved into the plant and animal kingdoms we now observe. Man, because of the evolution of the human brain, especially the part called the neo-cortex, is the most adaptive creature on the planet. This adaptability is largely due to the changes and stressors that we have faced and mastered. Therefore, we, unlike other animals, can live in any climate or ecosystem, at various altitudes, and avoid the danger of predators. Moreover, most recently, we have learned to live in the air, under the sea, and even in space, where no living creatures that we know of have ever survived. So then, what is so wrong with stress?
A brief history of stress
A key to the understanding of the negative aspects of stress is the concept of milieu interiur (the internal environment of the body), which was first advanced by the great French physiologist, Claude Bernard. In this concept, he described the principles of dynamic equilibrium. In dynamic equilibrium, constancy, a steady state (situation) in the internal bodily environment, is essential to survival. Therefore, external changes in the environment or external forces that change the internal balance must be reacted to and compensated for if the organism was to survive. Examples of such external forces include temperature, oxygen concentration in the air, the expenditure of energy, and the presence of predators. In addition, diseases were also stressors that threatened the constancy of the milieu interiur.
The great neurologist, Walter Cannon, coined the term "homeostasis" to further define the dynamic equilibrium that Bernard had described. He was also the first to recognize that stressors could be emotional as well as physical. Through his experiments, he demonstrated the "fight or flight" response that man and other animals share when threatened. Further, Cannon traced these reactions to the release of a powerful neurotransmitter, called nor-epinephrine (nor-adrenaline), from a part (the medulla) of the adrenal gland. (Neurotransmitters are the body's chemicals that carry messages to and from the nerves.)
Hans Selye, another early scientist of stress, extended Cannon's observations. He included, as part of the body's stress response system, a small gland at the base of the brain, called the pituitary. He described the control by this gland of the secretion of hormones (e.g., cortisol) by the other part (the cortex) of the adrenal gland. Additionally, he actually introduced the term "stress" from physics and engineering and defined it as "mutual actions of forces that take place across any section of the body, physical or psychological."
In his experiments, Selye induced stress in rats in a variety of ways. He found typical and constant psychological and physical responses to the adverse situations that were imposed on the rats. In rats exposed to constant stress, he observed enlargement of the adrenal glands, gastrointestinal ulcers, and a wasting away (atrophy) of the immune (defense) system. He called these responses to stress the general adaptation (adjustment), or stress syndrome. He discovered that these processes, which were adaptive (healthy, appropriate adjustment) and normal for the organism in warding off stress, could become much like illnesses. That is, the adaptive processes, if they were excessive, could damage the body. Here then, is the beginning of an understanding of why stress, really over-stress, can be harmful, and why the word stress has earned such a bad name.
There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions. These include anxiety disorders, depression, high blood pressure, certain ulcers and other gastrointestinal diseases, some cancer, and even aging itself. Stress also seems to increase the frequency and severity of migraine headaches, asthma attacks, and blood sugar fluctuations in diabetics. Overwhelming psychological stress (such as the events of Sept. 11th) can cause both temporary (transient) and long lasting (chronic) symptoms of a serious psychiatric illness called posttraumatic stress disorder (PTSD). (For more information on PTSD, read the posttraumatic stress disorder article.) But, how does a healthy, adaptive response to stress become our enemy?
What is the healthy response to stress?
A key aspect of an adaptational response to stress is the time course. Responses must be initiated rapidly, maintained for a proper amount of time, and then turned off to insure an optimal result. An over-response or the failure to shut off a response can have negative biological consequences to the individual. Healthy human responses to stress involve three components:
• The brain handles (mediates) the immediate response. This response signals the adrenal medulla to release norepinephrine.
• The hypothalamus (a central area in the brain) and the pituitary gland initiate (trigger) the slower, maintenance response. This response signals the adrenal cortex to release cortisol and other hormones.
• Many neural (nerve) circuits are involved in the behavioral response. This response increases arousal (alertness, heightened awareness), focuses attention, inhibits feeding and reproductive behavior, reduces pain perception, and redirects behavior.
The combined results of these three components of the stress response maintain the internal balance (homeostasis), increase energy production and utilization, and alter electrolyte (chemical elements) and fluid balance. They also gear up the organism for a quick reaction through the sympathetic nervous system (SNS). The sympathetic nervous system operates by increasing the heart rate, increasing blood pressure, redirecting blood flow to the heart, muscles, and brain and away from the GI tract, and releasing fuel (glucose and fatty acids) to help fight or flee the danger.
How does the response to stress work?
While the complete story is not fully known, the last 20 years of research has taught us much about how the response to stress works. The two main systems involved are the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. (These systems are described below.) Triggered (activated) primarily by an area in the brain stem (lowest part of brain) called the locus coeruleus, the sympathetic nervous system secretes nor-epinephrine. The 5 most important concepts to remember about these two systems are:
1. They are governed by a feedback loop to regulate their response. (In a feedback loop, increased amounts of a substance -- e.g., a hormone -- inhibits the release of more of that substance, while decreased amounts of the substance stimulates the release of more of that substance.)
2. They interact with each other.
3. They influence other brain systems and functions.
4. Genetic (inherited) variability affects the responses of both systems. (That is, depending on their genes, people can respond differently to similar stresses.)
5. Prolonged or overwhelming responses of these systems can be harmful to an individual.
What is the role of the hypothalamus-pituitary-adrenal (HPA) axis (grouping) in stress?
The HPA axis is a grouping of responses to stress by the brain and the pituitary and adrenal glands. First, the hypothalamus (a central part of the brain) releases a compound called corticotrophin releasing factor (CRF), which was discovered in 1981. The CRF then travels to the pituitary gland, where it triggers the release of a hormone, ACTH. The ACTH is released into the bloodstream and causes the cortex of the adrenal gland to release the stress hormones, particularly cortisol, which is a corticosteroid. Cortisol affects the availability of the fuel supply (carbohydrate, fat, and glucose metabolism), which is needed to respond to stress. However, if cortisol levels stay increased for too long, then muscle breakdown, a decreased inflammatory response, and suppression of the immune (defense) system occur.
Because they suppress the immune system, corticosteroids in measured doses are used to treat many illnesses that are characterized by an overactive immune system, such as asthma and inflammatory bowel disease. For the same reason, they are used to help reduce the chances that our body will immunologically reject a transplanted organ. Corticosteroids also can cause fluid retention and high blood pressure. Therefore, it is critical that the response to corticosteroids be carefully controlled (modulated). This control is usually accomplished by a feedback mechanism in which increased cortisol levels feeding back to the hypothalamus and pituitary turn off production of ACTH. In addition, extremely high levels of cortisol can cause depression and psychosis, which, however, disappear when the levels return to normal.
What is the role of the locus coeruleus in stress?
The locus coeruleus has many connections to other parts of the brain, particularly areas that bring in and process sensory information. (The senses include sight, hearing, smell, taste, and touch.) The locus coeruleus secretes nor-epinephrine and stimulates other brain centers to do the same. It is like the pacemaker (controls the tempo) of the brain. Thus, it increases arousal (heightened awareness, alertness) and vigilance (watchfulness, carefulness), and adjusts (modulates) the action of the autonomic nervous system. The autonomic nervous system regulates blood flow, heart rate, blood pressure, and breathing (respiration). It can also temporarily shut down the gastrointestinal (GI) and sexual systems until the crisis is over. These initial reactions, to get our blood flowing, heart pumping, and muscles energized, occur very quickly and automatically.
How do the connections in the brain work in stress?
The HPA axis and the locus coeruleus systems are linked through the hypothalamus and the brain area known as the limbic system. The limbic system is the control area for emotion and the processing area for memory. These linkages are critical. For example, if you see the bushes rustling, your locus coeruleus immediately starts things (the stress response) rolling. However, then, if you see that it is not a mountain lion, but a golden retriever in the bush, your memory of the tameness of the dog will turn off the stress response. Similarly, if a person is nervous before a public speaking engagement and the first minute or two goes well, this happy feeling will turn down the locus coeruleus. These internal adjustments are why experienced public speakers often start off with a joke. It's as much to calm themselves down (if the joke goes well), as it is to entertain you.
The connections also include the endogenous (within the body) opiate (opium-like) system and the reward (dopamine) system. Thereby, during stress, pain is reduced and an extremely happy feeling (euphoria) may result. These connections partially account for "runner's high" and have a great deal to do with why we like roller coasters and scary movies.
Here's how the connections work. The limbic system performs an emotional analysis and memory review of the information provided by the senses. Then, the multiplicity of connections allows us to determine whether the current stress is:
• One that has been mastered in the past and successfully adapted to
• Not a threat at all
• A clear and present danger
All of this internal activity must occur in milliseconds, and it does.
What do we know about using (activating) and over-using our internal systems that respond to stress?
Animal and human research has taught us much about our internal stress systems. When laboratory animals are exposed to a prolonged stress (usually food deprivation, mild electrical stimulation of the foot, or handling), they develop a stress syndrome. This syndrome consists of high blood pressure (hypertension), loss of appetite, weight loss, muscle wasting, GI ulcers, loss of reproductive function, suppression of the immune system, and depression. Researchers also noticed that long duration (chronic) stress sensitizes (makes more responsive) the stress system. That is, the system then over-responds to new acute stressors. They further noticed that the administration of certain drugs, such as amphetamines or cocaine, could also sensitize the stress response. Moreover, constant stress increases the self-administration of drugs in laboratory animals. So, the more stress there is, the more mice seek the drugs, and the more the sensitivity (increased responsiveness) to stress is increased!
Early separation from the mother has also been seen as another potent stressor in animals. Such separation has been linked to increased levels of the stress hormones that cause the stress syndrome, including depression. Studies in humans are underway to evaluate how maternal stress, even early in the pregnancy, can affect the developing fetus. For example, maternal stress may predispose fetuses to developing depression as children or adults.
Why does maternal stress affect the fetus? The answer is the shared blood circulation between the mother and the fetus. You see, from the mother's blood, the fetus gets both the good (e.g., nutrients and oxygen) and the bad. The bad components of the blood can include alcohol, nicotine, illicit drugs, prescription drugs, and stress chemicals, such as cortisol and nor-epinephrine.
These animal and human studies seem to indicate that stress leads to depression. In other words, chronic stress in the mother's womb (in utero) or early deprivation (separation from the mother) can predispose a person to developing the psychiatric syndrome of clinical depression in later life. Furthermore, other experiments show that the administration of stress hormones can actually decrease brain connections and even brain cells in crucial areas, such as the limbic system (area of the brain controlling emotion and memory). This loss of brain connections and cells then can lead to further maladaptive (inadequate adjustment) responses to stress.
What's more, some particular kinds of stress seem to be even more detrimental than other types. That is, some types of stress can actually lead to diseases. For example, stresses that are unpredictable and uncontrollable seem to be the greatest culprits. (This is why we don't yet know the full effects of Sept 11th.) On the other hand, stresses with which we can cope and master are not necessarily bad. In fact, we can learn from these stresses, predict their reoccurrence, and develop action plans to reduce or avoid them in the future. In this way, some stresses can actually trigger new personality growth and biologically brought about adaptive (healthy adjustment) changes. Indeed, much of psychotherapy is empirically (guided by practical experience rather than theory) based on this concept. As a matter of fact, many therapists are unaware of the biological processes (mechanisms) that form the basis of their work.
Conclusions about the effects of stress
Uncontrollable, unpredictable, and constant stress has far-reaching consequences on our physical and mental health. Stress can begin in the womb and recur throughout the lifespan. One of the pathological (abnormal) consequences of stress is a learned helplessness that leads to the hopelessness and helplessness of clinical depression. But, in addition, many illnesses, such as chronic anxiety states, high blood pressure (hypertension), heart (cardiovascular) disease, and addictive disorders, to name a few, also seem to be influenced by chronic or overwhelming stress.
Nature, however, has provided us with wonderful processes (mechanisms) to cope with stressors through the HPA axis and the locus coeruleus/sympathetic nervous system. Furthermore, research has shown us the biological processes (mechanisms) that explain what we all intuitively know is true. Which is, that too much stress, particularly when we cannot predict it or control its reoccurrence, is harmful to our health.
How can we manage stress?
If we think about the causes of stress, the nature of the stress response, and the negative effects of some types of stress (prolonged, unexpected, unmanageable), several healthy management strategies become clear. First, exercise. You see, since the stress response prepares us to fight or flee, our bodies are primed for action. Unfortunately, however, we usually handle our stresses while sitting at our desk, standing at the water cooler, or behind the wheel stuck in traffic. Exercise on a regular basis helps to burn off and use up the stress hormones and neurochemicals. Thus, exercise can help avoid the damage to our health that prolonged stress can cause. In fact, studies have found that exercise is a potent anti-depressant, anxiolytic (combats anxiety), and sleeping pill for many people, without taking any pills.
For centuries in Eastern religious traditions, the benefits of meditation and other relaxation techniques have been well known. Now, Western medicine and psychology have rediscovered that particular wisdom, translated it into simple non-spiritual methods, and scientifically verified its effectiveness. Thus, one or two 20 to 30 minute meditation sessions a day can have lasting beneficial effects on health. Indeed, advanced meditators can even significantly control blood pressure and heart rate as well.
Elimination of drug use and no more than moderate alcohol use are key to the successful management of stress. We know that people, when stressed, seek these outlets. But, we also know that many of these substances sensitize (make even more responsive) the stress response. As a result, small problems produce big surges of stress chemicals. What's more, these attempts with drugs and alcohol to mask stress often prevent the person from facing the problem directly. Consequently, they are not able to develop effective ways to cope with or eliminate the stress.
In fact, even prescription drugs for anxiety, such as diazepam (Valium), lorazepam (Ativan), or alprazolam (Xanax), can be counterproductive in the same way. Therefore, these medications should only be used cautiously under the strict guidance of a physician. If, however, stress produces a full blown psychiatric problem, like posttraumatic stress disorder (PTSD), clinical depression, or anxiety disorders, then psychotropic medications, particularly the SSRIs, are extremely useful. Examples of the SSRI (selective serotonin reuptake inhibitor) medications include sertraline (Zoloft), paroxetine (Paxil), or fluoxetine (Prozac).
We know that chronic or uninterrupted stress is very harmful. It is important, therefore, to take breaks and decompress. Take lunch and don't talk about work. Take a walk instead of a coffee break. Use weekends to relax and don't schedule so many events that Monday morning will seem like a relief. Learn your stress signals. Take regular vacations, or even long weekends or mental health days, at intervals that you have learned are right for you.
Create predictability in your work and home life as much as possible. Structure and routine in your life can't prevent the unexpected from happening. However, they can provide a comfortable framework from which to respond to the unexpected. Think ahead and try to anticipate the varieties of possibilities, good and bad, that may become realities at work or home. Generate scenarios and response plans. You may find that the "unexpected" really doesn't always come out of the blue. With this kind of preparation, you can turn stress into a positive force to work for your growth and change.
What's in the future for stress?
Stress is part of life and will always be around. The keys to dealing with stress are appropriate control of stressful factors and management of our physical (physiological) and mental (psychological) responses. In this regard, some exciting work is being done on early treatment (intervention) in extremely stressful events (such as Sept. 11th). This intervention, called CISD (critical incident stress debriefing), involves discussing the traumatic event as soon as possible after the event. In fact, CISD can lessen extreme (pathological) reactions to stress and often prevent PTSD in its worst forms from occurring. Hopefully, the concepts of CISD can be translated into helpful strategies for managing the more common (normal) types of stress.
We all have slightly different stress responses because of our genetic make-up. In the future, perhaps, we will be able to alter our genes, for example, if we are genetically determined to be over or under reactors. In fact, the field of pharmacogenetics (medicines that enter the cells' DNA and turn on or off certain genes) is very promising in the area of stress.
Stress At A Glance
• Stress is a normal part of life that can either help us learn and grow or can cause us significant problems.
• Stress releases powerful neurochemicals and hormones that prepare us for action (to fight or flee).
• If we don't take action, the stress response can lead to health problems.
• Prolonged, uninterrupted, unexpected, and unmanageable stresses are the most damaging types of stress.
• Early separation from a mother can lead to altered stress responses and depression later in life.
• The stresses of the mother can affect the stress response of the fetus, and perhaps predispose the child to psychiatric illness later in life.
• Stress can be managed by regular exercise, meditation or other relaxation techniques, structured time outs, and learning new coping strategies to create predictability in our lives.
• Many of our ways in dealing with stress - drugs, pain medicines, alcohol, smoking, and eating -- actually worsen the stress and can make us more reactive (sensitive) to further stress.
• While there are promising treatments for stress, the management of stress is mostly dependent on the willingness of a person to make the changes necessary for a healthy lifestyle.
Anxiety and Depression Together
Provided by Psychology Today
Are you anxious or are you depressed? In the world of mental health care, where exact diagnosis dictates treatment, anxiety and depression are regarded as two distinct disorders. But in the world of real people, many suffer from both conditions. In fact, most mood disorders present as a combination of anxiety and depression. Surveys show that 60-70% of those with depression also have anxiety. And half of those with chronic anxiety also have clinically significant symptoms of depression.
The coexistence of anxiety and depression--called comorbidity in the psych biz--carries some serious repercussions. It makes the course of disorder more chronic, it impairs functioning at work and in relationships more, and it substantially raises suicide risk.
Over the past couple of years, clinicians and researchers alike have been moving towards a new conclusion: Depression and anxiety are not two disorders that coexist. They are two faces of one disorder.
"They're probably two sides of the same coin," says David Barlow, Ph.D., director of the Center for Anxiety and Related Disorders at Boston University. "The genetics seem to be the same. The neurobiology seems to overlap. The psychological and biological nature of the vulnerability are the same. It just seems that some people with the vulnerability react with anxiety to life stressors. And some people, in addition, go beyond that to become depressed."
They close down. "Depression seems to be a shutdown," explains Barlow. "Anxiety is a kind of looking to the future, seeing dangerous things that might happen in the next hour, day or weeks. Depression is all that with the addition of 'I really don't think I'm going to be able to cope with this, maybe I'll just give up.' It's shutdown marked by mental, cognitive or behavioral slowing."
At the core of the double disorder is some shared mechanism gone awry. Research points to overreactivity of the stress response system, which sends into overdrive emotional centers of the brain, including the "fear center" in the amygdala. Negative stimuli make a disproportionate impact and hijack response systems.
Mental health professionals often have difficulty distinguishing anxiety from depression, and to some degree they're off the hook. The treatments that work best for depression also combat anxiety. Cognitive-behavioral therapy (CBT) gets at response patterns central to both conditions. And the drugs most commonly used against depression, the SSRIs, or selective serotonin reuptake inhibitors, have also been proved effective against an array of anxiety disorders, from social phobia to panic and post-traumatic stress disorder (PTSD). Which drug a patient should get is based more on what he or she can tolerate rather than on symptoms.
And therein lies a problem. According to physicians Edward Shorter of Canada and Peter Tyrer of England, the prevailing view of anxiety and depression as two distinct disorders, with multiple flavors of anxiety, is a "wrong classification" that has led the pharmaceutical industry down a "blind alley." It's bad enough that the separation of anxiety and depression lacks clinical relevance. But it's also "one reason for the big slowdown in drug discovery in psychiatric drugs," the two contend in a recent article published in the British Medical Journal. It's difficult to create effective drugs for marketing-driven disease "niches."
Who is at risk for combined anxiety and depression? There's definitely a family component. "Looking at [what disorders populate] the family history of a person who presents with either primary anxiety or depression provides a clue to whether he or she will end up with both," says Joseph Himle, Ph.D., associate director of the anxiety disorders unit at University of Michigan.
The nature of the anxiety disorder also has an influence. Obsessive-compulsive disorder, panic disorder and social phobia are particularly associated with depression. Specific phobias are less so.
Age plays a role, too. A person who develops an anxiety disorder for the first time after age 40 is likely also to have depression, observes Himle. "Someone who develops panic attacks for the first time at age 50 often has a history of depression or is experiencing depression at the same time."
_ Usually, anxiety precedes depression, typically by several years. Currently, the average age of onset of any anxiety disorder is late childhood/early adolescence. Psychologist Michael Yapko, Ph.D., contends that presents a huge opportunity for the prevention of depression, as the average age of first onset is now mid-20s. "A young person is not likely to outgrow anxiety unless treated and taught cognitive skills," he says. "But aggressive treatment of the anxiety when it appears can prevent the subsequent development of depression."
"The shared cornerstone of anxiety and depression is the perceptual process of overestimating the risk in a situation and underestimating personal resources for coping." Those vulnerable see lots of risk in everyday things--applying for a job, asking for a favor, asking for a date.
Further, anxiety and depression share an avoidant coping style. Sufferers avoid what they fear instead of developing the skills to handle the kinds of situations that make them uncomfortable. Often enough a lack of social skills is at the root.
In fact, says Jerilyn Ross, LICSW, president of the Anxiety Disorders Association of America, the link between social phobia and depression is "dramatic. It often affects young people who can't go out, can't date, don't have friends. They're very isolated, all alone, and feel cut off."
Sometimes anxiety is dispositional, andsometimes it's transmitted to children by parental overconcern. "The largest group of depression/anxiety sufferers is Baby Boomers," says Yapko. "The fastest growing group is their children. They can't teach kids what they don't know. Plus their desire to raise perfect children puts tremendous pressures on the kids. They're creating a bumper crop of anxious/depressed children."
_ Treatment seldom hinges on which disorder came first. "In many cases," says Ross, "the depression exists because the anxiety is so draining. Once you treat the anxiety, the depression lifts."
In practice, treatment is targeted at depression and anxiety simultaneously. "There's increasing interest in treating both disorders at the same time," reports Himle. "Cognitive behavioral therapy is particularly attractive because it has applications to both."
Studies show that it is effective against both. But sometimes the depression is so incapacitating that it has to be tackled first. Depression, for example, typically interferes with exposure therapy for anxiety, in which people confront in a graduated way situations they avoid because they give rise to overwhelming fear.
"Exposure therapy requires substantial effort," explains Himle. "That's effort that depressed people often do not have available to them." Antidepressants can make a difference. Most SSRIs are approved for use in anxiety disorders and are the first line of drug therapy. But which drug works best for whom can not be predicted in advance. It takes some trial and error.
Ross finds CBT 80-90% successful in getting people functioning well, "provided it's done correctly." Not all psychotherapy is CBT, which has a very specific set of procedures, nor is every mental health professional trained in CBT. "Patients have to make sure that is what they are really getting."
Medication and CBT are equally effective in reducing anxiety/depression. But CBT is better at preventing relapse, and it creates greater patient satisfaction. "It's more empowering," says Yapko. "Patients like feeling responsible for their own success." Further, new data suggests that the active coping CBT encourages creates new brain circuits that circumvent the dysfunctional response pathways.
Treatment averages 12 to 15 weeks, and patients can expect to see significant improvement by six weeks. "CBT doesn't involve years and years of talk therapy," says Ross. "There's homework, practice and development of lifestyle changes. Once patients learn how to identify the trigger thoughts or feelings, or events or people, they need to keep doing that. CBT gives people the tools they need."
Dok nasa forumska psihijatrica ovo procita izgubice volju da se druzi sa nama :wink:
WithdrawnWater
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blankiat:
Dakle, ajmo onda ponovo: nakon citanja prilozenih tekstova, priznajem da Nemackim ne vladam dobro, ali sam pohvatala 'kljucne reci' - kolko mogu da razumem tekst govori o afektivnim poremecajima i depresiji u globalu (cak i njenim ranije koriscenim nazivima koji su vec duze vreme izbaceni iz klasifikacija a koriste se u zargonskom medicinskom izrazavanju - agitirana depresija, larvirana depresija), njenoj bioloskoj osnovi i genezi kao i o tretmanu.
Drugi tekst odlicno razumem jer mi je engleski govorni jezik, i dakle u njemu nista ne implicira postojanje bilo cega sto se moze i u blagoj naznaci definisati kao 'anksiozna depresija'; postoji naravno anksiozno-depresivni poremecaj, sto je nesto sasvim drugo. Ne postoji stresna depresija, deprsija kao simptom u klinickom smislu moze biti uzrokovana (ali i ne mora)produzenim izlaganjem stresu bilo koje vrste, i moze se razviti kao prateci ili vodeci simptom mnogih klinickih slika (akutnog i hronicnog stresnog poremecaja, fobicnih poremecaja, itd). Poviseni nivo kortizola u serumu NE IZAZIVA depresiju kao klinicku dijagnozu, a MOZE da izazove depresivnu reakciju (ukoliko je taj nivo JAKO povise u dugom vremenskom periodu), i jos nije jasno da li poremecaj ose Hipotalamus - hipofiza- nadbubreg ima dominantan uticaj na izazivanje depresivnog (afektivnog) poremecaja (dakle unipolarne, major depresije) ili nivo kortiozola raste zbog depresivnog poremecaja.
Korelacija anksioznosti i depresivnosti(dakle SIMPTOMA ), kao i samog anksioznog i depresivnog POREMECAJA niko nije sporio pa ni ja, sto nas opet vcraca na moju konstataciju da anksiozna depresija ne postoji kao entitet, i na moje pitanje coveku koji je postavio pitanje - sta ga zapravo interesuje - klinicke slike, depresivnost kao simptom, anksiozni poremecaji koje prati depresija....sve razlicite stvari!.
Nista od navedenog teksta (za ovaj na Engleskom tvrdim) ne podrzava gore navedenu izjavu da je anksiozna depresija (i.e. stresna depresija) izazvana povisenjem nivoa kortizola u serumu i uzrokovana strahom zbog neke specificne situacije kroz duze vreme - prosto zato sto 'anksiozna depresija' ne postoji; ne sporeci pri tome da prolongirani stres moze da izazove afektivne poremecaje, ili kasniju anksiozno-depresivnu klinicku sliku, stojim i dalje pri tvrdnji da je dato objasnjenje skup neshvacenih polucinjenica i ne primenjljivih fakata na konkretno pitanje sa pocetka teme, uz takodje netacnu tvrdnju da se daju antidepresivi koji 'stvaraju euforicno stanje' a nemaju efekta na sam poremecaj(?).
Pozdrav.
WithdrawnWater
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Nista Vi ne brinite, pa moram da se edukujem svaki dan, zar da mi nesto promakne!!gane011:
Sad posle ovih tekstova mnogo mi je lakse, jer nista novo nisam saznala sto vec ne znam, nikakvi dramaticni prevrati nisu se dogodili a da su mi promakli, i na koncu svega - ja jesam bila u pravu ( a znate kako ja volim da sam u pravu!! :wink: )Kako vas, bre, ne mrzi da trosite toliko vremena na forumska prepucavanja! :shock: :shock:
dr
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Uf, Jeko...kad nesto znas da znas, da vladas materijom , znas da si potpuno u pravu ...onda te naravno ne mrzi da prosvetis i druge.LepaJeka:
dr:Uf, Jeko...kad nesto znas da znas, da vladas materijom , znas da si potpuno u pravu ...onda te naravno ne mrzi da prosvetis i druge.LepaJeka:
Znam, znam, ali vidis li ti koliko ovde ima teksta na tri jezika, a o jednoj jedinoj stvari. Treba sve to procitati, pa malo razmisliti, pa onda sastaviti adekvatan odgovor... i tako ode pola dana! A kao sto nam je svima poznato, na kraju balade niko od njih dvoje nece priznati da je pogresio...
I cemu onda to gubljenje vremena???
Nadam se da razumes sta hocu da kazem. Ipak je ovo samo virtuelan svet...
dr
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Ma naravno da te razumem ali kad neko potegne svetsku zdravstvenu organizaciju u postu pomislis da ti je nesto promaklo u novim vestima...kad ono medjutim ...
...
WithdrawnWater
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LepaJeka:dr:Uf, Jeko...kad nesto znas da znas, da vladas materijom , znas da si potpuno u pravu ...onda te naravno ne mrzi da prosvetis i druge.LepaJeka:
Znam, znam, ali vidis li ti koliko ovde ima teksta na tri jezika, a o jednoj jedinoj stvari. Treba sve to procitati, pa malo razmisliti, pa onda sastaviti adekvatan odgovor... i tako ode pola dana! A kao sto nam je svima poznato, na kraju balade niko od njih dvoje nece priznati da je pogresio...
I cemu onda to gubljenje vremena???
Nadam se da razumes sta hocu da kazem. Ipak je ovo samo virtuelan svet...
Ih, bre - pola dana?! :shock: Precera ga! Pa sve to citanje sa razmisljanjem ni 15 minuta (kad citas nesto sto ti je poznato razmisljas 'u hodu', mada - ovaj tekst na Nemackom angazovao mi je dobrih 5 minuta obzirom da tim jezikom ne vladam! :wink: ). I jos oko 5 za odgovor - eto ti celog posla!
A i sto bi priznavali - na kraju balade naravno da ja NISAM pogresila. (Sto bi reko jedan moj prijatelj, Machak, dr ga zna - 'Ti si mozda u pravu ali ja svakako nisam u krivu!'
)jedno pitanje za dr.Neznam gde da ga svrstam:
38god. pije lekove za pritisak.
utiču li oni na gubitak želje za seksom! Inače bio vrlo aktivan
38god. pije lekove za pritisak.
utiču li oni na gubitak želje za seksom! Inače bio vrlo aktivan
dr
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Da, ukoliko uzima lekove iz grupe beta blokatora...