Stress and Its Management

What is stress?:
Stress is a slippery concept. We sometimes use the word informally to describe threats or
challenges ("Ben was under a lot of stress"), and at other times our responses ("Ben
experienced acute stress"). To a psychologist, the dangerous truck ride was a stressor. Ben's
physical and emotional responses were a stress reaction. And the process by which he
related to the threat was stress.
Thus, stress is not just a stimulus or a response. It is the process by which we appraise and cope
with environmental threats and challenges. Stress arises less from events themselves than
from how we appraise them (Lazarus, 1998).
But stressors can also threaten us. And experiencing severe or prolonged stress
may harm us. Children's physiological responses to severe child abuse put them at later
risk of chronic disease (Repetti et al., 2002). Those who had post-traumatic stress reactions
to heavy combat in the Vietnam War went on to suffer greatly elevated rates of circulatory,
digestive, respiratory, and infectious diseases (Boscarino, 1997).

The Stress Response System

Medical interest in stress dates back to Hippocrates (460-377 B.c.). But it was not
until the 1920s that Walter Cannon (1929) confirmed that the stress response is part of a
unified mind-body system. He observed that extreme cold, lack of oxygen, and emotion-
arousing incidents all trigger an outpouring of the stress hormones epineph rine and
norepinephrine from the central core of the adrenal glands. This is but one part of the
sympathetic nervous system's response. When alerted by any of a number of brain
pathways, the sympathetic nervous system, as we have seen, increases heart rate and
respiration, diverts blood from digestion to the skeletal muscles, dulls pain, and releases
sugar and fat from the body's store's—all to prepare the body for the wonderfully adaptive
response that Cannon called fight or flight.

Selye's general adaptation syndrome This girl being carried to freedom and
medical attention managed to escape her terrorist captors in a three-day school holdup in
North Ossetia in 2004. After such a trauma, the body enters an alarm phase of temporary
shock. From this it rebounds, as stress resistance rises. If the stress is prolonged, as it was
for the 400 school hostages and their waiting loved ones, wear and tear may lead to
exhaustion.

Canadian scientist Hans Selye's (1936, 1976) 40 years of research on stress

extended Cannon's findings and helped make stress a major concept in both psychology
and medicine. Selye studied animals' reactions to various stressors, such as electric
shock, surgical trauma, and immobilizing restraint. He discovered that the body's
adaptive response to stress was so general—like a single burglar alarm that sounds no matter
what intrudes—that he called it the general adaptation syndrome (GAS).
Selye saw the GAS as having three phases. Let's say you suffer a physical or
emotional trauma. In Phase 1, you experience an alarm reaction due to the sudden
activation of your sympathetic nervous system. Your heart rate zooms. Blood is diverted
to your skeletal muscles. You feel the faintness of shock. With your resources
mobilized, you are now ready to fight the challenge during Phase 2, resistance. Your
temperature, blood pressure, and respiration remain high, and there is a sudden outpouring
of hormones. If persistent, the stress may eventually deplete your body's reserves during
Phase 3, exhaustion. With exhaustion, you are more vulnerable to illness or even, in
extreme cases, collapse and death.
Few medical experts today quarrel with Selye's basic point: Although the human
body comes designed to cope with temporary stress, prolonged stress can produce
physical deterioration. The brain's production of new neurons slows (Mirescu & Gould,
2006). In one study, women who suffered enduring stress as caregivers for children with
serious disorders displayed a symptom that is a normal part of the aging process . The
most stressed women had cells that looked a decade older than their chronological age, which
may help explain why severe stress seems to age people. Even fearful, easily stressed rats
have been found to die sooner (after about 600 days) than their more confident siblings,
which average 700-day life spans (Cavigelli & McClintock, 2003). Such findings serve as
further incentives to today's health psychologists, as they ask: What causes stress? And how
does stress affect us?
Stressful Life Events

What events provoke stress responses?

Research has focused on our responses to three types of stressors: catastrophes, sig -
nificant life changes, and daily hassles.

Catastrophes

Catastrophes are unpredictable large-scale events, such as war and natural disasters, that
nearly everyone appraises as threatening. Although people often provide one another with
aid as well as comfort after such events, the health consequences can be significant. In the
three weeks after the 9/11 terrorist attacks, two-thirds of Americans surveyed by University
of Michigan researchers said they were having some trouble concentrating and sleeping
(Wahlberg, 2001). In another national survey, New Yorkers were especially likely to report
such symptoms (NSF, 2001). Sleeping pill prescriptions rose by a reported 28 percent in the
New York area (HMHL, 2002).
In disaster's wake, rates of psychological disorders such as depression and anxiety
rose an average 17 percent. In the four months after Hurricane Katrina, New Orleans
reportedly experienced a tripled suicide rate (Saulny, 2006). Refugees fleeing their
homeland also suffer increased rates of psychological disorders. Their stress is twofold: the
trauma of uprooting and family separation, and the challenges of adjusting to a foreign
culture's new language, ethnicity, climate, and social norms (Pipher, 2002; Williams & Berry,
1991). In years to come, relocations necessitated by climate change may also produce such
effects. Significant Life Changes. The second type of life-event stressor is a significant
personal life change—the death of a loved one, the loss of a job, leaving home, a marriage, a
divorce. Life transitions and insecurities are often keenly felt during young adulthood.
Some psychologists study the health effects of life changes by following people
over time to see if such events precede illnesses. Others compare the life changes recalled by
those who have or have not suffered a specific health problem, such as a heart attack. A
review of these studies commissioned by the U.S. National Academy of Sciences revealed
that people recently widowed, fired, or divorced are more vulnerable to disease (Dohrenwend
et al., 1982). A Finnish study of 96,000 widowed people confirmed the phenomenon: Their
 risk of death doubled in the week following their partner's death (Kaprio et al., 1987).
Experiencing a cluster of crises puts one even more at risk.

Daily Hassles As we noted earlier, our happiness stems less from enduring good fortune
than from our response to daily events—a hoped-for medical result, a perfect exam score, a
gratifying e-mail, your team's winning the big game.
This principle works for negative events, too. Everyday annoyances—rush-
hour traffic, aggravating housemates, long lines at the store, too many things to do, e-mail
spam, and obnoxious cell phone talkers—may be the most significant sources of stress (Kohn
& Macdonald, 1992; Lazarus, 1990; Ruffin, 1993). Although some people can simply shrug
off such hassles, others are "driven up the wall" by them. People's difficulties in letting go of
unattainable goals is another everyday stressor with health consequences (Miller & Wrosch,
2007). Over time, these little stressors can add up and take a toll on our health and well -
being. Hypertension rates are high among residents of impoverished areas where the stresses
that accompany inadequate income, unemployment, solo parenting, and overcrowding are
part of daily life for many people. In Europe, hypertension rates are likewise highest in
countries where people express the least satisfaction with their lives.
For minority populations, daily pressures may be compounded by racism, which
—like other stressors—can have both psychological and physical consequences. Thinking
that some of the people you encounter each day will distrust you, dislike you, or doubt your
abilities makes daily life stressful. Such stress takes a toll on the health of many African-
Americans, driving up blood pressure levels (Clark et al., 1999; Mays et al., 2007).
Stress and the Heart

Elevated blood pressure is just one of the factors that increase the risk of
coronary heart disease. Although infrequent before 1900, this condition became by the
1950s North America's leading cause of death, and it remains so today. In addition to
hypertension and a family history of the disease, many behavioral and physiological factors
—smoking, obesity, a high-fat diet, physical inactivity, and an elevated cholesterol level—
increase the risk of heart disease. The psychological factors of stress and personality also play
a big role.
The stage was set for Friedman and Rosenman's classic nine-year study of
more than 3000 healthy men aged 35 to 59. At the start of the study, they interviewed each
man for 15 minutes about his work and eating habits. During the interview, they noted
the man's manner of talking and other behavioral patterns. Those who seemed the most
reactive, competitive, hard-driving, impatient, time-conscious, supermotivated, verbally
aggressive, and easily angered they called Type A. The roughly equal number who were more
easygoing they called Type B. Which group do you suppose turned out to be the most
coronary prone?
By the time the study was complete, 257 men had suffered heart attacks; 69 per cent of
them were Type A. Moreover, not one of the "pure" Type Bs had suffered a heart attack.
As often happens in science, this exciting discovery provoked enormous public in-
terest. But after the honeymoon period, in which the finding seemed definitive and
revolutionary, other researchers began asking: Is the finding reliable? If so, what is the toxic
component of the Type A profile: Time-consciousness? Competitiveness? Anger?
More recent research has revealed that Type A's toxic core is negative emotions—
especially the anger associated with an aggressively reactive temperament (Smith, 2006;
Williams, 1993). Type A individuals are more often "combat ready." You may recall from
this chapter's discussion of anger that when we are harassed or challenged, our active
sympathetic nervous system redistributes blood flow to our muscles and away from internal
organs such as the liver, which normally removes cholesterol and fat from the blood. Thus, a
Type A person's blood may contain excess cholesterol and fat that later gets deposited around
the heart. Further stress may trigger the altered heart rhythms that, in those with weakened
hearts, can cause sudden death (Kamarck & Jennings, 1991). Hostility also correlates with
other risk factors, such as smoking, drinking, and obesity (Runde & Suls, 2006). In
important ways, people's minds and hearts interact.
The effect of an anger-prone personality appears most noticeably in studies in
which interviewers assess verbal assertiveness and emotional intensity. One study of
young and middle-aged adults found that those who react with anger over little things are
the most coronary-prone, and suppressing negative emotions only heightens the risk (Kupper
& Denollet, 2007). Another study followed 13,000 middle-aged people for 5 years
(Williams et al., 2000). Among those with normal blood pressure, people who had scored
high on anger were three times more likely to have had heart attacks, even after researchers
 controlled for smoking and weight. The link between anger and heart attacks also appeared in
a study that followed 1055 male medical students over an average of 36 years. Those who had
reported being hot-tempered were five times more likely to have had a heart attack by age 55
(Chang et al., 2002). As Charles Spielberger and Perry London (1982) put it, rage "seems
to lash back and strike us in the heart muscle." Pessimism seems to be similarly toxic.
Laura Kubzansky and her colleagues (2001) studied 1306 initially healthy men who a
decade earlier had scored as optimists, pessimists, or neither. Even after other risk factors
such as smoking had been ruled out, pessimists were more than twice as likely as optimists
to develop heart disease.
Depression, too, can be lethal. The accumulated evidence from 57 studies suggests that
"depression substantially increases the risk of death, especially death by unnatural causes
and cardiovascular disease" (Wulsin et al., 1999). One study of 7406 women age 67 or
older found that among those with no depressive symptoms, 7 percent died within six
years, as did 24 percent of those with six or more depressive symptoms (Whooley &
Browner, 1998). In the years following a heart attack, people with high scores for depression
are four times more likely than their low-scoring counterparts to develop further heart
problems (Frasure-Smith & Lesperance, 2005). Depression is disheartening.
Recent research suggests that heart disease and depression may both result when chronic
stress triggers persistent inflammation (Matthews, 2005; Miller & Blackwell, 2006). Stress,
as we will see, disrupts the body's disease-fighting immune system, thus enabling the body
to focus its energies on fleeing or fighting the threat. Yet stress hormones' enhance one
immune response, the production of proteins that contribute to the inflammation.
Although inflammation helps fight infections, persistent in flammation can produce
problems such as asthma or clogged arteries, and even, it now seems, depression

Stress and Susceptibility to disease

How does stress make us more vulnerable to disease?

Not so long ago, the term psychosomatic described psychologically caused physical
symptoms. To laypeople, the term implied that the symptoms were unreal—"merely"
psychosomatic. To avoid such connotations and to better describe the genuine physiological
effects of psychological states, most experts today refer instead to stress- related
psychophysiological illnesses, such as hypertension and some headaches. Stress also affects
our resistance to disease, and this understanding has led to the burgeoning development of the
field of psychoneuroimmunology (PNI). PNI studies how psychological, neural, and
endocrine processes affect our immune system (psychoneuro-immunology), and how all these
factors influence our health and wellness.

Stress and AIDS

AIDS has become the world's fourth leading cause of death and the number one
killer in Africa. As its name tells us, AIDS is an immune disorder—an acquired immune
deficiency syndrome caused by the human immunodeficiency virus (HIV), which is spread
by the exchange of bodily fluids, primarily semen and blood.
If stress restrains the immune system's response to infections, could it also ex -
acerbate the course of AIDS? Researchers have found that stress and negative emotions
do correlate with (a) a progression from HIV infection to AIDS, and (b) the speed of
decline in those infected (Bower et al., 1998; Kiecolt-Glaser & Glaser, 1995; Leserman et al.,
1999). HIV-infected men faced with stressful life circumstances, such as the loss of a
partner, exhibit somewhat greater immune suppression and a faster disease progression.

Stress and Cancer

Stress and negative emotions have also been linked to cancer's rate of progression.
To explore a possible connection between stress and cancer, experimenters have im -
planted tumor cells into rodents or given them carcinogens (cancer-producing sub-
stances). Those rodents also exposed to uncontrollable stress, such as inescapable
shocks, were more prone to cancer (Sklar & Anisman, 1981). With immune systems
weakened by stress, tumors developed sooner and grew larger.
Some investigators have reported that people are at increased risk for
cancer within a year after experiencing depression, helplessness, or bereavement. One large
Swedish study revealed that people with a history of workplace stress had 5.5 times greater
risk of colon cancer than those who reported no such problems, a difference not
attributable to differing age, smoking, drinking, or physical characteristics (Courtney
et al., 1993). Other researchers have found no link between stress and human cancer
(Edelman & Kidman, 1997; Fox, 1998; Petticrew et al., 1999, 2002). Concentration camp
 survivors and former prisoners of war, for example, have not exhibited elevated cancer rates.
Behavioral medicine research provides yet another reminder of one of
contemporary psychology's overriding themes: Mind and body interact; everything
psychological is simultaneously physiological. Psychological states are physiological
events that influence other parts of our physiological system. Just pausing to think about
biting into an orange section—the sweet, tangy juice from the pulpy fruit flooding across
your tongue—can trigger salivation. As the Indian sage Sand Parva recognized more than
4000 years ago, "Mental disorders arise from physical causes, and likewise physical
disorders arise from mental causes." There is an interplay between our heads and our health.
We are biopsychosocial systems.
4. Promoting Health

PROMOTING HEALTH BEGINS WITH implementing strategies that prevent illness and
enhance wellness. Health maintenance includes alleviating stress, preventing illness, and
promoting well-being.
Coping with Stress
What factors affect our ability to cope with stress?

Stressors are unavoidable. This fact, coupled with the fact that persistent stress correlates with
heart disease, depression, and lowered immunity, gives us a clear message. We need to learn to
cope with the stress in our lives. We address some stressors directly, with problem-focused
coping. For example, if our impatience leads to a family fight, we may go directly to that family
member to work things out. If, despite our best efforts, we cannot get along with that family
member, we may also incorporate an emotion-focused coping, such as reaching out to
friends to help address our own emotional needs.
When challenged, some people tend to respond more with cool problem-focused coping,
others with emotion-focused coping (Connor-Smith & Flachsbart, 2007). We tend to use
problem-focused strategies when we feel a sense of control over a situation and think we can
change the circumstances or change ourselves. We turn to emotion-focused strategies when we
cannot—or believe we cannot—change a situation. Emotion-focused strategies can be non-
adaptive. However, sometimes a problem-focused strategy (catching up with the reading) more
effectively reduces stress and promotes long-term health and satisfaction.
Optimism and Health
Another influence on our ability to cope with stress is whether our basic outlook is optimistic or
pessimistic. Psychologists Michael Scheier and Charles Carver (1992) have reported that
optimists—people who agree with statements such as, "In uncertain times, I usually expect the
best"—perceive more control, cope better with stressful events, and enjoy better health.
During the last month of a semester, students previously identified as optimistic report less
fatigue and fewer coughs, aches, and pains. And during the stressful first few weeks of law
school, those who are optimistic ("It's unlikely that I will fail") enjoy better moods and
stronger infection-thwarting immune systems (Segerstrom et al., 1998). Optimists also
respond to stress with smaller increases in blood pressure, and they recover more quickly from
heart bypass surgery.

Those who manage to find humor in life's daily events also seem to benefit. Among 54,000
adult Norwegians, those scoring in the top quarter on humor appreciation were 35 percent
more likely to be alive 7 years later, and the difference was even greater within a cancer -
patient subgroup (Svebak et al., 2007). There is not yet enough consistent evidence to
suggest that "laughter is the best medicine" (Martin, 2001, 2002). But some studies
suggest that mirthful humor (not hostile sarcasm) may defuse stress and strengthen
immune activity (Berk et al., 2001; Kimata, 2001). People who laugh a lot (which arouses,
massages muscles, and relaxes the body [Robinson, 1983]) also have exhibited a lower
incidence of heart disease (Clark et al., 2001).
Social Support
Social support also matters. That's what James Coan and his colleagues (2006) dis covered
when they subjected happily married women to the threat of electric shock to an ankle while
lying in an MRI machine. During the experiment, some of the women held their
husband's hand. Others held the hand of an anonymous person or no hand at all. While
awaiting the occasional shocks, the women's brains were less active in threat-responsive
areas if they held their husband's hand. This soothing benefit was greatest for those
reporting the highest-quality marriages.
Seven massive investigations, each following thousands of people for several years, revealed
that close relationships predict health. Compared with those having few social ties, people are
less likely to die prematurely if supported by close relationships with friends, family, fellow
workers, members of a faith community, or other support groups (Cohen, 1988; House et al.,
1988; Nelson, 1988).
Carefully controlled studies indicate that married people live longer, healthier lives than the
unmarried (Kaplan & Kronick, 2006; Wilson & Oswald, 2002). The Na tional Center for
Health Statistics (2004) reports that regardless of people's age, sex, race, and income, they
tend to be healthier if married.
How can we explain this link between social support and health? Is it because healthy
people are more supportive and marriage-prone? But people with supportive friends and
marriage partners eat better, exercise more, sleep better, and smoke less, and therefore cope
with stress more effectively (Helgeson et al., 1998). Supportive friends can also help buffer
immediate threats. Humans aren't the only source of stress-buffering comfort. After stressful
events, Medicare patients who have a dog or other companionable pet are less likely to visit
their doctor (Siegel, 1990).
More than 50 studies further reveal that social support calms the cardiovascular system,
lowering blood pressure and stress hormones (Graham et al., 2006; Uchino et al., 1996,
1999).
Close relationships give us an opportunity to confide painful feelings, a social support
component that has now been extensively studied (Frattaroli, 2006). In one study, health
psychologists James Pennebaker and Robin O'Heeron (1984) contacted the surviving
spouses of people who had committed suicide or died in car accidents. Those who bore their
grief alone had more health problems than those who could express it openly. Talking about
our troubles can be "open heart therapy."
Suppressing emotions can be detrimental to physical health. Another study, of 437
Australian ambulance drivers, confirmed the ill effects of suppressing one's emotions after
witnessing traumas (Wastell, 2002).
Even writing about personal traumas in a diary can help (Burton & King, 2008; Hemenover,
2003; Lyubomirsky et al., 2006). In one experiment, volunteers who did this had fewer
health problems during the ensuing four to six months (Pennebaker, 1990). As one
participant explained, "Although I have not talked with anyone about what I wrote, I was
finally able to deal with it, work through the pain instead of trying to block it out. Now it
doesn't hurt to think about it."
Talking about a stressful event can temporarily arouse people, but in the long run it calms them,
by calming limbic system activity (Lieberman et al., 2007; Mendolia & Kleck, 1993).
Managing Stress
What tactics can we use to manage stress and reduce stress-related ailments?
Having a sense of control, developing more optimistic thinking, and building social support
can help us experience less stress and thus improve our health. Moreover, these factors
interrelate: People who are upbeat about themselves and their future tend also to enjoy
health-promoting social ties (Stinson et al., 2008). But sometimes we cannot alleviate stress
and simply need to manage our stress. Aerobic exercise, biofeedback, relaxation,
meditation, and spirituality may help us gather inner strength and lessen stress effects.
Aerobic Exercise.
Aerobic exercise is sustained exercise that increases heart and lung fitness. Jogging, swimming,
and biking are common examples. Such exercise strengthens the body. Does it also boost the
spirit?

Exercise and Mood. Many studies suggest that aerobic exercise can reduce stress, depression,
and anxiety. For example, 3 in 10 American and Canadian people, and 2 in 10 British people
who do aerobic exercise at least three times a week also manage stressful events better,
exhibit more self-confidence, feel more vigor, and feel depressed and fatigued less often
than those who exercise less (McMurray, 2004). In a Gallup survey, nonexercisers were twice
as likely as exercisers to report being "not too happy" (Brooks, 2002). But if we state this
observation the other way around—that stressed and depressed people exercise less—cause and
effect become unclear.
Other studies confirm that exercise reduces depression and anxiety and is there fore a useful
adjunct to antidepressant drugs and psychotherapy . Not only is exercise about as
effective as drugs, some research suggests it better prevents symptom recurrence (Babyak et
al., 2000; Salmon, 2001).
Researchers are now wondering why aerobic exercise alleviates negative emotions. Exercise orders
up mood-boosting chemicals from our body's internal pharmacy (Jacobs, 1994; Salmon, 2001).
Perhaps the emotional benefits of exercise are also a side effect of increased warmth and body
arousal (counteracting depression's low arousal state), or of the muscle relaxation and sounder
sleep that occur afterward. Or perhaps a sense of accomplishment and an improved physique
enhance one's emotional state.
Exercise and Health Other research reveals that exercise not only boosts our mood, but also
strengthens the heart, increases blood flow, keeps blood vessels open, and lowers both blood
pressure and the blood pressure reaction to stress (Ford, 2002; Manson, 2002). Compared with
inactive adults, people who exercise suffer half as many heart attacks (Powell et al., 1987).
Biofeedback, Relaxation, and Meditation
Knowing the damaging effects of stress, could we train people to counteract stress, bringing their
heart rate and blood pressure under conscious control?
Miller was experimenting with biofeedback, a system of recording, amplifying, and feeding
back information about subtle physiological responses. Biofeedback instruments mirror the results
of a person's own efforts, thereby allowing the person to learn techniques for controlling a
particular physiological response.
After a decade of study, however, researchers decided the initial claims for biofeed back were
overblown and oversold (Miller, 1985). A 1995 National Institutes of Health panel declared
that biofeedback works best on tension headaches.
The years of rigorous testing and research on biofeedback exemplify the scientific attitude
toward new but unproven health care treatment (For more on this topic, see Thinking
Critically About Complementary and Alternative Medicine on the next page).
Simple methods of relaxation, which require no expensive equipment, can produce many of the
same results biofeedback once promised. For example, dozens of studies have found that
relaxation procedures can help alleviate headaches, hypertension, anxiety, and insomnia
(Nestoriuc et al., 2008; Stetter & Kupper, 2002). Such findings would not surprise Meyer
Friedman and his colleagues. To find out whether teaching Type A heart attack victims to
relax might reduce their risk of another attack, the researchers randomly assigned hundreds of
middle-aged, male heart-attack survivors to one of two groups.
Cardiologist Herbert Benson (1996) became intrigued with meditative relaxation when he
found that experienced meditators could decrease their blood pressure, heart rate, and
oxygen consumption and raise their fingertip temperature. His study led him to what he calls
the relaxation response, described in the Close-Up box above.
Psychologist Richard Davidson reports that Buddhist monks who are experienced in meditation
display elevated levels of the left frontal lobe activity associated with positive emotions. To
explore whether such activity is a result of meditation, Davidson and his colleagues (2003) ran
baseline brain scans of volunteers who were not experienced meditators, and then randomly
assigned them either to a control group or to an eight-week course in "mindfulness meditation."
Compared with both the control group and their own baseline, the meditation participants
exhibited noticeably more left-hemisphere activity, and also improved immune functioning after
the training. Such effects may help explain the astonishing results of a study that randomly
assigned 73 residents of homes for the elderly either to daily meditation or to none. After three
years, one-fourth of the non-meditators had died, but all the meditators were still alive
(Alexander et al., 1989). A more recent study found that hypertension patients assigned to
meditation training had (compared with other treatment groups) a 30 percent lower
cardiovascular death rate over the ensuing 19-year study period (Schneider et al., 2005).