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2 Stress, Trauma, and Related Disorders

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Learning Objectives

After reading this chapter, you should be able to:

• Define stress and explain where it comes from.

• Discuss both the physical and psychological sources of stress.

• Analyze the direct and indirect ways stressors affect both psychological and physical health.

• Understand the causes and treatment modalities for posttraumatic stress disorder.

• Understand acute distress disorder.

• Explain the interplay between physical and psychological illnesses.

• Explain why some people are more prone to suffer from the effects of stress than others.

• Explain methods that can be used to help people better cope with stress.

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Section 2.1 Stress: Origins, Definitions, and Theories

2.1 Stress: Origins, Definitions, and Theories The word stress is used widely in both psychological writing and the popular press, so widely in fact that its meaning is not always clear. Stress is used to refer to both a cause (a “stressful” job, for example) and an effect (“I am feeling stressed”). Our understanding of what stress is and how it affects us has changed and evolved throughout history. This chapter examines the concept of stress from the historical, biological, social, and psychological perspectives.

Origins: 460 BCE–1600s Hippocrates often referred to the effects of the emotions on health. For example, the ancient Greek teachers advised doctors to maintain a calm demeanor lest their patients become frightened. Showing fear, they believed, would exacerbate a patient’s symptoms. Aristotle added anger as another emotion that, like fear, could cause illness. For centuries, doctors continued to believe in a causative link between strong negative emotions and illness, but this connection was broken in the Renaissance by the European philosopher Rene Descartes, who argued that the body and the esprit (French for “soul” or “mind”) were separate entities that communicated through the pineal gland found at the base of the brain. This philosophical position has come to be known as Cartesian dualism.

Later Years: 1800s–1900s The classical view began to reemerge in the middle of the 19th century when doctors first began to observe an illness called neurasthenia (“nerve weakness”; Paciaroni & Bogousslavsky, 2014). The symptoms of neurasthenia included fatigue, aches and pains, sore throat, and low-grade fever. No physiological cause for neurasthenia was uncovered; it was blamed on hard work, striving for success, and changing sex roles. Neurasthenia is important, however, because its attribution to psychosocial causes provided the groundwork for Sigmund Freud’s claim that the physical symptoms of hysteria were the bodily manifestations of emotional traumas experienced in early childhood.

According to Freud, childhood emotional traumas leave a residue of psychic energy that can be “converted” into physical symptoms. Indeed, followers of Freud often referred to hysteria manifested by physical symptoms as conversion hysteria. Note that hysterical symptoms often mimic those associated with physical disorders (such as blindness, deafness, and paral- ysis), but Freud did not consider hysterical patients to be physically sick (although prominent neurologists such as Charcot disagreed).

Psychosomatic Medicine The field that came to be known as psychosomatic medicine received a considerable boost in scientific respectability from the work of the Harvard physiologist Walter Cannon. Accord- ing to Cannon (1939), organisms (people) faced with a threatening stimulus mobilize their

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Section 2.1 Stress: Origins, Definitions, and Theories

physiological resources to combat or escape the threat (“fight or flight”). Cannon called the physi- ological response to threat the emergency reac- tion (or alarm reaction) and showed that it is con- trolled by the sympathetic nervous system (see Figure 2.1) and by hormones secreted mainly by the adrenal glands. Once the person has safely escaped or defeated the cause of the threat, the emergency reaction dissipates. However, if the threat persists, the emergency reaction may begin to affect a per- son’s health.

General Adaptation Syndrome The emergency reaction described by Cannon is the body’s way of coping with immediate threats. However, the emergency reaction cannot persist indefinitely. Long-term or frequently recurring threats cause the body to gradually wear out. Dete- rioration takes place in a series of stages described by the medical physiologist Hans Selye as the gen- eral adaptation syndrome, or GAS (Selye, 1950). According to Selye (1950), stress is the body’s non- specific response to any demand made upon it. Not everyone reacts the same to stressful events, of course. For a student who receives weekly allergy shots, getting a more painful cortisone injection into a finger might not cause them a lot of stress. But to someone who has a fear of injections, the possibility of getting a painful injection could cause extreme stress, perhaps even an avoidance response.

The general adaptation syndrome occurs in three stages: alarm, resistance, and exhaustion (Selye, 1950). The three stages are associated with biological markers such as changes in hormone patterns, the production of more stress hormones, and the gradual depletion of the body’s energy resources. GAS begins with a stressor that produces an emergency reaction. Following the emergency reaction, the person enters what is known as a resistance stage. If the emergency reaction can be described as the mobilization of the body’s defenses, then the resistance stage is similar to all-out war. During the resistance stage, the person uses his or her physiological resources to minimize tissue damage. At the same time, the adrenal glands release corticosteroids (“stress hormones”), which further increase blood sugar for energy while reducing inflammation and pain. Body functions that are not directly related to avoiding harm (reproduction, digestion, growth) are gradually shut down. This only works for a time, however. If the threat persists, the body’s defenses become progressively depleted. In the final stage, called exhaustion, illness becomes likely. Selye’s view of GAS is depicted in Figure 2.1.

Bettmann/Getty Images According to Walter Cannon, individu- als undergo a physiological response when faced with a threatening stimulus and use these physiologi- cal resources to combat or escape the threat. Cannon called the physiological response the emergency reaction or alarm reaction.

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Section 2.1 Stress: Origins, Definitions, and Theories

Figure 2.1: Selye’s general adaptation syndrome (GAS)

Long-term or frequently recurring threats will eventually cause the body to wear out. Selye’s general adaptation syndrome, or GAS, describes these steps. This model begins with the alarm stage, which is a short-term, immediate response to a crisis through sympathetic system activation and epinephrine release and is often called “fight-or-flight.” In the resistance stage, long-term metabolic adjustments occur. Next is the exhaustion stage, which includes the collapse of vital systems. These three stages gradually lead to death.

Causes may include:

Exhaustion of lipid reserves

Inability to produce glucocorticoids

Cumulative damage to vital organs

Alarm phase Sympathetic system activation and epinephrine release:

1. Mobilization of glucose reserves

2. Changes in circulation

3. Increases in heart and respiratory rates

4. Increased energy use by all cells

“Fight or flight”

Immediate, short-term response to crisis

Resistance phase 1. Mobilization of remaining energy reserves Adipose tissue releases lipids Skeletal muscles release amino acids

2. Elevation of blood glucose concentrations. Liver synthesizes glucose from amino acids and lipids.

3. Conservation of glucose. Peripheral tissues break down lipids to obtain energy

Long-term metabolic adjustments occur

Exhaustion phase

Collapse of vital systems

Death

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Section 2.2 Sources of Stress

Any form of external pressure can trigger GAS. People who have particularly demanding jobs (such as the U.S. president, emergency department doctors, or emergency medical techni- cians) may experience the first stages of GAS every day. We can cope with moderate levels of stress, but extreme stress causes us to break down and become ill (Alevizos, Karagkouni, Panagiotidou, Vasiadi, & Theoharides, 2014). For example, stress can bring about and worsen conditions such as asthma and atopic dermatitis, and may bring about coronary inflamma- tion and worsen allergies (Alevizos et al., 2014).

What Constitutes a Stressor? Selye preferred to use the word stressor to refer to causes, reserving the word stress for the results produced by a stressor. Over the years, the boundaries of what constitutes a stressor have been extended gradually. Stressors have come to include not only physical threats, but also emotional experiences (divorce, for example), unpleasant internal states (fatigue), and the subjective feeling of being under pressure. With such a broad definition, practically any- thing can be a stressor, but all stressors are related in one very important way—they have the potential to trigger a strong emotion leading to GAS.

Selye believed that the effects of stress are nonspecific. The same physiological response can lead to widely different conditions. To explain why people develop different illnesses in response to stress, Selye postulated that genetic weaknesses, inadequate diet, infections, and other individual differences mediate the effects of stress. The specific mechanisms by which stress interacts with these mediating factors to produce illness are discussed next.

2.2 Sources of Stress To summarize our discussion of stress so far, stress and physical illness go together. This is true not just for traditional psychosomatic conditions such as peptic ulcer but also for meta- bolic conditions such as diabetes. In addition, catastrophes, important life events, and every- day hassles can also cause significant stress. This section will cover these latter sources of stress first, and then look at health issues, using diabetes to illustrate how stress affects physi- cal health as well as mental health.

Catastrophes When asked to imagine the psychological and social causes of stress, most people immedi- ately think of large-scale cataclysmic events: floods, earthquakes, airplane accidents. A cata- clysmic event is dreaded more than a common disease that affects one person at a time, even when the common disease kills more people. This excessive fear of horrific events seems to have negative effects on health. One reason for the extreme stress produced by cataclysmic events is their unpredictability. Most of us go through life with optimistic attitudes. We act as if disasters happen only to others. When we are asked about the probability of having a car accident, going bankrupt, or dying young, most of us rate our luck as better than average (Trumbo, Meyes, Marlatt, Peek, & Morrissey, 2014). This concept is called comparative opti- mism, or optimistic bias: the belief that we are less likely than other people to be harmed by

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Section 2.2 Sources of Stress

bad events. We seem to share an illusion of invulnerability (“Bad things won’t happen to me”). Catastrophes (momentous tragic events that can range from a moment of very bad luck to a moment where the per- son’s life or livelihood is ruined or ended) shatter this protective illusion; they show us how tenuous our good luck really is. This is why catastrophes frighten us more than more common killers such as diabetes. It is also why horrific experiences that threaten people’s lives may produce symptoms long after the original event (see the discussion of posttraumatic stress disorder [PTSD] later in this chapter).

Important Life Events Most stressors are fairly common—job loss, bereavement, divorce. These types of negative life events can lead to what the DSM–5 calls adjustment disorders, psychological disorders marked by anxiety, depression, withdrawal, and overall impairments in psychological func- tioning (American Psychiatric Association [APA], 2013). These common life events also have the power to make people physically ill, or perhaps even lead to death. Interestingly, posi- tive life events, such as getting married, having a child, or getting a new job that you always dreamed about, can also be considered stressors.

One of the first researchers to study the relationship between life events and illness in a sys- tematic way was the psychiatrist Adolf Meyer (1866–1950), an early adherent of Freud. To study the effects of stress, Meyer devised the “life-chart” technique. He would draw a time line (a graph of dates) with a person’s illnesses on one side and significant life events on the other. Meyer claimed that illnesses often appeared just after significant life changes (especially job loss and separation).

Over the years, considerable evidence has been amassed to support Meyer’s claim. For exam- ple, long-term unemployment has been found to be related to various illnesses, including heart disease, cirrhosis of the liver (probably from overuse of alcohol), hypertension, various psychiatric conditions, and suicide (Brand, 2015). Unemployment reduces self-esteem and makes people dependent on others (Brand, 2015).

Meyer’s work influenced Thomas Holmes, a medical doctor who became interested in the relationship between life events and illness (Holmes & Rahe, 1967). Holmes routinely asked patients about their personal experiences before they had become ill. Like Meyer, he found a relationship between life changes and illness. By studying medical charts, Holmes produced a list of life events that seemed most often to precede illness. Holmes assumed that any life change, positive or negative, could produce stress if it required an adjustment in the way a person had previously lived.

AP Photo/Stuart Ramson The possibility of horrific events engenders immense stress or fear in many people, largely due to their unpredictability.

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Section 2.2 Sources of Stress

Following Holmes, scientists have repeatedly demonstrated the role of stressful life events in various physical and mental illnesses (Ezeamama et al., 2016). Despite these findings, the relationship between life-stress and illness should be interpreted with caution. When stress- ors such as traumas and chronic negative events are measured, their impacts on physical and mental health are substantial (Ezeamama et al., 2016). Moreover, even strong correlations cannot be taken as evidence that life-stress causes illness. They could just as easily mean that illness causes life-stress.

Everyday Hassles The average day is full of hassles. Daily annoyances plague all of us: spending time in rush-hour traffic, waiting at the bank, dealing with noisy neighbors, getting caught in the rain or snow, losing house keys. If we are lucky, we also have positive experiences: visiting with friends, performing well at school or at work, dining out.

Daily hassles can take their toll. For exam- ple, busy urban white-collar workers, who are exposed to many more daily annoyances than their rural counterparts, are consider- ably more likely to suffer from headaches, peptic ulcers, and hypertension (De Brou- wer et al., 2014). The inflammation that causes so much pain to arthritis sufferers is exacerbated by daily hassles (De Brouwer et al., 2014). Pregnant women whose lives are full of hassles are more likely to have premature and low-birth-weight babies than are women with more relaxed personal lives (Bussières et al., 2015). Studies of those with diabetes have shown mixed results, with both positive and negative associations, due to differences in the studies’ designs and methodologies (Joseph & Golden, 2017). Other researchers have found positive associations between diabetes and stress (Smith et al., 2013).

Chronic Illness A chronic illness such as diabetes may itself be a significant source of stress (Franks, Lucas, Parris-Stephens, Rook, & Gonzalez, 2010). For those with diabetes, frequent absences from class or work and concern about future diabetes-related medical conditions are facts of life. Additionally, those with insulin-dependent diabetes need to be diligent about watching their sugar intake, monitoring their blood sugar levels, and adjusting their insulin dosages. When one adds all of these concerns to a perhaps already too busy life, stress can result.

Raquel Carbonell/age fotostock/SuperStock Everyday hassles, like crowded intersections and rush-hour traffic, can take their toll on the human body. Urban workers are more likely to experience hypertension, peptic ulcers, and headaches, whereas rural inhabitants are less likely to suffer from these ailments.

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Section 2.2 Sources of Stress

Chronic Pain and Headaches Although pain is not itself an illness, it has the capacity to affect every aspect of our lives. The acute pain that accompanies a toothache or an illness or injury can keep us from thinking about anything else. This type of severe pain can affect immune system functioning (Hatfield & Umberger, 2015). Fortunately, healing usually ensures that acute pain will subside over time. In contrast, chronic pain persists indefinitely. Often, this type of pain leads to depression (Zhu, Galatzer-Levy, & Bonanno, 2013). But not all studies see as strong a connection between chronic pain and unipolar depression (Rayner et al., 2016). This discrepancy demonstrates that research on some concepts has inconsistent conclusions. You will see this again in later chapters.

More than 25% of Americans are estimated to suffer from some form of chronic pain, with current estimates ranging from 30% to 40% of the U.S. adult population (Gatchel, McGreary, McGreary, & Lippe, 2014). Americans spent about $2.6 billion on over-the-counter pain medi- cations and another nearly $14 billion on outpatient analgesics in 2004 (Kingsbury, 2008). More recent data show that the annual cost of chronic pain in the United States is between $560 and $635 billion (Gatchel et al., 2014).

Although chronic pain often has a physiological trigger, it may be exacerbated by stress. In severe cases, chronic pain may even be considered a psychological disorder. For example, the DSM–IV–TR (APA, 2000) contained diagnostic criteria for pain disorder. The criteria for this disorder included severe pain that is not feigned and that causes distress or impairment in social, occupational, or other areas of functioning. Most important are the onset, severity, exacerbation, or maintenance of the pain. The validity of the pain disorder diagnosis was a controversial subject. Some authors claimed that it was too inclusive and might lead to over- diagnosis (Fishbain, 1996). Because of the controversy, pain disorder was removed from the DSM–5 and was replaced with somatic symptom disorder, with predominant pain (APA, 2013). Regardless, all observers agree that pain is worsened by stress.

We also know that individuals may react very differently to the same level of pain: Some may continue work and social activities; others may drop out of life completely (Jensen, Schmidt, Pedersen, & Dahl, 1991). Those who cope well are optimistic, have good support networks,

and feel in control of their lives (Hanssen, Vancleef, Vlaeyen, & Peters, 2014). These characteristics also describe people who are resistant to stress.

Approximately 42% of the world’s adult popula- tion experiences headaches each year (Ferrante et al., 2013; Palacois-Cena et al., 2017). Over the years, complicated classification systems have been developed to characterize different types of head- aches, but the two most common are tension and migraine. Tension headaches were traditionally thought to result from tense muscles in the neck and head, whereas migraines are thought to be caused by the contraction and dilation of blood ves- sels in the head. Migraines are more severe than tension headaches, often requiring a day or more to

Christopher Robbins/DigitalVision/Thinkstock Around 42% of the world’s adult population suffers from headaches each year.

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Section 2.3 Effects of Stress

resolve. Some research suggests that the differences between the two types of headaches are not so clear-cut; both types of headaches seem to be associated with the same physiological phenomena (Waldie, Buckley, Bull, & Poulton, 2015). Therefore, it is possible that migraines and tension headaches have similar causes but that migraines represent a more severe form of headache.

Psychological variables moderate pain in two ways: through inhibition of pain impulses and by the production of chemicals called endogenous opioids (endorphins). In its simplest form, psychological inhibition can be construed as shutting the “gate” that allows pain stimuli to be transmitted to the brain (Melzack & Wall, 1982). According to the gate control theory, pain stimuli are transmitted to the brain via the dorsal horns of the spinal column, which serve as a kind of gate. Pain stimuli open the gate, but inhibitory signals sent by the brain can close the gate and keep pain stimuli from reaching the brain. This seems to be what happens when soldiers are injured in battle; some do not feel any pain until after the battle is over (Melzack & Wall, 1982). Endorphins are chemicals produced by the body that, like opiates (heroin, for instance), can serve to reduce pain. Some evidence indicates that people who cope well with their pain produce higher levels of endorphins than do those who fail to cope (Bandura, O’Leary, Taylor, Gauthier, & Gossard, 1987). It seems possible that, in addition to the endor- phins, we may also have specialized chemical pain-reduction systems (Chapman, Tuckett, & Song, 2008).

2.3 Effects of Stress To understand the complex web of interactions between external stressors and the stress produced by chronic illness, we need to take a closer look at the precise mechanisms by which stress exerts its effects on physical and psychological health. Specifically, we will examine two ways in which stress affects health: (a) the direct effects of stress on physiological functioning and (b) the indirect effects of stress on health-relevant behaviors.

Direct Physiological Effects of Stress As we have seen in the discussion of the general adaptation syndrome, stress has direct effects on physiological functioning. As shown in Figure 2.2, stress causes the release of certain hor- mones, which increases the rate of blood clotting, raises respiration and blood pressure, and prepares the body for exertion.

The direct effects of stress on physiological functioning have also been implicated in cardiac arrest (heart attack) and stroke (when brain damage results from ruptured or blocked blood vessels). According to Sapolsky (1992), the corticosteroid hormones produced by GAS have both beneficial and harmful effects. They reduce inflammation and inhibit pain, but they may also weaken neurons, especially in the hippocampus. In the short term, the body produces special proteins to protect neurons and other cells from hormone damage, but their effective- ness weakens with prolonged or repeated stress (Marcuccilli & Miller, 1994). Once the hippo- campus has been weakened, it can no longer play its moderating role, and the stress response becomes difficult to “turn off.”

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Section 2.3 Effects of Stress

Indirect Effects of Stress on Health

Effects of Stress on Cognition Stress exerts profound effects on memory, judgment, and other aspects of cognition (Vogel, Fernández, Joëls, & Schwabe, 2016). Studies of airline pilots, for example, have shown that as they become increasingly stressed, they become less alert. They have attention lapses and become easily distracted. Stress does seem to be a factor for pilot burnout (Yang, Zhao, Wu, & Lu, 2014).

The effects of stress are insidious because they are not immediately apparent to the indi- vidual concerned. Even when they were slow to respond to their instrument readings, pilots believed they were as efficient as they were when not under stress.

Figure 2.2: Corticosteroid release in response to stress

When the brain perceives a stressor, the hypothalamus releases CRF (corticotropin releasing factor) and other hormones. The CRF triggers the release of ACTH (adrenocorticotropic hormone, or corticotrophin) in the anterior pituitary. The ACTH travels in the bloodstream to the adrenal glands, where it triggers the release of corticosteroids.

Source: Robert Sapolsky, Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress Related Diseases, and Coping. San Francisco: W.H. Freeman, 1998, p. 33. Reprinted by permission.

Hypothalamus

CRF Posterior pituitary

Anterior pituitary

Glucocorticoids (corticosteroids)

ACTH

Adrenal gland

Kidney

Stressor

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Section 2.3 Effects of Stress

However, stress tends to affect information-processing capacity in complex ways (Critten- den & Heller, 2017). Stress does not always lead to poor decision making. Moderate amounts of anxiety (such as that produced by an upcoming performance, for example) may actually serve to focus attention on essential information. However, high levels of stress can shrink information-processing capacity to the point where important information is ignored. Studies of airline pilots have found them more likely to read their instruments incorrectly when flying in bad weather. Presumably, this is because coping with a storm produces stress (Broadbent, 1973). Perhaps this a more relevant analogy: When a student procrastinates and waits until the last minute to complete a 10-page paper, the closer the student gets to the deadline, the more stress is induced, which makes it more likely the student will leave out the main points required for a good paper.

The Stress-Illness Cycle As already noted, illness can be a source of stress. It can interfere with cognitive and emo- tional functioning and exacerbate the effect of external stressors. Illness can also produce stress through its effects on social functioning. Some illnesses produce stress because they are perceived as a sign of weakness. For example, people with liver disease resulting from the overuse of alcohol and people with AIDS resulting from intravenous drug use are often stig- matized and shunned because their illness is perceived as self-inflicted (Weiner, 1993), and this stigmatization can cause stress.

Clinical psychologists need to be sensitive to the many ways in which physical, social, and psy- chological factors interact. Helping people requires that we somehow prevent the tendency for stress and illness to feed off one another. However, before we examine how this might be accomplished, we need first to examine why some people seem better able to withstand stress than others. Specifically, we need to understand differences in coping skills.

Let’s examine the case study of William Cole.

The Case of William Cole: Part 1

University Hospital Psychology Service

CONFIDENTIAL

Consultation Note

Psychologist: Dr. Stewart Berg

Referral: Dr. M. Jankowitz

Reason for Referral: The client was brought to the Emergency Room in a diabetic coma. He responded well to medical treatment, but he seemed withdrawn and complained of chronic headaches. Dr. Jankowitz requested advice about the patient’s state of mind and about the potential for his mental state to affect his illness.

(continued)

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

Stress can have a profound psychological effect on the individual, as we will see in the next section, in which we examine posttraumatic stress disorder (PTSD).

2.4 Posttraumatic Stress Disorder (PTSD) Posttraumatic stress disorder (PTSD) existed long before the Vietnam War, but it had not been formally identified as a diagnosable condition. PTSD was previously known as “shell shock,” initially identified by Myers (1915), or “battle fatigue.” In 1980, the newly published DSM–III gave the disorder a name. PTSD was defined as an extreme anxiety response to trau- matic, life-threatening events that were “outside the range of normal human experience.” By

The Case of William Cole: Part 1 (continued)

Behavioral Observations: William Cole is an 18-year-old African American male. He is of average height but rather thin. He was neatly dressed and clean shaven. He entered my office slowly and hesitantly. Although he cooperated by answering questions, he volunteered little and seemed withdrawn. He avoided making eye contact, and his facial expression was tense. He frequently held his forehead in his hand.

History: William is a first-year student and the first member of his family to attend college. He is assisted by a student loan and has a job working in the library. His father works in an automobile factory, and his mother is a telephone company employee. They live in Los Angeles and see their son on holidays. He calls home every Sunday.

William reports being an athletic child with a close group of same-sex friends. He first learned that he had diabetes at age 13. His mother took him to the family doctor because he was always tired and thirsty and he urinated frequently. A blood test at the time confirmed the diagnosis. William’s illness could not be controlled by diet. He required daily insulin injections. At first, William would not believe he was sick and resisted treatment. He continued to “hang out” with his friends and to play football and baseball. Eventually, however, he says he “accepted” his illness.

William reports that his mother became his nurse. She made sure that he followed a proper diet, checked his urine for sugar (several times each day), and administered his injections. She posted a chart of glucose test results on the bathroom door. William gradually lost contact with his friends. He says this was because his mother urged him to avoid sports or any other activity where he could get physically hurt.

A combination of diet and insulin kept William’s condition stable for 5 years. The only exceptional incident occurred toward the end of his junior year in high school. He was preparing for his examinations and was feeling left out because he did not have a date for the junior prom. He felt weak but kept going to school. He fainted in class and, although he quickly revived, was taken to the hospital, where he spent one day.

Since William entered college, he has had no serious diabetic episodes until the current one, although he has had trouble sleeping and has experienced loss of appetite. He claims not to have told any of the other students of his illness.

See appendix for full case study.

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

giving Vietnam veterans’ symptoms a name, and by making PTSD a recognized mental condition, the DSM–III legitimized the claims for help from veter- ans (and others who experience extreme trauma).

The main symptoms of PTSD are anxiety, the avoidance of stimuli associated with the trauma, flashbacks in which the traumatic event is relived mentally, and a “numbing” of emotional responses (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). Additional symptoms include hyperarousal such as sleep disturbance, increased irritability, and hyper- vigilance. You might also see negative beliefs and expectations about oneself, persistent distorted blame on oneself or others, and feelings of detach- ment and constricted affect (APA, 2013; Sareen, 2014). Not surprisingly, PTSD has been found to affect practically every aspect of everyday life and is among the disorders most strongly associated with suicidal behavior, including attempts (Sareen, 2014). People with PTSD also typically have interpersonal, relationship, and parenting struggles, and a reduction in house- hold income as they have difficulty maintaining a job or perhaps even going to work (Sareen, 2014).

PTSD is not limited to veterans who survive a war. PTSD also affects victims of violence, espe- cially rape (Sareen, 2014), as well as those who witness acts of extreme violence such as the September 11, 2001 terror attacks on the World Trade Center in New York City and most likely those who witnessed the Las Vegas shooting in October 2017. Recognizing that the symptoms of PTSD appear differently in children younger than 6 years old, the DSM–5 includes a sepa- rate subcategory: posttraumatic stress disorder for children 6 years and younger (APA, 2013). Within the subcategory posttraumatic stress disorder, notes within specific criteria differenti- ate how children older than age 6 might manifest symptoms. For example, a child’s dreams may be frightening, but the content of the dreams might be unrecognizable (APA, 2013). Chil- dren who have been abused, for example, often exhibit behavioral changes (an outgoing child may become reclusive; a quiet child may start acting aggressively). Young children who have been toilet trained may go back to soiling themselves and bed-wetting. Left untreated, PTSD symptoms can last a lifetime (APA, 2013; Potts, 1994).

A summary checklist of major diagnostic criteria for PTSD, adapted from the DSM–5 (APA, 2013), appears below:

• The individual is exposed, directly or indirectly, to a threatening or traumatic event: death or threatened death, severe injury, sexual violence, and so on.

• Presence of one or more of the following intrusive symptoms: • Recurrent, involuntary distressing memories • Recurrent distressing dreams where the content(s) is/are related to the traumatic

event • Dissociative features such as flashbacks, where the individual feels as though the

trauma is reoccurring • Intense distress when exposed to cues related to the experienced trauma • Marked physiological reactions when reminded of the trauma(s)

Ingemar Edfalk/Blend Images/SuperStock Many soldiers are affected by posttrau- matic stress disorder long after the danger of combat is over.

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

• The person continually avoids trauma-like stimuli. • The person is unable to recall key features of the event(s). • The individual displays changes in arousal and reactivity, such as excessive alertness,

extreme startle responses, or sleep disturbances. • These symptoms and stress last at least one month.

The DSM–5 moved PTSD out of the chapter titled “Anxiety Disorders” and into the “Trauma and Stressor-Related Disorders” chapter. Although commonalities remain, this demonstrates that PTSD has unique features that separate it from anxiety disorders.

Etiology of PTSD Approximately 7.8% of the population has PTSD (Bisson et al., 2013). For someone to qualify for diagnosis, PTSD symptoms must be present for at least one month (most of the DSM–5 disorders require that symptoms be present at least six months). In addition, if the diagnostic criteria are not met until, minimally, six months after the event’s occurrence (though some symptoms may be present), the specifier “with delayed expression” is used (APA, 2013).

Unlike most psychological disorders, the etiology of PTSD is defined in its diagnostic crite- ria—it is caused by experiencing, either directly or indirectly, an extraordinarily stressful, traumatic event (see Figure 2.3). (Etiology refers to the study of the causes or origins of dis- ease, in this case mental illnesses.) The 9/11 attacks provide an excellent example. Direct exposure would refer to individuals who were at the Twin Towers when the planes struck or when the towers collapsed. Indirect exposure would refer to watching the second plane strike on television, or hearing or reading about the attacks.

Given a severe enough trauma, even well-adjusted people may develop PTSD (Clark, Watson, & Mineka, 1994). Yet, most people manage to escape even the most terrifying events with no signs of disorder (Bolton, Jordan, Lubin, Litz, & Gold, 2017). What protects such people? What makes others succumb? The usual answer to these questions is that some people are more vulnerable than others. They may have preexisting psychological disorders or a family history of psychological disorder, especially depressive disorders, anxiety disorders, and con- duct disorder (Sareen, 2014). Vulnerable people may inherit a disposition to develop PTSD (Andreasen, 1995; Koenen et al., 2003; True, Rice, Eisen, & Heath, 1993). There is evidence that people with PTSD have higher levels of stress hormones than others (Burijon, 2007), although the evidence is vague (Bachmann et al., 2005). Certainly, people who develop PTSD seem to have strong emotional reactions to life’s problems (Burijon, 2007).

We should not discount the important role played by a person’s social environment. Consider, for example, the finding that PTSD is more common among African American and Hispanic Vietnam War veterans than among white veterans, especially white officers. Does this mean that, compared with white officers, African American and Hispanic enlisted men are less able to respond to challenging situations, or more prone to ignore problems? Not necessarily. Forces outside the individual, such as poor social support, may also play an etiological role in PTSD (Sareen, 2014). Seeking treatment for post-combat-related issues often carries social stigma that may prevent an individual from obtaining the needed help.

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

Figure 2.3: Posttraumatic stress disorder

A model of the causes of PTSD.

Source: From “Posttrumatic Stress Disorder” by T. M. Keane & D. H. Barlow (2002), in Anxiety and Its Disorder: The Nature and Treatment of Anxiety and Panic, by D. H. Barlow, 2nd ed. New York: Guilford Press. Copyright © 2004 by Guilford Press. Reprinted by permission.

(or alternative intense basic emotions, such as anger, distress)

True alarm

(or strong, mixed emotions)

Learned alarm

Focused on reexperienced emotions

Anxious apprehension Avoidance or numbing of emotional response

Experience of trauma

Moderated by social support and ability to cope

Post-traumatic stress disorder

Generalized psychological vulnerability

Generalized biological vulnerability

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

Therapeutic Treatment for PTSD With the publication of the DSM–III (APA, 1980), mental health professionals began to devote increasing attention to PTSD. With increased research, it has been determined that early intervention is of paramount importance to make treatment success more likely. In therapy, trauma victims were encouraged to discuss their troubles in groups made up of victims of similar traumas. It is generally accepted that the social support provided by these groups is an important ingredient of successful therapy (Sareen, 2014). However, group discussions alone may not always be sufficient. Other therapeutic interventions may also be needed. The most common behavioral intervention is exposure (Koch & Haring, 2008). Victims are helped to confront their memories of the traumatic event so that their anxiety can be extin- guished. Flooding, cognitive restructuring (discussed in Chapter 3), desensitization, and stress- management training are also used to help clients overcome their anxiety and to teach them how to cope with anxiety-provoking situations that may arise in the future (Bisson et al., 2013).

Some research has reported successful treatment of PTSD using a technique called eye move- ment desensitization and reprocessing (EMDR), in which people are asked to visualize images of the traumatic event (Bisson et al., 2013). Once the images are clear, clients are required to follow the movements of the clinician’s finger (or a pencil) with their eyes while holding their head still. Because it is a relatively new type of intervention, the effectiveness of EMDR has been controversial, and early research results are inconclusive. Some researchers believe the exposure itself and not the eye movement may be responsible for the success with this treat- ment method (McGuire, Lee, & Drummond, 2014). A growing body of research aims to deter- mine the legitimacy and efficacy of this approach. Some research suggests that EMDR results in more rapid symptom reductions than other, comparable treatment modalities (McGuire et al., 2014).

Drug Treatment for PTSD The U.S. Food and Drug Administration has approved only two medications for PTSD treat- ment: the selective serotonin reuptake inhibitors (SSRIs) paroxetine (Paxil) and sertraline (Zoloft). They seem to help alleviate anxiety and panic attacks, making other PTSD symp- toms more manageable (Golier, Legge, & Yehuda, 2007). Antidepressants alone are not usu- ally effective in treating the insomnia and nightmares that often accompany PTSD. Options include using atypical antipsychotics such as risperidone (Risperdal), as well as zopiclone (Zimovane), a sedative-hypnotic (sleeping aid).

An experimental form of drug treatment involves using 3,4-methylenedioxymethamphet- amine, more commonly known as MDMA. This is not ecstasy or Molly, designer drugs sold on the street that contain MDMA as well as other, perhaps lethal, substances. The Multidisci- plinary Association for Psychedelic Studies (MAPS) is currently researching the use of MDMA with PTSD victims. Preliminary studies have shown that MDMA in conjunction with psy- chotherapy can help people overcome PTSD, and possibly other disorders as well. MDMA is known for increasing feelings of trust and compassion toward others, which could make it an ideal adjunct to psychotherapy for PTSD (MAPS, n.d.). The primary method of treating PTSD remains psychotherapy.

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Section 2.6 Illness of the Mind or the Body: A Dubious Distinction

Early Intervention and Prevention of PTSD The prevention of PTSD works best with early intervention. For soldiers, this means institut- ing treatment at the first sign of stress (Samter et al., 1993). Many victims of trauma never get treatment. For example, rape victims rarely seek psychological help in the period imme- diately following the rape. Of those who seek treatment at all, only between 19% to 39% seek treatment right away (Price, Davidson, Ruggiero, Acierno, & Resnick, 2014). They do not see themselves as psychologically disturbed but as victims of a crime that they would rather for- get. Unfortunately, sometimes the police, lawyers, and the press make sure that the attack is never far from the victim’s mind. Some victims may even find themselves being blamed for the attack. The stress can build up until it produces a stress disorder (Falsetti, Resnick, Dan- sky, Lydiard, & Kilpatrick, 1995). Police reactions often seem to influence how rape victims feel, possibly affecting the severity of PTSD, since arrest and sentencing of the perpetrator often do not occur (Venema, 2014). It is at this point that victims seek assistance.

2.5 Acute Stress Disorder The DSM–5 recognizes another disorder associated with trauma: acute stress disorder. Simi- lar to PTSD, this disorder occurs in response to traumas, but acute stress disorder is diag- nosed when the symptoms typically occur immediately after the trauma. The symptoms must last for at least three days and no longer than a month after the trauma to qualify for this diagnosis (APA, 2013). The symptoms of acute distress disorder are similar to those for PTSD: persistent reexperiencing of the trauma through flashbacks, intrusive thoughts, and night- mares. A person experiencing acute stress disorder may avoid reminders of the trauma and may feel numb or detached, or report feeling as if he or she is in a dreamlike state. Although it is a short-term response to trauma, people with acute distress disorder are at risk for con- tinuing to experience posttraumatic stress symptoms for many additional months.

2.6 Illness of the Mind or the Body: A Dubious Distinction Diabetes may not seem particularly relevant to abnormal psychology because it is a physical disease. Traditionally, abnormal psychologists have limited their interest in physical diseases to the so-called psychophysiological or psychosomatic disorders (psycho = mind, somatic = body)—disorders in which psychological factors produce “real” physical diseases, such as peptic ulcer, asthma, hypertension, and headaches. Psychosomatic conditions were thought to differ from other physical illnesses because psychological factors played a significant role in their etiology. Asthma, for example, was attributed to loss or separation, ulcers to stress- producing jobs, headaches to helplessness, and hypertension was supposedly the result of repressed anger. In recent years, it has become increasingly clear that this approach to physi- cal illness is too simplistic. For example, we now know that many peptic ulcers are the result of a bacterial infection that thrives on stress, which results in a physical condition (peptic ulcer). This is a perfect example of the diathesis-stress model of psychopathology discussed in Chapter 1.

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Section 2.6 Illness of the Mind or the Body: A Dubious Distinction

Because of the interplay between physiological and psychological factors, distinguishing between pure physical illnesses and those with psychological components is now widely rec- ognized as artificial and futile. Social and psychological factors affect all illnesses, from the common cold to cancer, from hernia to heart disease, from skin rashes to diabetes. Those studying behavioral medicine examine the interaction between psychology and physiology, seeking to learn how psychological factors (a) make people susceptible (or resistant) to ill- ness, (b) alter the course of an illness, (c) influence compliance with medical treatment, and (d) affect health-related behavior. Today’s serious illnesses tend more and more to be the result of behavioral choices—smoking, using drugs, and drinking alcohol to excess (Oyama & Andrasik, 1992). Understanding and preventing illness-causing behaviors such as smoking have the potential to do more to improve public health than building any number of new hos- pitals. The disciplines contributing to behavioral medicine are depicted in Figure 2.4.

Figure 2.4: Disciplines contributing to behavioral medicine

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 5.1, p. 196.

Biological sciences

(biochemistry, immunology)

Professional studies

(nursing, physical therapy)

Social sciences

(anthropology, sociology)

Psychological and

behavioral sciences

Medical sciences

(pathology, radiology)

Behavioral Medicine

Early versions of the DSM included a variety of “psychosomatic disorders.” These no longer appear in the DSM–5, which refers instead to “psychological factors affecting other medical conditions.” This diagnosis is applied when psychological factors appear to cause, exacer- bate, or delay recovery from a medical condition or when psychological factors interfere with

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Section 2.7 Factors That Modify the Effects of Stress

treatment. The DSM–5 also acknowledges that causality can go both ways. In other words, medical conditions can produce or exacerbate psychological problems.

The DSM–5 includes several diagnoses that recognize the interaction between psychologi- cal variables and physical illness (for example, “sexual dysfunction due to a general medical condition”). However, these diagnoses hardly do justice to the complex interactions that take place between psychological factors and health.

Psychological interventions, such as the provision of social support, are often aimed at help- ing clients to comply with their treatment regimen, thereby limiting complications. Thus, interventions designed to address psychological factors such as social isolation not only have direct psychological effects but also help to reduce the severity of the physiological disease. Improved physical health, in turn, affects psychological well-being by reducing depression and social isolation. This is a typical pattern. Psychological and physiological variables inter- act continuously, with one set of variables affecting and being affected by the other. The aim of this chapter is to illustrate the role of psychology in understanding and treating psychological disorders as well as in fostering health. (See Part 2 of William Cole’s case in the appendix.)

2.7 Factors That Modify the Effects of Stress Coping means finding effective ways to adapt to the problems and difficulties presented by stress. In general, successful coping is marked by compliance with the treatment regimen, by acceptance of the limitations and challenges of the illness, and by attempting to lead as “normal” a life as possible. Unsuccessful coping is evidenced by poor treatment compliance, shame, and social isolation.

Poor compliance is not surprising in chronic conditions, especially those in which the treat- ment regimen is complicated. However, noncompliance also occurs when treatment is simple. For example, among women who have had breast cancer, fewer than half follow their doctors’ recommendations for simple breast self-examinations (Taylor et al., 1984). Because compli- ance is essential to long-term health, considerable research has been devoted to clarifying why patients fail to comply with the recommended treatment. This research has identified several important factors (for example, people comply better with clear instructions; warm doctor-patient relationships facilitate compliance), but the most important factor seems to be the way in which people appraise the stress produced by illness (Miller, Shoda, & Hurley, 1996). Some people deny being sick; others make a hobby out of it. Denial reduces compli- ance, whereas obsessive attention to one’s health increases compliance. In this section, we will see that treatment compliance depends on learning to cope with stress.

Appraisals The effects of a stressor depend to a large extent on how the stressor is perceived. Thus, the first step in coping is to appraise the stress-producing situation (Taylor & Aspinwall, 1996). The appraisal of life events results in emotional, physiological, and behavioral responses that interact with one another in complex ways to determine how people cope with illness (see Figure 2.5).

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Section 2.7 Factors That Modify the Effects of Stress

Figure 2.5: Life events

The effects of life events depend on how they are appraised.

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 5.9, p. 217.

Life events

Hassles

Catastrophies

Illness

Appraisal of event

Emotional responses

Physiological responses

Behavioral responses

According to Richard Lazarus (1993), there are two types of appraisal: primary and second- ary. In primary appraisal, the individual assesses the personal implications of an event. Events may be appraised as irrelevant, beneficial, or stress-inducing. Secondary appraisal is con- cerned with what, if anything, should be done. If an event is appraised as stress-inducing, the individual may then appraise the harm done and decide how to prevent a future recurrence. If the harm has not yet been done, appraisal may take the form of how to avoid or minimize harm. Appraisals often include a comparison of costs and benefits. Cognitive appraisals need not be so calculated or rational; they do not even have to be conscious. However, at some level, our response to stress is always based on our personal perception of external events.

Denial is a primitive form of coping, but it can sometimes be useful. If an illness is untreat- able, denying the facts may help the ill person make the most of what life remains. However, if a condition can be helped by a change in behavior, denial may make matters worse. A less extreme form of denial is to admit that one has an illness but to minimize its seriousness. Again, if treating life-threatening illnesses as minor annoyances allows a person to lead a fuller life than would otherwise be the case, a little denial is probably a good thing. However, if carried too far, denial can lead people to ignore the limitations imposed by illness—and possibly to take unwise health risks.

In contrast to those who minimize their illness, some people cope by becoming obsessed with their condition. They devote a lot of their energy to managing their disease. If their obsessiveness increases their quality of life, then it is a reasonable way of coping. However, if their extreme concern with their health causes other activities and relationships to suf- fer, then it is not a successful way of coping. Instead of controlling their illness, obsessive people may wind up achieving the opposite; they may find that their illness controls them. What is required is a happy medium between minimization and obsessive attention that pro- vides a balance between controlling illness and not letting it take over one’s life. Lazarus and his colleagues (Folkman & Lazarus, 1990; Lazarus, 1993) call denial and obsessiveness

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Section 2.7 Factors That Modify the Effects of Stress

emotion-focused coping. The goal of emotion-focused coping is to manage feelings to make ourselves feel better (Doron, Stephan, Maiano, & Le Scanff, 2011). Problem-focused coping, by contrast, involves making a plan of action and dealing directly with the stressor (Doron et al., 2011). For example, when faced with a difficult final exam, emotion-based coping could take the form of avoiding thinking about the exam in order to reduce anxiety. In contrast, problem-focused coping would involve formulating a schedule for studying and a procedure for self-assessment.

It is important to know when to apply different types of coping. Relying on emotion-focused coping when problem-focused coping could result in a better outcome leads to negative results. Consider the final exam example. Problem-focused coping could lead to a better grade. But emotion-focused coping likely would not. However, problem-focused coping works only when a person has the ability to remedy the situation by taking some action. When events are not in a person’s control, problem-focused coping may lead to frustration and more stress. When action is futile, it makes more sense to rely on emotion-focused coping. An example of using the wrong type of coping would be to rely on alcohol instead of dealing with the stressor or managing feelings. While alcohol does make one feel relaxed and perhaps better for a short while, eventually it wears off and the problems resurface, as they were avoided and not prop- erly handled.

Why do some people manage to cope successfully with their illness, whereas others never seem to be able to adjust? At least part of the answer lies in the coping resources available to the individual.

Social Support Coping is not simply a matter for the person who is ill. It involves family members and friends as well. Some family members try to distance themselves from the ill relative (perhaps to avoid the pain of a loved one’s suffering). Others derive enhanced self-esteem from helping the individual cope (Kovacs & Feinberg, 1982). Provided that it does not lead to overprotec- tiveness and dependency, the latter attitude is more helpful to someone attempting to come to grips with a chronic illness.

Given that all family members are affected by one member’s chronic illness, it is not sur- prising that family conflict affects how well chronically ill people cope (Leeman et al., 2016). People with diabetes who live in harmonious families seem to have better control of their blood sugar than do those who live in distressed or unhappy families. It should be noted, how- ever, that some studies have failed to find a strong relationship between family harmony and diabetic control (Gowers, Jones, Kiana, North, & Price, 1995; Kovacs, Kass, Schnell, Goldston, & Marsh, 1989). One possible reason for the discrepant results is the reliance on self-report. Members of dysfunctional families may be reluctant to admit that disharmony exists.

To be effective, however, social support must be appropriate for a person’s stage of develop- ment. For example, daily questioning (“Have you had your insulin this morning?”) improves treatment compliance in young children but actually makes it worse in adolescents, who resent this intrusion on their autonomy and independence (Idalski-Carcone, Ellis, Weisz, & Naar-King, 2011).

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Section 2.7 Factors That Modify the Effects of Stress

Social support contributes to health in several ways. First, by providing acceptance, social ties may help maintain self-esteem. Second, friends provide help in times of trouble and sym- pathetic ears for the expression of painful feelings. Third, members of self-help groups are important sources of new information about the disease and its control.

Of course, it is always possible that people who are sick withdraw from social con- tact. In such cases, illness has affected their social life rather than the other way around. We should not expect miracles from strong social support, however. Social support does not act in a vacuum. As described in the next section, individual differences and external social events can moderate the effects of social support. There may even be times when social support is not beneficial, as explained in the accompanying Highlight.

Rawpixel/iStock/Thinkstock During times of illness, friends may offer a sympathetic ear or help maintain self-esteem.

Highlight: When Social Support Increases Stress

To be of value, social support must work to facilitate positive goals. Friends who want to take you out for a pizza the night before an important exam may think they are being supportive, but the outcome of their behavior may be that you fail the exam.

A compelling demonstration of the potential costs of social support may be found in a study by Baumeister and Steinhilber (1984). These researchers examined baseball World Series records from 1924 to 1982 and basketball semifinal and championship series for the years 1967 to 1982. They were particularly interested in the success of the home team. Teams playing at their home field or stadium have an audience of supporters to cheer them on. This is a form of “social support” that is usually interpreted as giving the home team an advantage over the visitors. Overall, the statistics confirmed this advantage. Both baseball and basketball teams are more successful in front of their fans. However, this advantage was evident only early in the season. End-of-season championships, such as the World Series, produced quite the opposite results. Home teams were more likely to lose.

The pressure of playing in front of fans, of not wanting to lose at home, may cause a team to “choke.” Teams actually performed better without the social support provided by their hometown crowds. See Baumeister (1995) and Wallace, Baumeister, and Vohs (2005) for more support of these findings.

Bill Cobb/SuperStock The stress of playing at their home field in a stadium crowded with fans can have a negative effect on baseball teams when stakes are high, such as during the World Series.

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Section 2.7 Factors That Modify the Effects of Stress

Individual Characteristics Stress affects people in markedly different ways; an event that has a devastating effect on one person may hardly affect another. This section looks at some of the reasons for these individual differences: knowledge, hardiness, self-esteem, locus of control, and attributions.

Knowledge At first glance, coping with treatment for a chronic illness may appear to be simply a matter of knowledge. We reason that once the patient knows what needs to be done and why, compli- ance should follow. Knowing what to do (and why) does not guarantee healthy behavior. One reason that knowledge does not guarantee healthy behavior is that the illusion of invulner- ability discussed earlier leads most of us to minimize the probability of bad outcomes. Medi- cal students and students of clinical psychology are exceptions. They tend to err in the oppo- site direction, exaggerating their susceptibility to illness. They may even develop the signs and symptoms of the diseases they study (known as a psychosomatic reaction or a somatic symptom disorder). Called medical student syndrome, this reaction was discussed in Chapter 1. Overestimating one’s susceptibility to illness is just as misleading and maladaptive as is minimizing it. In both cases, knowledge does not guarantee appropriate behavior.

Hardiness People who withstand stress when their coworkers, friends, and relatives break down may possess certain protective personality traits. Optimists, for example, tend to withstand stress better than pessimists. Around examination time, optimistic students report less fatigue and fewer colds, aches, and pains than their pessimistic peers. Hardiness can be defined as a stress-resistant personality characteristic that is made up of control, commitment, and chal- lenge (Vealey & Perritt, 2015). These individuals believe that they are in control of their lives and that they have the power to influence people and events around them. They welcome challenge by seeing it as a necessary means for personal growth. Finally, they usually respond to difficult situations rationally and productively (Vealey & Perritt, 2015). There is also some evidence that hardiness and optimism are inherited dispositions (Caprara, Steca, Alessandri, Abela, & McWhinnie, 2009). These findings are certainly worth further investigation, but we should be careful not to overemphasize them. Most of all, we should avoid characterizing people who fall ill as lacking healthy personality traits.

Self-Esteem Being different, not being able to do the same things as others, takes its toll on self-esteem. Low self-esteem, in turn, leads to a discrepancy between a person’s real and ideal self. Human- ists attribute many psychological problems to such a discrepancy. Not every ill person has low self-esteem, of course. However, it is all too common among individuals who seek therapy, and at the least, low self-esteem can create more stress in one’s life. For example, although some people might think that an intellectually gifted child has a huge advantage over many other children in her class, many do not understand that it is often difficult for these children to “fit in,” as they are seen as different by their peers. This can lower their self-esteem and may lead these children to feel out of place or ostracized.

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Section 2.7 Factors That Modify the Effects of Stress

Locus of Control The concept of locus of control is quite interesting. Its definition is simple: the extent to which people believe they have power over events in their lives (Rotter, 1966). One way to look at this concept is to ask yourself: Do I control my life or does something else (like a God, demon, the moon, sun, weather) control it? This concept, brilliant in its simplicity, has a significant impact on our daily lives. Adults are usually considered responsible enough to comply with treatment. However, not all people accept this responsibility. In theory, at least, people who have an external locus of control—who believe that external forces are more likely to deter- mine what happens to them than their own actions—should be less likely to adhere to a treat- ment regimen than those who have an internal locus of control (Lefcourt, 1992). People who have an internal locus of control believe that their life’s outcomes are under their control and occur because of their actions, not because of external factors out of their control.

Studies of locus of control have produced a mixed picture (May, 1991; Wertlieb, Jacobson, & Hauser, 1990). Some report an external locus of control among chronically ill people; some do not. Internal locus of control has also been found not to be related to treatment adherence and follow through (Carbone, Zebrack, Plegue, Joshi, & Shellhaas, 2013; Gibson, Held, Khawnekar, & Rutherford, 2016). One possible reason for the discrepant results is the reciprocal effect of health status on locus of control.

Despite uncertainties about the precise relationship between locus of control and illness, ample evidence indicates that feeling in control helps reduce stress. Feelings of control come from three factors: familiarity, predictability, and controllability. Familiarity reduces stress by making us more aware of what to expect. This is why your first job interview is likely to elicit a greater alarm reaction than your second or third. Predictability exerts an effect on stress independent from familiarity. In a demonstration of the effects of predictability, labora- tory rats produced a more intense autonomic reaction to unpredictable electric shock than to shocks of exactly the same voltage occurring on a predictable schedule (Weiss, 1977). Indeed, animals who received unpredictable shocks developed peptic ulcers at a much greater rate than did rats who received predictable shocks. Providing the animals with a way of avoiding or shutting off the shock reduces the stress response even further. This last finding suggests that controllability also determines a stressor’s effect (Henderson, Snyder, Gupta, & Banich, 2012). Similar effects have been found among older people placed in nursing homes without their consent (Rodin, 1986). They decline rapidly and die sooner than people who are allowed to choose for themselves where they will live and to determine their own daily activities. See the accompanying Highlight for additional discussion of locus of control and its impact on our daily lives.

Health Beliefs and Attributions Instead of focusing on a global belief such as internal or external locus of control, some researchers have studied the relationship between more specific beliefs and treatment com- pliance. For example, among those with diabetes, adherence to the treatment regimen may be related to specific beliefs about themselves and their illness (Gonzalez, Shreck, Psarors, & Safren, 2015). Some of these beliefs include the following:

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Section 2.7 Factors That Modify the Effects of Stress

• Susceptibility (“I will not develop complications.”) • Severity (“Diabetes is not really all that serious.”) • The benefits of compliance (“If I don’t stick to the regimen all of the time, it won’t

hurt me in the long run.”) • The costs of compliance (“My injections keep me from going out at night.”)

It is not surprising that health beliefs were better predictors of adherence than of blood sugar levels. Even when adherence is perfect, blood sugar levels may vary depending on numerous physiological and emotional factors (Brownlee-Duffeck et al., 1987).

One unusual result of the study by Martha Brownlee-Duffeck and her colleagues was their finding that, among adolescents, those who perceived their illness as severe (and their sus- ceptibility to complications as high) had poorer adherence to treatment than did those who minimized their illness. This relationship was exactly the opposite of the one the researchers expected to find. One explanation is that people who do not adhere to treatment are just being realistic. They know that with their severe illness they are more likely to develop complica- tions, so why waste their effort? This explanation implies that health beliefs may both affect behavior and be affected by behavior (May, 1991).

Highlight: Locus of Control

Do you like to play Powerball or Mega Millions? Do you say a prayer before you buy your tickets? Do you believe that your path in life is predetermined, out of your hands? When things are in a dark place in your life, do you attribute this to demons and wait it out, or do you take charge and say that you will turn things around? How about a professional athlete who says that his team won the Super Bowl because he prayed and his prayers came true? These are all examples of locus of control. Some are examples of external locus of control, where the player, you, or another person believes that external forces are more likely than not to determine life’s outcomes. Here’s a question to ask: Is this a psychologically healthy perspective? After all, the person is saying, “Let come what may. I really am not important in determining the outcome.” Yes, sometimes things happen over which we have little to no control, but if a person consistently believes this, he or she may just sit back and not even try. Could this lead to anxiety or unipolar depression?

What about internal locus of control? Do you control what occurs in your life? Does the athlete, as skilled as she is, control whether the ball goes in the net? Do you have control over your course grades? Is this a psychologically healthy outlook? Some research has found that people with a more internal locus of control seem to be better off; for example, they tend to be more achievement oriented and to get better-paying jobs. But there is a caution. Do financial or other privileges cause the locus-of-control perspectives, or do the beliefs regarding control cause the situation (Hans, 2000)? Regardless, it is important to realize that no matter what, some things are beyond our control, while other things are very much in our control. If you are happy with who you are, one perspective is not necessarily better than the other.

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Section 2.8 Helping People Cope

2.8 Helping People Cope Practically every type of psychological treatment has been applied to helping people cope with stress, chronic pain, and the management of illnesses such as diabetes (Bradley, 1994; Rubin & Peyrot, 1992; Shillitoe & Christie, 1990). The main aim is to reduce stress, thereby reducing pain and preventing illness or exacerbations of illness. The general term stress management has come to be applied to the various approaches to reducing stress (Lehrer & Woolfolk, 1993). Some treatments take a direct approach, teaching relaxation and other stress-reduction skills. Others take an indirect approach. They attempt to change cognitions and behaviors, which may in turn lead to better health through better diabetic management. Every coping process and every coping resource is a potential candidate for intervention. Thus, psychologists may try to build a person’s self-esteem, provide social support, or even reorient a person’s locus of control from external to internal. (See Figure 2.6.)

Stress Reduction Through Relaxation One popular and effective method of stress reduction is Edmund Jacobson’s (1938) progres- sive muscle relaxation technique. Individuals are instructed to alternately tense and relax different groups of muscles. For example, focusing on the muscles of the lower arm, the indi- vidual would make a fist and then relax it. The person then continues to move throughout the rest of the body, focusing on different muscle groups until the entire body is relaxed. The goal is to make individuals aware of muscle tension and to give them practice in relaxing dif- ferent muscle groups. When muscle tension is not a prominent symptom, therapists may use other relaxation techniques, such as transcendental meditation, in which the person focuses attention on quietly repeating a specific syllable (the mantra), or hypnosis. In each case, the underlying rationale is that relaxation is incompatible with stress. Individuals who learn to relax in stressful situations should have fewer and less-intense alarm reactions. Fewer alarm reactions mean less strain on the heart, the nervous system, and the immune system.

In one now-classic demonstration of the power of relaxation, middle-aged heart attack survi- vors were randomly assigned to one of two conditions (Friedman & Ulmer, 1984). One group received advice from cardiologists about exercise, medications, and diet. The second group received the same advice plus continuing counseling on how to relax (eat slowly, smile at oth- ers and laugh at yourself, admit mistakes, and take time to enjoy life). The two groups were followed for three years. During that period, members of the relaxation group had only half the number of heart attacks as the first group. Friedman and Ulmer note that “no drug, food, or exercise program ever devised, not even a coronary bypass surgical program, could match the protection against recurrent heart attacks” of simply learning to relax (p. 141).

Evidence shows that relaxation training given to patients undergoing treatment for various diseases, including cancer, made them less fatigued and depressed and more likely to finish the treatment course (Demiralp, Oflaz, & Komurcu, 2010). The benefits of relaxation train- ing are not limited to people being treated for an illness. Employers have found that offering training in relaxation and other aspects of stress management at the workplace can improve employee performance (Quick, Murphy, & Hurrell, 1992).

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Section 2.8 Helping People Cope

Biofeedback Biofeedback has been used as an adjunct to stress-management programs (Kotazaki et al., 2014). Biofeedback is a technique that trains people to improve their health by controlling certain bodily processes that normally happen involuntarily, such as heart rate, blood pres- sure, and muscle tension. Electrodes are attached to the person’s skin and the results are displayed on a monitor. For example, biofeedback has been used to try to reduce the muscle tension that seems to accompany some headaches, and to lower blood pressure. However, ini- tial claims for biofeedback—that it might be a cure for migraines, hypertension, peptic ulcers, and many other conditions—are now clearly seen to have been exaggerated (Miller, 1974). Biofeedback has beneficial effects in some conditions for some people, but, when used alone, the benefit of biofeedback for relieving stress and reducing symptoms is probably no greater than that provided by relaxation training.

Figure 2.6: Stress relief

What do people do to relieve stress? According to one large survey, most watch television or listen to music.

Source: Adapted from R. J. Corner, Abnormal Psychology, 6th ed. New York: Worth Publishers, 2007.

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Section 2.8 Helping People Cope

Exercise Research has indicated that exercise, both aerobic and resistance training, reduces the anxiety and depression often associated with stress (Martinsen, 1990; Martinsen, Hoffart, & Solberg, 1989; Rethorst, & Trivedi, 2013; Singh, Clements, & Fiatarone, 1997) and can be as effective as conventional pharma- cotherapy (Blumenthal et al., 2007). As you might expect, some studies do not support these findings (Bartley, Hay, & Bloch, 2013). Numerous studies show that those who exer- cise live longer and spend fewer days in the hospital than those who do not (Wen, Wai, Tsai, & Chen, 2014). Of course, it is always

possible that people who are sick do not feel like exercising. As we have seen frequently, it is difficult to separate cause and effect when dealing with correlational data.

Behavioral and Cognitive-Behavioral Treatment All aspects of behaviorism, including modeling, rational emotive behavior therapy, and con- ditioning, may be used to help people develop new coping skills. For example, people with diabetes who fear needles are likely to miss injections. Helping them to overcome this fear through desensitization (any decrease in reactions or sensitivity to a stimulus or stimuli), for instance, would benefit them by helping them comply with treatment. Reward-based pro- grams, in which those with diabetes are rewarded for keeping to their diets or their schedules for monitoring blood sugar, can have a similar effect.

Given the evidence from human and animal studies suggesting that immune functioning is decreased by stress, psychological interventions have also targeted the immune system. Using a wide variety of therapeutic techniques, including relaxation, hypnosis, exercise, con- ditioning, and cognitive therapy, psychologists have been able to increase the level of immune functioning (Kiecolt-Glaser & Glaser, 1992; Zakowski, Hall, & Baum, 1992). Of course, the problem of clinical significance that affects the field in general also applies to treatment stud- ies. Specifically, it has still not been demonstrated that increasing immune system function has a direct beneficial effect on health. (Keep in mind that, apart from AIDS, most infections increase immune function, yet this increased production of white blood cells is hardly an indicator of good health.)

Family Interventions Stress and illness have profound effects not just on physical functioning but also on psycho- logical and social identity (Kaplan, 1996; Morse & Johnson, 1991). Suffering affects a person’s self-concept, and it subjects other family members to a burden that may require different family members to take on different caregiver roles. The spouse of someone receiving painful

Demkat/iStock/Thinkstock Both aerobic exercise and resistance training can reduce anxiety and depression commonly associated with stress.

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Section 2.8 Helping People Cope

chemotherapy, for example, must cope not only with caring for the patient but also with other family matters, and with fears for the patient’s future. Sometimes, family therapy is required to help families deal with the burden of one member’s illness. Self-help groups for patients and their families are often useful sources of social support.

Environmental and Community Interventions Because trauma and stressor-related disorders often result from threatening environments, community interventions can sometimes be as effective as individual treatment. For example, increased police patrols reduce the stress that comes from living in high-crime areas, antipov- erty programs reduce the stress that comes from poverty, and employment programs help to reduce the stress created by job loss. Combinations of behavioral and cognitive interventions have also been used to modify a community’s health-relevant behaviors. For example, people at high risk for illness may be taught strategies to minimize the risks while learning how to avoid dangerous behaviors (Bennett, Wallace, Carroll, & Smith, 1991). See the accompanying Highlight for some ways to cope with your own stress.

Highlight: Self-Help in Coping With Stress

Even without psychological interventions, there are some things you can do to help yourself cope with stress:

• Appraise the situation. Isolate the problem. Find out as much as you can about the stressor, its causes, and its correlates. Consider alternative actions.

• Examine your appraisal. Is it realistic? Avoid catastrophizing. If you have failed an examination, is it really the end of the world? Perhaps you can try again. A study plan may help. Even if you cannot erase the failure, you may find you are better at something else. Catastrophizing leads to stress. Realistic appraisals lead to calm but hopeful acceptance.

• Be aware of your defenses. Are you denying reality? Are you rationalizing? • Reduce stress and practice coping skills. Learn to relax. Talk to friends. Exercise. Eat

and sleep well. Join self-help groups where appropriate. • Take the necessary actions, but do not be impulsive. Consider possible actions,

and list the pros and cons of each. Do not be impulsive. Do not take an action just because of the need to do something. However, once you have decided what to do, then do it. Procrastination just produces more stress.

• Remain flexible. Adaptive behavior means not being locked into any course of action. You must be willing to change direction when the situation warrants it.

No matter which psychological intervention is used, sociocultural factors must be taken into account (Radley, 1993). We cannot begin to help people cope with stress and illness until we first understand how they perceive stress and illness (Dasen, Berry, & Sartorius, 1988). Special efforts must be made to target these groups and their beliefs if prevention is to be successful.

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Chapter Summary

Stress: Origins, Definitions, and Theories • Early theories in the field of psychosomatic medicine postulated a specific connec-

tion between certain personalities and certain diseases. These theories claimed that specific unconscious conflicts produced specific diseases.

• It is difficult to prove that a personality type or psychological conflict actually causes a disease.

• Selye’s general adaptation syndrome, or GAS, was an elaboration of Cannon’s emer- gency reaction. There are three stages: emergency (or alarm), resistance (during which the person uses all of his or her physiological resources to minimize tissue damage), and, finally, the exhaustion stage (in which illness and injury become likely).

• Selye used the word stressor to refer to external threats to well-being that could trig- ger GAS. Strong or repeated stress causes the body’s defenses to crumble, making illness likely.

Sources of Stress • Stress can arise from catastrophes, important life events, everyday hassles, chronic

illness, and chronic pain and headaches.

Effects of Stress • Stress has been shown to weaken the nervous system, making it more prone to

injury from incidents such as stroke. • Stress also reduces the effectiveness of the immune system. • The effects of stressors may be mediated by individual differences. • In addition to its direct physiological effects, stress affects health indirectly by inter-

fering with health-relevant behaviors. Stress affects memory, judgment, and other aspects of cognition.

Posttraumatic Stress Disorder (PTSD) • The main symptoms of PTSD are anxiety, avoidance of stimuli associated with the

trauma, flashbacks, and a “numbing” of emotional responses. The DSM–5 recognizes that the symptoms of PTSD may be different in children and has different diagnostic criteria for children under age 6.

• PTSD is caused by exposure to an extraordinarily stressful, traumatic event. • The most common behavioral intervention for PTSD is exposure. Other methods of

treating PTSD include flooding, desensitization, cognitive restructuring, and stress- management training.

• Eye movement desensitization and reprocessing (EMDR) has been used to treat PTSD.

• Antidepressant medication may help reduce some of the symptoms of PTSD. • The prevention of PTSD occurs best with early intervention following a traumatic

event.

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Chapter Summary

Acute Stress Disorder • Acute stress disorder is diagnosed when the symptoms occur immediately after the

exposure to the trauma and must last at least three days to a month after the expo- sure to the trauma.

Illness of the Mind or the Body: A Dubious Distinction • In the past, a small number of conditions were labeled psychosomatic or psycho-

physiological (peptic ulcer, asthma, headaches, hypertension). Today, this distinction between illnesses with and without psychological components is considered artifi- cial. Psychological factors play a role in all illnesses.

• The opposite is also true: All illnesses have psychological effects. The reciprocal effects of stress and illness are best understood using a “stress and coping” model. That is, the effects of various stressors on health are mediated by coping, which, in turn, depends on an individual’s coping resources.

Factors That Modify the Effects of Stress • Primary appraisal involves an assessment of the implications of an event for the

individual. Events may be appraised as irrelevant, beneficial, or stress-inducing. • Secondary appraisals are concerned with what, if anything, should be done. Cogni-

tive appraisals need not be rational or even conscious. • Response to stress is always based on our appraisal (conscious or unconscious) of

the threat and our perception of how to deal with it. • Emotion-focused coping is aimed at managing feelings. • Problem-focused coping attempts to challenge stressors directly by making a plan of

action and dealing with the source of stress. • Problem-focused coping works best when a person has the ability to remedy the

situation by taking some action. • Some people manage to cope successfully with stress or their illness, whereas others

never seem to be able to adjust. Part of the answer lies in the coping resources avail- able to the individual.

• Social support provides a source of help in times of trouble and gives people a way of expressing their painful feelings to one another.

• Other factors that affect coping include knowledge (about health practices), hardi- ness, high self-esteem, locus of control, and health beliefs.

Helping People Cope • The most widely applied intervention strategy for helping people cope with stress is

relaxation. The underlying rationale is that teaching people how to use relaxation to reduce the intensity and frequency of emergency reactions and GAS will reduce their stress.

• Fewer episodes of alarm reactions mean less strain on the heart, the nervous system, and the immune system.

• Exercise, biofeedback, behavior modification, self-help groups, and many other interventions have all been found useful in helping people cope with stress.

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Chapter Summary

Critical Thinking Questions

1. What are your views on the theory that psychological processes can cause physical symptoms?

2. Discuss how you best cope with stress. Do you think that these techniques would work well for your friends? Why or why not?

3. Discuss how, in your view, denial can help or hinder people coping with serious ill- ness and stress.

4. Give your views on why we cannot make a diagnosis of PTSD until the symptoms have been present for at least one month. Is this really enough time to recover from a traumatic event?

5. Why are social support systems important in helping people cope with stress and stressful situations?

6. We discussed locus of control in this chapter. Discuss whether yours is internal or external, and how you feel about that.

7. One issue mentioned in this chapter is that some people with insulin-dependent diabetes are afraid of injections. Let’s presume you had a good friend in this exact situation. What techniques would you use to help him or her overcome this fear?

8. Discuss whether or not stress is increasing in today’s society, the reasons this might be the case, and whether or not stress disorders are becoming more common.

Key Terms acute stress disorder A short-term response to a traumatic event with symp- toms like posttraumatic stress disorder. The onset of symptoms occurs immediately after the trauma and lasts at least three days to no longer than one month after the trauma.

adjustment disorders Psychological disorders marked by anxiety, depression, withdrawal, and overall impairments in psychological functioning. The core feature is the presence of emotional or behavioral symptoms in response to an identifiable stressor. The stressor may be a single event, or there may be multiple stressful events. These disorders can have the power to make people physically ill, or perhaps even lead to death.

behavioral medicine The study of the interaction between psychology and physiology.

biofeedback A technique that trains people to improve their health by controlling cer- tain bodily processes that normally happen involuntarily, such as heart rate, blood pres- sure, and muscle tension.

comparative optimism Also called opti- mistic bias: when we believe that we are less likely than other people to be harmed by bad events.

conversion hysteria What Freudians often referred to as hysteria manifested by physi- cal symptoms.

coping Finding effective ways to adapt to the problems and difficulties presented by stress.

desensitization Any decrease in reactions or sensitivity to a stimulus or stimuli.

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Chapter Summary

emergency (alarm) reaction The body’s physiological response to threat.

emotion-focused coping A coping tech- nique, such as denial or obsessiveness, that involves managing feelings to make our- selves feel better.

etiology The study of the causes or origins of disease, in this case mental illnesses.

external locus of control An individual’s belief that their problems are caused by external events (such as demons, the moon, stars, and so on) and thus cannot be con- trolled by their own behaviors.

general adaptation syndrome (GAS) When long-term or frequently recurring threats cause the body to gradu- ally wear out. Deterioration takes place in a series of three stages: alarm, resistance, exhaustion.

hardiness A stress-resistant personality characteristic that is made up of control, commitment, and challenge. Hardy individu- als believe that they are in control of their lives and that they have the power to influ- ence people and events around them.

internal locus of control The belief that an individual’s life’s outcomes are under their control and occur because of their actions, not because of external factors out of their control.

migraines Neuralgia thought to be caused by the contraction and dilation of blood ves- sels in the head.

posttraumatic stress disorder (PTSD) A disorder that typically occurs after being exposed to a traumatic event such as war or violence; symptoms include anxiety, the avoidance of stimuli associated with the trauma, flashbacks in which the traumatic event is relived mentally, and a “numbing” of emotional responses. Additional symptoms include physiological arousal or hyper- arousal such as sleep disturbance, increased irritability, and hypervigilance.

problem-focused coping A coping tech- nique that involves making a plan of action and dealing directly with the stressor.

psychophysiological or psychosomatic disorders Disorders in which psychological factors produce “real” physical diseases.

stress Usually refers to both a cause (a “stressful” job, for example) and an effect (for example, “I am feeling stressed”).

stress management Refers to the various approaches to reducing stress.

stressor Cause(s) of stress.

tension headaches Neuralgia traditionally thought to result from tense muscles in the neck and head.

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