Stress Disorders

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Chapter 6
Slides Handouts by Karen Clay Rhines,
Ph.D. Seton Hall University

• Stress Disorders

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Stress, Coping, and the Anxiety Response

• The state of stress has two components
• Stressor event creating demands
• Stress response reactions to the demands
• Influenced by how we appraise (a) the event, and
  (b) our capacity to react to the event
  effectively
• People who sense that they have the ability and
  resources to cope are more likely to take
  stressors in stride

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Stress, Coping, and the Anxiety Response

• When we appraise a stressor as threatening, the
  natural reaction is fear
• Fear is a package of physical, emotional, and
  cognitive responses
• Stress reactions, and the fear they produce, are
  often at play in psychological disorders
• People who experience a large number of stressful
  events are particularly vulnerable to the onset
  of GAD, social phobia, panic disorder, and OCD,
  as well as other psychological problems

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Stress, Coping, and the Anxiety Response

• Stress also plays a more central role in certain
  psychological disorders, including
• Acute stress disorder
• Posttraumatic stress disorder
• Technically, DSM-IV-TR lists these patterns as
  anxiety disorders
• as well as certain physical disorders called
  psychophysiological disorders
• These disorders are listed in the DSM-IV-TR under
  psychological factors affecting medical
  condition

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Stress and Arousal The Fight-or-Flight Response

• The features of arousal and fear are set in
  motion by the hypothalamus
• Two important systems are activated
• Autonomic nervous system (ANS)
• An extensive network of nerve fibers that connect
  the central nervous system (the brain and spinal
  cord) to the bodys other organs
• Contains two systems sympathetic and
  parasympathetic
• Endocrine system
• A network of glands throughout the body that
  release hormones

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Stress and Arousal The Fight-or-Flight Response

• There are two pathways by which the ANS and the
  endocrine systems produce arousal and fear
  reactions
• Sympathetic nervous system
• Hypothalamic-pituitary-adrenal pathway

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Stress and Arousal The Fight-or-Flight Response

• When confronting a dangerous situation, the
  hypothalamus first activates the sympathetic
  nervous system, which stimulates key organs
  either directly or indirectly
• When the perceived danger passes, the
  parasympathetic nervous system helps return
  bodily systems to normal

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Stress and Arousal The Fight-or- Flight Response

• The second pathway is the hypothalamic-pituitary-a
  drenal (HPA) pathway
• When confronted by stressors, the hypothalamus
  sends a message to the pituitary gland, which
  signals the adrenal cortex to release
  corticosteroids the stress hormones into the
  bloodstream

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Stress and Arousal The Fight-or-Flight Response

• The reactions displayed by these two pathways are
  referred to as the fight-or-flight response
• People differ in their particular patterns of
  autonomic and endocrine functioning and therefore
  also in their particular ways of experiencing
  arousal and fear

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Stress and Arousal The Fight-or-Flight Response

• People differ in
• Their general level of anxiety
• Called trait anxiety
• Some people are usually somewhat tense others
  are usually relaxed
• Differences appear soon after birth
• Their sense of threat
• Called state anxiety
• Situation-based (example fear of flying)

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The Psychological Stress Disorders

• During and immediately after trauma, many people
  become highly anxious and depressed
• For some, feelings persist well after the trauma
• These people may be experiencing
• Acute stress disorder
• Posttraumatic stress disorder (PTSD)
• The precipitating event usually involves actual
  or threatened serious injury to self or others
• Occurs following an event which would be
  traumatic to anyone (unlike other anxiety
  disorders)

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The Psychological Stress Disorders

• Acute stress disorder
• Symptoms begin within four weeks of event and
  last for less than one month
• Posttraumatic stress disorder (PTSD)
• Symptoms can begin at any time following the
  event but must last for longer than one month
• May develop from acute stress disorder

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What Triggers a Psychological Stress Disorder?

• Can occur at any age and affect all aspects of
  life
• 4 of U.S. population affected each year
• 7 of U.S. population affected sometime during
  life
• Approximately 2/3 seek treatment at some point
• Ratio of women to men is 21
• After trauma, 20 of women and 8 of men develop
  disorders
• Some events including combat, disasters, abuse,
  and victimization are more likely to cause
  disorders than others

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What Triggers a Psychological Stress Disorder?

• Combat and stress disorders
• It has long been recognized that soldiers
  experience distress during combat
• Called shell shock, combat fatigue
• Post-Vietnam War clinicians discovered that
  soldiers also experienced psychological distress
  after combat
• 30 of Vietnam combat veterans suffered acute or
  posttraumatic stress disorders
• An additional 22 had some stress symptoms
• 10 still experiencing problems

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What Triggers a Psychological Stress Disorder?

• Disasters and stress disorders
• Acute or posttraumatic stress disorders may also
  follow natural and accidental disasters
• Civilian traumas have been implicated in stress
  disorders at least 10 times as often as combat
  trauma
• Types of disasters include traffic accidents,
  weather, earthquakes, and airplane crashes

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What Triggers a Psychological Stress Disorder?

• Victimization and stress disorders
• People who have been abused, victimized, or
  terrorized often experience lingering stress
  symptoms
• Common victimization is sexual assault/rape
• 1 in 7 women is raped at some time during her
  life
• Psychological impact is immediate and may be
  long-lasting
• One study found that 94 of rape survivors
  developed an acute stress disorder within 12 days
  after assault

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What Triggers a Psychological Stress Disorder?

• Victimization and stress disorders
• Ongoing victimization and abuse in the family may
  also lead to stress disorders
• The experience of terrorism or the threat of
  terrorism often leads to posttraumatic stress
  symptoms

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Why Do People Develop a Psychological Stress
Disorder?

• Clearly, extraordinary trauma can cause a stress
  disorder
• However, the event alone may not be the entire
  explanation
• To understand why only some people develop stress
  disorders, researchers have looked to the
  survivors biological processes, personalities,
  childhood experiences, and social support
  systems, and to the severity of the trauma itself

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Why Do People Develop a Psychological Stress
Disorder?

• Biological and genetic factors
• Traumatic events trigger physical changes in the
  brain and body that may lead to severe stress
  reactions, and, possibly, stress disorders
• Some research suggests abnormal NT and hormone
  activity (especially norepinephrine and cortisol)
• There may be a biological/genetic predisposition
  to such reactions
• Evidence suggests that other biological changes
  and damage may also occur as a stress disorder
  sets in

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Why Do People Develop a Psychological Stress
Disorder?

• Personality factors
• Some studies suggest that people with certain
  personality profiles, attitudes, and coping
  styles are more likely to develop stress
  disorders
• Risk factors include
• Preexisting high anxiety
• A history of psychological problems
• Negative worldview
• A set of positive attitudes (called resiliency or
  hardiness) is protective against developing
  stress disorders

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Why Do People Develop a Psychological Stress
Disorder?

• Negative childhood experiences
• A wave of studies has found that certain
  childhood experiences increase risk for later
  stress disorders
• Risk factors include
• An impoverished childhood
• Psychological disorders in the family
• The experience of assault, abuse, or catastrophe
  at an early age
• Being younger than 10 years old when parents
  separated or divorced

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Why Do People Develop a Psychological Stress
Disorder?

• Social support
• People whose social support systems are weak are
  more likely to develop a stress disorder after a
  negative event
• Severity of the trauma
• The more severe the trauma and the more direct
  ones exposure to it, the greater the likelihood
  of developing a stress disorder
• Especially risky mutilation and severe injury
  witnessing the injury or death of others

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How Do Clinicians Treat the Psychological Stress
Disorders?

• Symptoms have been found to last an average of 3
  years with treatment and 5½ years without
  treatment
• Treatment type varies depending on type of trauma
• General goals
• End lingering stress reactions
• Gain perspective on traumatic experience
• Return to constructive living

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How Do Clinicians Treat the Psychological Stress
Disorders?

• Treatment for combat veterans
• Drug therapy
• Antianxiety and antidepressant medications are
  most common
• Behavioral exposure therapy
• Reduce specific symptoms, increase overall
  adjustment
• Use flooding and relaxation training
• Use eye movement desensitization and reprocessing
  (EMDR)
• Insight therapy
• Bring out deep-seated feelings, create
  acceptance, lessen guilt
• Often use family or group therapy formats rap
  groups
• Usually used in combinations

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How Do Clinicians Treat the Psychological Stress
Disorders?

• Psychological debriefing
• A form of crisis intervention that has victims of
  trauma talk extensively about their feelings and
  reactions within days of the critical incident
• Four-stage approach
• Normalize responses to the disaster
• Encourage expressions of anxiety, anger, and
  frustration
• Teach self-help skills
• Provide referrals
• Relief workers themselves may become overwhelmed
• Research on this type of intervention has called
  into question its effectiveness

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The Physical Stress Disorders Psychophysiological
Disorders

• In addition to affecting psychological
  functioning, stress can also have an enormous
  impact on physical functioning
• The idea that stress and related psychosocial
  factors may contribute to somatic illnesses has
  ancient roots René Descartes called a variation
  on this idea mind-body dualism

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The Physical Stress Disorders Psychophysiological
Disorders

• About 75 years ago, clinicians first identified a
  group of physical illnesses that seemed to result
  from an interaction of psychosocial and physical
  factors
• Early versions of the DSM labeled these illnesses
  psychophysiological, or psychosomatic, disorders
• DSM-IV-TR calls them psychological factors
  affecting medical condition

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The Physical Stress Disorders Psychophysiological
Disorders

• It is important to note that these
  psychophysiological disorders bring about actual
  physical damage
• They are different from apparent physical
  illnesses like factitious disorders or somatoform
  disorders, which will be discussed in Chapter 7

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Traditional Psychophysiological Disorders

• Before the 1970s, the best known and most common
  of the psychophysiological disorders were ulcers,
  asthma, insomnia, chronic headaches, high blood
  pressure, and coronary heart disease
• Recent research has shown that many other
  physical illnesses may be caused by an
  interaction of psychosocial and physical factors

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Traditional Psychophysiological Disorders

• Ulcers
• Lesions in the wall of the stomach that result in
  burning sensations or pain, vomiting, and stomach
  bleeding
• Affect up to 20 million people at some point in
  their lives
• Causal psychosocial factors
• Environmental stress, anger, anxiety, dependent
  personality style
• Causal physiological factors
• Bacterial infection

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Traditional Psychophysiological Disorders

• Asthma
• A narrowing of the bodys airways that makes
  breathing difficult
• Affects up to 20 million people in the U.S. each
  year
• Most victims are children at the time of first
  attack
• Causal psychosocial factors
• Environmental pressures, troubled family
  relationships, anxiety, high dependency
• Causal physiological factors
• Allergies, a slow-acting sympathetic nervous
  system, weakened respiratory system

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Traditional Psychophysiological Disorders

• Insomnia
• Difficulty falling asleep or maintaining sleep
• Affects 35 of people in the U.S. each year
• Causal psychosocial factors
• High anxiety or depression
• Causal physiological factors
• Overactive arousal system, certain medical
  ailments

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Traditional Psychophysiological Disorders

• Chronic headaches
• Tension headaches affect 40 million Americans
  each year
• Migraine headaches affect 23 million Americans
  each year
• Causal psychosocial factors
• Environmental pressures general feelings of
  helplessness, anger, anxiety, depression
• Causal physiological factors
• Abnormal serotonin activity, vascular problems,
  muscle weakness

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Traditional Psychophysiological Disorders

• Hypertension
• Chronic high blood pressure, usually producing no
  overt symptoms
• Affects 65 million Americans each year
• Causal psychosocial factors
• Constant stress, constant environmental danger,
  general feelings of anger or depression
• Causal physiological factors
• 10 caused by physiological factors alone
• Obesity, smoking, poor kidney function, high
  proportion of collagen rather than elastic tissue
  in an individuals blood vessels

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Traditional Psychophysiological Disorders

• Coronary heart disease
• Caused by a blocking of the coronary arteries
• Includes angina pectoris (chest pain), coronary
  occlusion (complete blockage of a coronary
  artery), and myocardial infarction (heart attack)
• Leading cause of death in men older than 35 years
  and women older than 40 years in the U.S.
• Causal psychosocial factors
• Job stress, high levels of anger or depression
• Causal physiological factors
• High level of cholesterol, obesity, hypertension,
  the effects of smoking, lack of exercise

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Traditional Psychophysiological Disorders

• A number of factors contribute to the development
  of psychophysiological disorders, including
• Sociocultural factors
• Psychological factors
• Biological variables

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Traditional Psychophysiological Disorders

• Sociocultural factors
• Stressful demands placed on people by their
  culture may set the stage for psychophysiological
  disorders
• Examples include poverty, violence, and nuclear
  threat (such as Three Mile Island)

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Traditional Psychophysiological Disorders

• Psychological factors
• According to many theorists, certain needs,
  attitudes, emotions, or coping styles may cause
  people to repeatedly overreact to stressors,
  thereby increasing their likelihood of developing
  psychophysiological disorders
• Examples a repressive coping style, Type A
  personality style

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Traditional Psychophysiological Disorders

• Biological factors
• Defects in the autonomic nervous system (ANS) are
  believed to contribute to the development of
  psychophysiological disorders
• Other more specific biological problems may also
  contribute
• For example, a weak gastrointestinal system may
  create a predisposition to developing ulcers

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Traditional Psychophysiological Disorders

• Clearly, sociocultural, psychological, and
  biological variables combine to produce
  psychophysiological disorders
• Although once thought to be unusual, the
  interaction of psychosocial and physical factors
  is now considered the rule of bodily function,
  not the exception
• In recent years, more and more illnesses have
  been placed in this category

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New Psychophysiological Disorders

• Since the 1960s, researchers have found many
  links between psychosocial stress and a range of
  physical illnesses

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New Psychophysiological Disorders

• Are physical illnesses related to stress?
• The development of the Social Adjustment Rating
  Scale in 1967 enabled researchers to examine the
  relationship between life stress and the onset of
  illness

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New Psychophysiological Disorders

• Are physical illnesses related to stress?
• Using the Social Adjustment Rating Scale, studies
  have consistently linked stresses of various
  kinds to a wide range of physical conditions
• Overall, the greater the amount of life stress,
  the greater the likelihood of illness
• Researchers have even found a relationship
  between traumatic stress and death

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New Psychophysiological Disorders

• Are physical illnesses related to stress?
• One key weakness of the Social Adjustment Rating
  Scale is that it fails to take into account the
  particular stress reactions of specific
  populations
• For example, women and men have been shown to
  react differently to certain life changes
  measured by the scale

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New Psychophysiological Disorders

• Researchers have increasingly looked to the
  bodys immune system as the key to the
  relationship between stress and infection
• This area of study is called psychoneuroimmunology

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New Psychophysiological Disorders

• Psychoneuroimmunology
• The immune system is the bodys network of
  activities and cells that identify and destroy
  antigens (foreign invaders, such as bacteria) and
  cancer cells
• Among the most important cells in this system are
  the lymphocytes
• Lymphocytes are white blood cells that circulate
  through the blood system and attack the invaders
• Lymphocytes include helper T-cells, natural
  killer T-cells, and B-cells

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Researchers now believe that stress can interfere
  with the activity of lymphocytes, slowing them
  down and increasing a persons susceptibility to
  viral and bacterial infections
• Several factors influence whether stress will
  result in a slowdown of the system, including
  biochemical activity, behavioral changes,
  personality style, and degree of social support

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Biochemical activity
• Stress leads to increased activity of the
  sympathetic nervous system, including a release
  of norepinephrine
• In addition to supporting nervous system
  activity, this chemical also appears to slow down
  the functioning of the immune system
• Similarly, the bodys endocrine glands reduce
  immune system functioning during periods of
  prolonged stress through the release of
  corticosteroids

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Behavioral changes
• Stress may set into motion a series of behavioral
  changes poor sleep patterns, poor eating, lack
  of exercise, increase in smoking and/or drinking
  that indirectly affect the immune system
• Personality style
• An individuals personality style, including
  their level of optimism, constructive coping
  strategies, and resilience, plays a role in
  determining how much the immune system is slowed
  down by stress

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New Psychophysiological Disorders

• Psychoneuroimmunology
• Social support
• Level of social support appears to play a role in
  immune system functioning
• People who have few social supports and feel
  lonely seem to display poorer immune functioning
  in the face of stress than people who do not feel
  lonely
• Studies have shown that social support and
  affiliation with others may actually speed up
  recovery from illness or surgery

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Psychological Treatments for Physical Disorders

• As clinicians have discovered that psychosocial
  factors may contribute to physical disorders,
  they have applied psychological treatment to more
  and more medical problems
• The most common of these interventions are
  relaxation training, biofeedback training,
  meditation, hypnosis, cognitive interventions,
  insight therapy, and support groups

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Psychological Treatments for Physical Disorders

• The field of treatment that combines
  psychological and physical interventions to treat
  or prevent medical problems is known as
  behavioral medicine

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Psychological Treatments for Physical Disorders

• Relaxation training
• People can be trained to relax their muscles at
  will, a process that sometimes reduces feelings
  of anxiety
• Relaxation training can be of help in preventing
  or treating medical illnesses that are related to
  stress
• Often used in conjunction with medication in the
  treatment of high blood pressure
• Often used alone to treat chronic headaches,
  insomnia, and asthma

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Psychological Treatments for Physical Disorders

• Biofeedback training
• Patients given biofeedback training are connected
  to machinery that gives them continuous readings
  about their involuntary bodily activities
• This procedure has been used successfully to
  treat pain from muscle tension, headaches, and
  muscular disabilities caused by stroke or
  accident
• Some biofeedback training has been effective in
  the treatment of asthma, irregular heartbeat,
  migraine headaches, and high blood pressure

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Psychological Treatments for Physical Disorders

• Meditation
• Although meditation has been practiced since
  ancient times, Western clinicians have only
  recently become aware of its effectiveness in
  relieving physical distress
• Meditation involves turning ones concentration
  inward and changing ones level of consciousness
• Meditation has been used to treat pain, high
  blood pressure, heart problems, insomnia, and
  asthma

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Psychological Treatments for Physical Disorders

• Hypnosis
• Individuals undergoing hypnosis are guided into a
  sleeplike, suggestible state during which they
  can be directed to act in unusual ways, to
  remember unusual sensations, or to forget
  remembered events
• With training, hypnosis can be done without a
  hypnotist (self-hypnosis)

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Psychological Treatments for Physical Disorders

• Hypnosis
• This technique is now used as an aid to
  psychotherapy and to treat medical conditions,
  including asthma, insomnia, high blood pressure,
  and infection

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Psychological Treatments for Physical Disorders

• Cognitive interventions
• People with physical ailments have sometimes been
  taught new attitudes or cognitive responses as
  part of treatment
• One intervention is self-instruction training, in
  which patients are taught to rid themselves of
  negative self-statements and to replace these
  with positive self-statements
• This technique has been used in pain management,
  headaches, ulcers, and back disorders

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Psychological Treatments for Physical Disorders

• Insight therapy and support groups
• If negative psychological symptoms (e.g.,
  depression, anxiety) contribute to a persons
  physical ills, therapy to address these emotions
  should help reduce the ills
• These techniques have been used to treat a
  variety of illnesses including asthma, cancer,
  headache, and arthritis

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Psychological Treatments for Physical Disorders

• Combination approaches
• Studies have found that the various psychological
  treatments for physical problems tend to be equal
  in effectiveness
• Psychological treatments are often most effective
  when used in combination and with medical
  treatment
• With these combined approaches, todays
  practitioners are moving away from the mind-body
  dualism of centuries past