Stress to Depression Dr. Villanueva (1).ppt

stress management

1. Stress or Depressed?
Reagan Joseph T. Villanueva MD
Southern Philippines Medical Center –
Institute of Psychiatry and Behavioral Medicine

2. Vincent Van Gogh,
Dutch Post-Impressionist Artist
(1853-1890)

4. April 15, 2009, ABS-CBN News

5. Goal
•Adverse Childhood Experiences
•what is stress and depression?
•neurobiology of stress and depression
•overview of treatment

6. 1. Did a parent or other adult in the
household often or very often…
Swear at you, insult you, put you down,
or humiliate you?
Or
Act in a way that made you afraid
that you might be physically hurt?
6

7. 2. Did a parent or other adult in the
household often or very often…
Push, grab, slap, or throw something at
you?
Or
Ever hit you so hard that you had
marks or were injured?

8. 3. Did an adult or person at least 5 years
older than you ever…
Touch or fondle you or have you touch
their body in a sexual way?
Or
Attempt or actually have oral, anal, or
vaginal intercourse with you?
8

9. 4. Did you often or very often feel that …
No one in your family loved you or thought
you were important or special?
Or
Your family didn’t look out for each other,
feel close to each other, or
support each other?

10. 5. Did you often or very often feel that …
You didn’t have enough to eat, had to wear
dirty clothes, and had no one to protect you?
Or
Your parents were too drunk or high to take
care of you or take you to the doctor if you
needed it?
10

11. 6. Were your parents ever separated or
divorced?
11

12. 7. Was your mother or stepmother:
Often or very often pushed, grabbed,
slapped, or had something thrown at her?
Or
Sometimes, often, or very often kicked,
bitten, hit with a fist, or hit with something
hard?
Or
Ever repeatedly hit at least a few minutes or
threatened with a gun or knife?

13. 8. Did you live with anyone who was a
problem drinker or alcoholic or who used
street drugs?
13

14. 9. Was a household member depressed or
mentally ill, or did a household member
attempt suicide?

15. •10. Did a household member go to
prison?

16. This is your ACE Score
Now add up your “Yes”answers:
_______
16

17. ACEs Score
ACE Score Prevalence
0 36.4%
1 26.2%
2 15.8%
3 9.5%
4 6.0%
5 3.5%
6 1.6%
7 or more 0.9%
Number of individual adverse childhood experiences are summed.
http://www.cdc.gov/ace/about.htm17

18. ACE Study Findings
ACE Scores Linked to Physical & Mental Health
Problems
•Twice as likely to smoke
•Seven times as likely to be alcoholics
•Six times as likely to have had sex before age 15
•Twice as likely to have cancer or heart disease
•Twelve times more likely to have attempted suicide
•Men with six or more ACEs were 46times more likely to have
injected drugs than men with no history of adverse childhood
experiences
Compared with people with no ACEs, those with four or more ACEs were:
Source: Adverse Childhood Experiences
(ACE) Study. Information available at
http://www.cdc.gov/ace/index.htm

19. Emotional Problems

20. Childhood Experiences
Underlie
Chronic Depression0
10
20
30
40
50
60
70
80
% With a Lifetime History of
Depression
0 1 2 3 >=4
ACE Score
Women
Men

21. Childhood Experiences
Underlie Suicide0
5
10
15
20
25
% Attempting Suicide
ACE Score
1
2
0
3
4+

22. 0
2
4
6
8
10
12
0 1 2 3 4 5 6 >=7
No
Yes ACE Score
Ever Hallucinated* (%)
Abused
Alcohol
or Drugs
*Adjusted for age, sex, race, and education.
ACE Score and Hallucinations

23. 0
5
10
15
20
25
30
35
40
45
012345678 Childhood Sexual Abuse and the
Number of Unexplained Symptoms
History of Childhood Sexual Abuse
Number of Symptoms

24. 0
5
10
15
20
25
30
35
40
0 1 2 3 >=4 ACE Score and Impaired Memory
of Childhood
ACE Score
ACE Score
1 2 3 4
5

25. Health Risk Behaviors

26. Adverse Childhood Experiences
and Current Smoking0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4-56 or more
ACE Score
%

27. Childhood Experiences and
Adult Alcoholism0
2
4
6
8
10
12
14
16
18
% Alcoholic
ACE Score
0
1
2
3
4+

28. ACE Score and Intravenous
Drug Use0
0.5
1
1.5
2
2.5
3
3.5
% Have Injected Drugs
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001

29. Serious Social Problems

30. Childhood Experiences Underlie
Rape0
5
10
15
20
25
30
35
% Reporting Rape
ACE Score
0
1
2
3
4+

33. Adverse Childhood Experiences
and
Likelihood of > 50 Sexual
Partners0
1
2
3
4
Adjusted Odds Ratio
0 1 2 3 4 or more
ACE Score

34. ACE Score and Unintended
Pregnancy or Elective Abortion0
10
20
30
40
50
60
70
80
% have Unintended PG, or AB
0 1 2 3 4 or more
ACE Score
Unintended Pregnancy
Elective Abortion

35. Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl0
5
10
15
20
25
30
35
Not 16-18yrs 11-15 yrs <=10 yrs
abused Age when first abused
1.3x
1.4x
1.8x
1.0 ref

36. Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had
Something Thrown at Oneself or One’s Mother as a Girl and the
Likelihood of Ever Having a Teen Pregnancy0
5
10
15
20
25
30
35
Never Once, Sometimes Often Very
Twice often
Pink =self
Yellow =mother

37. ACE Score and Indicators of
Impaired Worker Performance

38. Adult Disease and
Disability

39. Adverse Childhood Experiences
and
History of STD0
0.5
1
1.5
2
2.5
3
Adjusted Odds Ratio
0 1 2 3 4 or more
ACE Score

42. High Health and Mental
Health Care Costs

46. Poor Life Expectancy

47. Effect of ACEs on Mortality0
10
20
30
40
50
60
Percent in Age Group
0 2 4
ACE Score
19-34
35-49
50-64
>=65
Age Group

49. what is stress ?????

50. •Stress is a word that is used very commonly.
•generallyemployed forunpleasant phenomena
•Stress in itself is not a disease...an adaptative
response of our body to any demand.
Nicole Baumann, Jean-Claude Turpin, 2010. Neurochemistry of Stress. An
Overview. Neurochemical Research

51. Nicole Baumann, Jean-Claude Turpin, 2010. Neurochemistry of Stress. An
Overview. Neurochemical Research

53. Brain Region of Interest
•Cortex
•Hippocampus
•Amygdala
•Nucleus Accumbens

54. Hippocampus
•control of stress responses
•memory of everyday events,memories of words,
faces, and stories, including the stories of individual
lives
•involved in the encoding of aversively charged
memories,and the extinction of aversively charged
memory
•contextual aspect of fear conditioning
•Prolonged exposure to stress and high level of
glucocorticoids damage hippocampus by reduction of
dendritic branching, loss of dendritic spines, and
impairment of neurogenesis
•Hypofunctioning

55. Amygdala
•Limbic structure
•Emotional processing and is critical for
the acquisition of fear responses
•Mediates both stress responses and
emotional learning
•hyperresponsive

56. Cortex
•Medial prefrontal cortex
•restraint upon the hypothalamicpituitary-adrenal axis and
the sympathetic nervous system
•only cortical brain structure that sends direct connections
to the hypothalamus
•actively involved in restraining the amygdala fear system
and, among other tasks, promotes the extinction of
aversively charged emotional memories
•restraint of the amygdala fear system and its opposition to
the process of conditioned fear are two of the important
functions of the prefrontal cortex and very important in
opposition to depressive illness
•Mediates and exerts inhibitory control over stress responses
and emotional reactivity by connection with amygdala
•hypofunction

57. Nucleus Accumbens
•one ofthe main areas of the brain that responds to
dopamine stimulation
•experience of pleasure (sex, eating, and the enjoyment
of ideas and other people)

58. Hypothalamic-pituitary-adrenal axis
•Central coordinator of mammalian stress response
•Stress –hypothalamic paraventricular nucleus –CRH-
pituitary via portal circulation –ACTH –adrenal cortex –
release glucocoricoids –modulate metabolism, immune,
brain function
•Hippocampus and prefrontal cortex –inhibit HPA axis
•Amygdala and aminergergic brain stem neuron –activate
HPA axis

61. Stress and Depression

64. WHAT IS DEPRESSION?
•Sadness is a normal reaction to life’s struggles,
setbacks, and disappointments
•Depression is differentfrom normal sadness by:
–Affects your day-to-day life
–Interfering with your ability to work, study, eat,
sleep, and have fun
•The feelings of helplessness, hopelessness, and
worthlessness are intense and persistent, with little, if
any, relief

65. RISKFACTORS
•Experience of loss; end of relationship
•Lack of social support
•Stressful life experience
•Family history
•Trauma, abuse, neglect
•Alcohol & drug abuse
•Health problems or chronic pain
•Financial worries
•Major change at home, work, etc.

66. SYMPTOMS OF DEPRESSION
•Depressed mood
•Loss of interest in daily activities
•Sleep disturbance
•Appetite or weight changes
•Concentration problems
•Loss of energy
•Socially withdrawn
•Feelings of helplessness and hopelessness
•Recurrent thoughts of death and suicide

67. CAN DEPRESSION LOOK DIFFERENT
IN KIDS & TEENS
•Irritability/anger
•Behavioral problems
•Drug use; sexual promiscuity
•Academic problems
•Preoccupation with morbid
themes
•Heightened expression of
boredom
•Frequent aches & pains

68. Depression
•One of the more
commonly encountered
psychiatric disorders
•While many effective treatments are available, this
disorder is often underdiagnosed and
undertreated
•The incidence approaches 10% in primary care
patients, and 15% in medical patients

69. •Major depression is
currently the leading
cause of disease
burden in North
America and high-
income countries, and
fourth leading cause
worldwide
•In the year 2030, it is
predicted to be the
second leading
cause of disease
burden worldwide
(after HIV), according
to the World Health
Organization

70. •25% of individuals with
severe, chronic
medical illness (e.g.,
diabetes, myocardial
infarction, carcinomas,
stroke) develop
depression
•About 5% of individuals initially diagnosed as having MDD
subsequently are found to have another medical illness
which was the cause of their depression

71. MYTHS OR FACTS ?
•People who talk about suicide won’t really do it
•People who talk about or attempt suicide want to die
•Anyone who tries to kill him/herself must be crazy
•If a person is determined to kill him/herself, nothing is
going to stop them
•Talking about suicide may give someone the idea

72. Coping Depression
•Reach out and stay connected
–talk to friends
•Do things that make you feel good
–hobby
•Get moving
–exercise
•Eat a healthy, depression-fighting diet
•Get a daily dose of sunlight
•Challenge negative thinking

74. WHYTALKABOUTDEPRESSION& SUICIDE?
•16% of students between 13-15 years old have
seriously considered attempting suicide
WHO: Someone commits suicide every 40
seconds in the world
Suicide rate has alarmingly risen in the Philippines
Depressionis the strongest risk factor
(Global School Based Health Survey, WHO 2011)

75. LETSTALKABOUTSUICIDE
•12% among the adolescents with depressive disorders
•completed suicide occurs 5x higher in boys than in girls,
out of impulsiveness
•use of firearms or by hanging, usually in boys and by
ingestion in girls

76. •inability to cope with
stressors and the
feeling of helplessness
•genetics, biological and
social factors are
contributory

77. RISKFACTORS
•Relational, social, work, or financial loss
•Physical illness
•Previous suicide act
•Easy access to lethal methods, especially
guns
•Age, Culture, Lack of connectedness
•Exposure to sensational media reports of
suicide

78. SUICIDEWARNINGSIGNS
•Talking, writing, or joking about suicide or death
•Giving away prized possessions
•Making final arrangements
•Depressive symptoms
•Sudden, unexplained recovery from profound
depression
•Marked feelings of helplessness or hopelessness

79. •Risk-taking behavior
•Self-mutilating behavior (sometimes)
•A suicide plan
•Significant change in behavior
•Previous suicide attempts
•Significant loss
•Chemical (drug or alcohol) abuse

81. WHOAREATRISK

82. •High levels of hopelessness, poor
problem-solving skills and history of
aggressive behavior are risk factors
for suicide
•Profile of an adolescent who commit
suicide:
–high achiever and perfectionist character

83. WHOISATRISKOFDYINGBYSUICIDE
•Anyone

84. DIRECT QUESTIONING ABOUT SUICIDAL
THOUGHTS
IS NECESSARY

85. WHATCANYOU SAY?
•I’m glad you told me, I want to help.
•I’m glad you told me, and I am going to find
someone to help you.
•I will stay with you until help arrives.

86. WHAT NOT TO SAY…
•“It’s just a phase”
•“You’ll snap out of it”
•“Stop being so selfish”
•“You’re just trying to get attention”
•“Get over it”

87. MANAGEMENT
•Hospitalization
•Medications
•Psychotherapy

90. Good Day!