assessment

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period of time. If, for example, in the course of a year a woman started a new

business (39 LCUs), sent her son off to college (29 LCUs), moved to a new house (20 LCUs), and had a close friend die (37 LCUs), her stress score for the year would be 125 LCUs, a considerable amount of stress for such a period of time.

TABLE: 9-7

Most Stressful Life Events

Adults: Social Readjustment Rating Scale Students: Undergraduate Stress Questionnaire†

1. Death of spouse 1. Death (family member or friend)

2. Divorce 2. Had a lot of tests

3. Marital separation 3. It’s finals week

4. Jail term 4. Applying to graduate school

5. Death of close family member 5. Victim of a crime

6. Personal injury or illness 6. Assignments in all classes due the same day

7. Marriage 7. Breaking up with boy/girlfriend

8. Fired at work 8. Found out boy/girlfriend cheated on you

9. Marital reconciliation 9. Lots of deadlines to meet

10. Retirement 10. Property stolen

11. Change in health of family member 11. You have a hard upcoming week

12. Pregnancy 12. Went into a test unprepared

Full scale has 43 items. (Reprinted from: Journal of Psychosomatic

Research, Vol. 11, Holmes, T. H., & Rahe, R. H., The Social Readjustment Rating Scale, 213–218,

Copyright 1967, with permission from Elsevier.)

†Full scale has 83 items. (Information from: Crandall, C. S., Preisler, J. J., & Aussprung,

J. (1992). Measuring life event stress in the lives of college students: The Undergraduate Stress Questionnaire (USQ).

Journal of Behavioral Medicine, 15(6), 627–662.)

of NOTE …

i

i

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Their Words

“I would rather have anything wrong with my body than something wrong with my head.”

Sylvia Plath, The Bell Jar

With this scale in hand, Holmes and Rahe (1989, 1967) examined the

relationship between life stress and the onset of illness. They found that the LCU scores of sick people during the year before they fell ill were much higher than those of healthy people. If a person’s life changes totaled more than 300 LCUs over the course of a year, that individual was particularly likely to develop serious health problems.

Using the Social Readjustment Rating Scale or similar scales, studies have since linked stresses of various kinds to a wide range of physical conditions, from trench mouth and upper respiratory infections to cancer (Johnson et al., 2020; Seiler et al., 2020). Overall, the greater the amount of life stress, the greater the likelihood of illness (see Figure 9-4). Researchers even have found a relationship between traumatic stress and death. Widows and widowers, for example, display an increased risk of death during their period of bereavement.

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FIGURE 9-4

Stress and the Common Cold

In a landmark study, healthy participants were administered nasal drops containing common cold

viruses. In turn, the participants who had recently experienced more stressors came down with more

colds than did participants with fewer recent stressors. (Information from: Cohen et al., 1991.)

One shortcoming of Holmes and Rahe’s Social Readjustment Rating Scale is that it does not take into consideration the particular life stress reactions of specific populations. For example, in their development of the scale, the researchers sampled non-Hispanic white Americans predominantly. Few of the respondents

were African Americans or Hispanic Americans. But since their ongoing life experiences often differ in key ways, might not members of minority groups and non-Hispanic white Americans differ in their stress reactions to various kinds of life events? Research indicates that indeed they do (APA, 2020). One study found, for example, that African American and Hispanic American teachers perceived and reacted to occupational stressors (for example, heavy workload and administrator pressure) very differently than did non-Hispanic white American teachers (Rauscher & Wilson, 2017).

Why are marriage, moving to a new house, and other positive events also included on stress scales?

Finally, college students may face stressors that are different from those listed in the Social Readjustment Rating Scale. Instead of having marital difficulties, being

fired, or applying for a job, a college student may have trouble with a roommate, fail a course, choose a major, or apply to graduate school. When researchers use special scales to measure life events in this population, they find the expected relationships between stressful events and illness (Wu et al., 2020; Kaya et al., 2017) (see Table 9-7 again).

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Psychoneuroimmunology

How do stressful events result in a viral or bacterial infection? Researchers in an area of study called psychoneuroimmunology seek to answer this question by uncovering the links between psychosocial stress, the immune system, and health.

First line of defense When antigens first invade the body, lymphocytes are alerted by macrophages, big

white blood cells in the immune system that engulf antigens and then deliver antigen fragments to the

lymphocytes. Here a macrophage (pink) is handing off such fragments to a helper T-cell (green).

The immune system is the body’s network of activities and cells that identify and destroy antigens — foreign invaders, such as bacteria, viruses, fungi, and parasites — and cancer cells. Among the most important cells in this system are billions of lymphocytes, white blood cells that circulate through the lymph

system and the bloodstream. When stimulated by antigens, lymphocytes spring into action to help the body overcome the invaders. Our ability to fight off and overcome bacterial infections and viruses is dictated by how quickly and efficiently the lymphocytes and other white cells in our immune system operate.

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One group of lymphocytes, called helper T-cells, identifies antigens and then multiplies and triggers the production of other kinds of immune cells. Another group, natural killer cells, seeks out and destroys body cells that have already been infected by viruses, thus helping to stop the spread of a viral infection. A

third group of lymphocytes, B-cells, produces antibodies, protein molecules that recognize and bind to antigens, mark them for destruction, and prevent them from causing infection.

Religious protection? At a 2015 prayer vigil, church congregants hold up pictures of

nine Bible study participants who were shot and killed at the Emanuel African Methodist Episcopal Church in Charleston, South Carolina. Some relatives of the

victims told the mass murderer that they forgave him and were praying for him. Research indicates that people with strong institutional, religious, and social ties

o�en recover more readily and healthfully from the effects of traumatic events.

Various factors influence how effectively a person’s immune system operates. Insufficient sleep and poor diet, for example, slow down the system. So too does old age. The bodies of elderly people have significantly fewer lymphocytes than younger persons and thus slower-acting immune systems, putting the elderly at a great disadvantage when trying to overcome influenza, pneumonia, viral infections such as COVID-19, and other serious medical illnesses (Begley, 2020).

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Researchers have also come to appreciate that stress can interfere significantly with the activity of lymphocytes and other parts of the immune system, slowing those cells down and thus increasing a person’s susceptibility to viral and bacterial infections (Burton et al., 2020; Seiler et al., 2020). In a landmark study,

investigator Roger Bartrop and his colleagues (1977) in New South Wales, Australia, compared the immune systems of 26 people whose spouses had died 8 weeks earlier with those of 26 matched control group participants whose spouses had not died. Blood samples revealed that lymphocyte functioning was much lower in the bereaved people than in the controls. Still other studies have shown poor immune functioning in people who are exposed to long-term stress (Seiler et al., 2020; Gao et al., 2018). For example, researchers have found poorer immune functioning among those who provide ongoing care for a relative with

Alzheimer’s disease (Allen et al., 2017).

These stress studies seem to be telling a remarkable story. During periods when healthy people happen to have unusual levels of stress, they may remain healthy on the surface, but their stressors apparently slowed their immune systems so that they became susceptible to illness. If stress affects our capacity

to fight off illness, it is no wonder that researchers have repeatedly found a relationship between life stress and illnesses of various kinds (Cazassa et al., 2020; Seiler et al., 2020). But why and when does stress interfere with the immune system? A number of factors may influence whether stress will result in a slowdown of the system, including biochemical activity, behavioral changes, personality style, and degree of social support. Once again, these factors sometimes operate in combination.

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The ultimate body–mind connection? Although rare, sudden death may occur among people who have just experienced the death of a loved one, extreme danger,

or a severe loss of status (Engel, 1971, 1968). In 2017, movie legend Debbie Reynolds (right) died just one day

a�er the death of her daughter, actress and writer Carrie Fisher (le�). According to Reynolds’s son, “She

literally said ‘I want to be with Carrie’ and closed her eyes and went to sleep.”

BIOCHEMICAL ACTIVITY

As you’ll recall from Chapter 6, there are two brain–body stress routes by which stressors produce arousal throughout the brain and body (see pages 153–154). One is the sympathetic nervous system, which, among its many actions, triggers the release of the neurotransmitter norepinephrine. It turns out that in addition to its role in producing arousal, an extended release of norepinephrine can

influence the immune system adversely. Research indicates that if stress continues for too long a period, norepinephrine eventually travels to receptors on certain lymphocytes and gives them an inhibitory message to stop their activity, thus slowing down immune functioning (Seiler et al., 2020; Young et al., 2020).

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Recall also that the other brain–body stress route is the hypothalamic-pituitary- adrenal (HPA) axis, which, among its various actions, triggers the release of cortisol and other stress hormones. In addition to producing bodily arousal, an extended release of cortisol and other stress hormones can contribute to poorer immune system functioning. As in the case of norepinephrine, if stress continues for too long, the stress hormones travel to receptor sites located on certain lymphocytes and give an inhibitory message, again causing a slowdown of the activity of the lymphocytes (Seiler et al., 2020; Young et al., 2020).

Research has further indicated that another action of norepinephrine and the various stress hormones is to trigger an increase in the production of cytokines, proteins that bind to receptors throughout the body. At moderate levels of stress, the cytokines, another key player in the immune system, help combat infection. But as stress continues and more norepinephrine and stress

hormones are released, the growing production and spread of cytokines, particularly so-called pro-inflammatory cytokines, lead to chronic inflammation throughout the body, contributing at times to heart disease, stroke, and other illnesses (Chow & Chin, 2020).

BEHAVIORAL CHANGES

Stress may set in motion a series of behavioral changes that indirectly affect the immune system. Some people under stress may, for example, become anxious

or depressed, perhaps even develop an anxiety or depressive disorder. As a

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result, they may sleep badly, eat poorly, exercise less, or smoke or drink more — behaviors known to slow down the immune system (Venter et al., 2020; Levenson, 2018).

PERSONALITY STYLE

According to research, people who generally respond to life stress with optimism, constructive coping, and resilience — that is, people who welcome challenges and are willing to take control in their daily encounters — experience better immune system functioning and are better prepared to fight off illness (Sahoo et al., 2018). Some studies have found, for example, that resilient individuals tend to remain healthy after stressful events, while less resilient individuals seem more susceptible to illness (Asensio-Martinez et al., 2019; Rolin et al., 2018). Similarly, researchers have discovered that individuals with a

general sense of hopelessness die at above-average rates from heart disease and critical illnesses (Gruber & Schwanda, 2020). And, in a related vein, several studies suggest that people who are spiritual tend to be healthier than people without spiritual beliefs, and a few studies have linked spirituality to better immune system functioning (Ransome, 2020; Zidkova et al., 2020).

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A valiant fight Prior to his death in 2020, Alex Trebeck,

host of the popular game show Jeopardy!, survived stage 4 pancreatic cancer for 21 months, a

considerably longer period than usual for that stage. While fully appreciating the role of his medical

interventions, Trebeck also attributed his extended survival to psychosocial factors such as strong social

support, a positive attitude, constructive coping behaviors, and an open expression of his feelings.

Researchers have further found a relationship between certain personality characteristics and a person’s ability to cope effectively with cancer. They have found, for example, that patients with certain forms of cancer who display a helpless coping style and who cannot easily express their feelings, particularly anger, tend to have a poorer quality of life in the face of their disease than

patients who do express their emotions (Giulietti et al., 2020; Langford et al., 2020). A few investigators have even suggested a relationship between personality and cancer outcome, but this claim has not been supported clearly by research.

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SOCIAL SUPPORT

Finally, people who have few social supports and feel lonely tend to have poorer immune functioning in the face of stress than people who do not feel lonely (Balter et al., 2019). In a pioneering study, medical students were given the UCLA Loneliness Scale and then divided into “high” and “low” loneliness groups (Kiecolt-Glaser et al., 1984). The high-loneliness group showed lower lymphocyte

responses during a final exam period.

The power of support Cancer survivors clasp hands at the Susan G. Komen Race for

the Cure, a 5K run held annually throughout the world. The run not only raises funds and increases awareness about cancer, it helps survivors encourage one other —

applying research findings that social support can affect the immune system and improve recovery from various illnesses.

Other studies have found that social support and affiliation may actually help protect people from stress, poor immune system functioning, and subsequent

illness, or help speed up recovery from illness or surgery (HP, 2020c; Levenson, 2018). Similarly, some studies have suggested that patients with certain forms of cancer who receive social support in their personal lives or supportive therapy often have better immune system functioning and more successful recoveries than patients without such supports (Seiler et al., 2020).

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How might social distancing, isolation, and confinement — strategies used to contain epidemics and pandemics — actually hinder the ability of people to fight off other medical illnesses?

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Psychological Treatments for Physical Disorders

AS CLINICIANS HAVE discovered that stress and related psychological and sociocultural factors may contribute to physical disorders, they have applied psychological treatments to more and more medical problems. The most common of these interventions are relaxation training, biofeedback, meditation,

hypnosis, cognitive interventions, support groups, and therapies to increase awareness and expression of emotions. The field of treatment that combines psychological and physical approaches to treat or prevent medical problems is known as behavioral medicine.

Relaxation Training As you saw in Chapter 5, therapists sometimes teach clients to relax their muscles at will. The notion behind such relaxation training is that physical relaxation will lead to a state of psychological relaxation. In one version, therapists teach clients to identify individual muscle groups, tense them, release

the tension, and ultimately relax the whole body. With continued practice, they can bring on a state of deep muscle relaxation. Given that relaxation training is useful in the treatment of phobias and other anxiety disorders, clinicians believe that it can also help prevent or treat medical illnesses that are related to stress.

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Relaxing — and delicious! New stress relief programs, techniques, and products are constantly being introduced to the marketplace. These three individuals, for example, are able to unwind and relax in a chocolate spa at the Hakone Yunessun

spa resort in Japan.

Relaxation training, often in combination with medication, has been widely used in the treatment of high blood pressure. It has also been of some help in treating somatic symptom disorder, headaches, insomnia, asthma, diabetes, pain, certain vascular diseases, and the undesirable effects of certain cancer treatments (Seiler et al., 2020; Wong, 2020).

Biofeedback In biofeedback, therapists use electrical signals from the body to train people to

control physiological processes such as heart rate or muscle tension. Clients are connected to a monitor that gives them continuous information about their bodily activities. By attending to the signals from the monitor, they may gradually learn to control even seemingly involuntary physiological processes.

The most widely applied method of biofeedback uses a device called an electromyograph (EMG), which provides feedback about the level of muscular

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tension in the body. Electrodes are attached to the client’s muscles — usually the forehead muscles — where they detect the minute electrical activity that accompanies muscle tension (see Figure 9-5). The device then converts the electric energy, or potentials, coming from the muscles into an image, such as

lines on a screen, or into a tone whose pitch changes along with changes in muscle tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. Through repeated trial and error, the individuals become skilled at voluntarily reducing muscle tension.

FIGURE 9-5

Biofeedback at Work

This biofeedback system records tension in the forehead muscles of a person with

severe headaches. The system receives, amplifies, converts, and displays information about the tension, allowing the client to “observe” it and to try to

reduce his tension responses.

of NOTE … Funny Remedy

A�er watching a humorous video, research participants who laughed at the video showed decreases in stress and improvements in natural killer cell activity (Radcliff, 2017; Bennett, 1998).

In a classic study, EMG feedback was used to treat 16 patients who had facial pain caused in part by tension in their jaw muscles (Dohrmann & Laskin, 1978).

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Changes in the pitch and volume of the tone indicate changes in muscle tension. After “listening” to EMG feedback repeatedly, the 16 patients in this study learned how to relax their jaw muscles at will and later reported that they had less facial pain.

EMG feedback has also been used successfully in the treatment of headaches and muscular disabilities caused by strokes or accidents. Still other forms of biofeedback training have been of some help in the treatment of heartbeat irregularities, asthma, high blood pressure, stuttering, and pain (Fahrenkamp et al., 2020; Garza & Schwedt, 2019).

Meditation Although meditation has been practiced since ancient times, Western health care professionals have only recently become aware of its effectiveness in relieving physical distress. Meditation is a technique of turning one’s concentration inward, achieving a slightly changed state of consciousness, and temporarily ignoring all stressors. Typically, meditators go to a quiet place, assume a comfortable posture, utter or think a particular sound (called a mantra) to help focus their attention, and allow their mind to turn away from all outside thoughts and concerns. Many people who meditate regularly report

feeling more peaceful, engaged, and creative (Basso et al., 2019). Meditation has been used to help manage pain and to treat high blood pressure, heart problems, asthma, skin disorders, diabetes, insomnia, and even viral infections (Seiler et al., 2020; Kemper, 2019).

Doctors now prescribe psychological interventions for a range of medical problems, but many patients resist such treatments. Why?

One form of meditation that has been used in particular by patients suffering

from severe pain is mindfulness meditation (Stefan & David, 2020). Here, as you read in Chapters 3 and 5, mindfulness meditators pay attention to the feelings,

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thoughts, and sensations that are flowing through their mind during meditation, but they do so with detachment and objectivity and, most importantly, without judgment. By just being mindful but not judgmental of their feelings and thoughts, including feelings of pain, they are less inclined to label them, fixate on

them, or react negatively to them.

Hypnosis As you saw in Chapter 1, people who undergo hypnosis are guided by a hypnotist into a sleeplike, suggestible state during which they can be directed to act in unusual ways, feel unusual sensations, remember seemingly forgotten events, or forget remembered events. With training, some people are even able to induce their own hypnotic state (self-hypnosis). Hypnosis is now used as an aid to psychotherapy and to help treat many physical conditions.

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The hypnotic way Hypnosis is now widely used in medical procedures, particularly to help reduce and

control pain. Here, an anesthesiologist hypnotizes a patient undergoing major surgery at the University

Hospital Center of Liege in Belgium. Many surgeries at the hospital use a combination of hypnosis and a local

anesthetic rather than general anesthesia.

Hypnosis seems to be particularly helpful in the control of pain (McKernan et al., 2020). A breakthrough case study described a patient who underwent dental surgery under hypnotic suggestion: after a hypnotic state was induced, the dentist suggested to the patient that he was in a pleasant and relaxed setting listening to a friend describe his own success at undergoing similar dental surgery under hypnosis. The dentist then proceeded to perform a successful 25- minute operation (Gheorghiu & Orleanu, 1982). Although only some people are able to go through surgery while anesthetized by hypnosis alone, hypnosis

combined with chemical forms of anesthesia is apparently helpful to many patients. Beyond its use in the control of pain, hypnosis has been used successfully to help treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection (Cherry, 2020b; Otte et al., 2020).

Cognitive-Behavioral Interventions People with physical ailments have sometimes been taught new attitudes or cognitive responses toward their ailments as part of treatment (Hauer & Jones, 2020; Koffel, Amundson, & Wisdom, 2020). For example, an approach called self- instruction training, or stress inoculation training, has helped patients cope with severe pain (Sterling et al., 2019; Meichenbaum, 2017, 1993, 1975). In this training, therapists teach people to identify and eventually rid themselves of unpleasant thoughts that keep emerging during pain episodes (so-called negative self-statements, such as “Oh no, I can’t take this pain”) and to replace

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them with coping self-statements instead (for example, “When pain comes, just pause; keep focusing on what you have to do”).

of NOTE … Strange Coincidence

On February 17, 1673, French actor-playwright Molière collapsed onstage and died while performing

in Le Malade Imaginaire (The Hypochondriac).

Support Groups and Emotion Expression If anxiety, depression, anger, and the like contribute to a person’s physical ills, interventions to reduce these negative emotions should help reduce the ills. Thus it is not surprising that some medically ill people have profited from

support groups, including online support groups, and from therapies that guide them to become more aware of and express their emotions and needs (Plinsinga et al., 2019; Rice & Thombs, 2019). Research suggests that the discussion, or even the writing down, of past and present emotions or upsets may help improve a person’s health, just as it may help one’s psychological functioning (Pennebaker, 2018; Pennebaker & Smyth, 2016). In one study, asthma and arthritis patients who wrote down their thoughts and feelings about stressful events for a handful of days showed lasting improvements in their

conditions. Similarly, stress-related writing was found to be beneficial for patients with either HIV or cancer.

Combination Approaches Studies have found that the various psychological interventions for physical problems tend to be equally effective (Sawni & Breuner, 2017). Relaxation and biofeedback training, for example, are equally helpful (and more helpful than placebos) in the treatment of high blood pressure, headaches, and asthma. Psychological interventions are, in fact, most helpful when they are combined

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with other psychological interventions and with medical treatments (Seiler et al., 2020). For example, combinations of medication and psychological treatments such as support groups, mindfulness training, and relaxation training are often more effective than medication alone in the treatment of patients with coronary

heart disease and related medical problems (Allan, 2020; Tofler, 2019b).

Fighting HIV on all fronts As part of his treatment at the Wellness Center in San Francisco, this man meditates and writes letters to his HIV virus.

Isolation stressbusters Although social isolation was instituted to contain the spread of COVID-19, it also

generated immense personal stress that increased the risk of psychological difficulties and different medical problems. In order to help reduce such risks, a man in Germany strapped on his climbing gear to hang on a roof

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beam in his apartment living room (le�) and a woman in New Jersey spent her housebound time practicing yoga and watching her favorite TV series (right).

Clearly, the treatment picture for physical illnesses has been changing

dramatically. While medical treatments continue to dominate, today’s medical practitioners are traveling a course far removed from that of their counterparts in centuries past.